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Benefits Overview
As always, you may contact our Customer Communications Department at (313) 964-2400, if you have questions. Medical Benefits Participants and beneficiaries are able to obtain services from the physician or hospital of their choice. However, benefits are paid differently based upon whether the services are rendered by in-network or out-of-network providers. In-Network Benefits The Blue Cross Blue Shield (BCBS) PPO Network is the MCTWF nationwide medical network for hospitals and physicians. To be eligible for in-network level benefits, you must use a BCBS PPO Network provider, where benefits for services obtained will be paid and you will have minimal or no out-of-pocket expense. Participants and their families are responsible for applicable deductibles and coinsurance at the in-network benefit level, but are not subject to balance billing. For BCBS PPO network medical providers and hospitals inside of Michigan link to BCBSM and for medical providers and hospitals nationwide link to BCBS.
Out-of-Network Benefits Covered services received by any provider outside of the BCBS PPO Network are subject to out-of-network benefit deductibles and coinsurance levels. MCTWF provides benefits based on its maximum allowable benefit (MAB) schedule and you are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. However, if services are provided by a Blue Cross Blue Shield Traditional Network or MultiPlan Network provider, benefits are provided subject to out-of-network deductibles and coinsurance levels, but there is no balance billing exposure. Wellness Program This is a program developed to promote a proactive rather than reactive approach to maintaining your well-being through preventative care. The Program includes women's, men's and children's health benefits. In general, the Program provides for a periodic evaluation by your primary care physician and age appropriate screening (adults) and immunizations (children), with all copays and deductibles waived for in-network provider services only. Dental and Orthodontic Benefits Participants and beneficiaries are able to obtain services from the dental provider of their choice. Like Medical Benefits, benefits are paid differently based upon whether services are rendered by in-network or out-of-network providers. In-Network Benefits MCTWF contracts with Delta Dental for its Out-of-Network Benefits If you choose an out-of-network provider, covered services are paid according to a fee schedule. You are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. Orthodontic benefits are available under Dental Plan 1 only for your eligible dependent children through age 18, subject to a coinsurance and per person lifetime maximum. Optical Benefits Participants and beneficiaries are able to obtain services from the optical provider of their choice. MCTWF provides benefits for exams, frames, lenses, and contacts in lieu of glasses once every 12 months, as well as laser vision correction once per eye per lifetime. Benefits are paid based upon whether services are rendered by in-network or out-of-network providers. In-Network Benefits The DeltaVision Network is the MCTWF nationwide optical network. If you choose an in-network provider, MCTWF pays the full cost of the examination and a pair of single, bifocal or trifocal lenses, a higher reimbursement than that of an out-of-network provider for frames and contact lenses and a $250 per eye per lifetime maximum for laser vision correction. Out-of-Network Benefits If you choose an out-of-network provider, covered services are paid according to a fee schedule as well as a $250 per eye per lifetime maximum for laser vision correction. You are responsible for paying any difference between the cost of the service and the amount paid by MCTWF. Prescription Drug Benefits You can get prescriptions filled for up to a 90 day supply through the retail pharmacy program at CVS Caremark participating retail pharmacies with a copayment or coinsurance according to the generic or brand name fill you receive. You may also obtain up to a 90 day supply of covered prescription drugs through CVS Caremark's mail service prescription drug program with a copayment or coinsurance according to the generic or brand name fill you receive. CVS Caremark's Specialty Pharmacy Services provides specialty injectable, infusable and oral drugs for individuals with chronic or genetic conditions. Through this service you receive convenient mail delivery of specialty medications, personalized service and educational support for your specific therapy. Disability Benefits Weekly Accident and Sickness Benefits are available to employee participants who suffer short-term illness or injuries. This benefit provides weekly income for up to 26 weeks (for most Plans). Benefits begin on the first day following medical attention after the last day worked due to an accident, and on the eighth day following medical attention after the last day worked due to illness. Total and Permanent Disability Benefits are available to employee participants who suffer a physical or mental condition that is expected to continue for the remainder of their lives. This benefit provides a monthly income for up to 80 months (for most Plans). Retiree Benefits MCTWF provides retiree medical and prescription drug benefits to retired participants and spouses generally to age 65 or until they become Medicare eligible, and retiree death benefits. Participation in the retiree plans requires a monthly or quarterly self-contribution. The eligibility rules and contribution amounts are described in your SPD. Death Benefits MCTWF provides Death and Accidental Death/Dismemberment benefits as follows:
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