Michigan Conference of Teamsters Welfare Fund





























Schedule of Benefits
Benefit Package 145




Date Inquired About: 2/8/2026
Today's Date: 2/8/2026 		Effective January 2026


MCTWF
Michigan Conference of Teamsters Welfare Fund (MCTWF)
Benefit Package 145
SCHEDULE OF BENEFITS
 
Retiree Health BenefitBCBS PPO NetworkNon-BCBS PPO Network
Annual Maximum (effective 1/1/2022)

Annual Deductible

Coverage/Coinsurance

Annual Out-of-Pocket Maximum		$300,000 per person

$100 individual

85% /15% of CC

$1,000 per person in excess of deductible.		$300,000 per person

$100 individual

75%/25% of MAB

$2,000 per person in excess of deductible.
In-Patient Hospital ExpensesCovered 85%* of CC subject to deductible for up to 365 days semi-private room or private room if medically necessary
Covered 75%* of MAB subject to deductible for up to 365 days semi-private room or private room if medically necessary
Hospital Emergency Expenses
   (must meet criteria) 		Covered 85%* of CC subject to deductibleCovered 85%* of MAB subject to deductible
Mental Health & Substance
Use Disorder Benefits
(must receive prior authorization for inpatient services by calling BCBS at 800-762-2382)		Inpatient Hospital:Covered 85%* of CC subject to deductible
Inpatient Physician:Covered 85%* of CC subject to deductible
Outpatient Physician:Covered 85%* of CC subject to deductible		Inpatient Hospital:Covered 75%* of CC subject to deductible
Inpatient Physician:Covered 75%* of MAB subject to deductible
Outpatient Physician:Covered 75%* of MAB subject to deductible
Surgical ExpensesCovered 85%* of CC subject to deductible
Covered 75%* of MAB subject to deductible
Specified Organ Transplant Program
Expenses		Covered 100% of CC.
Must use a designated facility.		Covered 100% of CC.
Must use a designated facility.
Maternity Expenses
Pre/Post Natal Delivery
Covered 85%* of CC subject to deductible

Covered 75%* of MAB subject to deductible
Anesthesia ExpensesCovered 85%* of CC subject to deductible
Covered 75%* of MAB subject to deductible
Ambulance Expenses
Ground/Air/Water
Covered 85%* of CC subject to deductible

Covered 85%* of MAB subject to deductible
X-ray and Diagnostic Testing
Expenses
Covered 85%* of CC subject to deductible

Covered 75%* of MAB subject to deductible
Laboratory Expenses
  Fluids/Pathology/Diagnostic Tests
Covered 85%* of CC subject to deductible

Covered 75%* of MAB subject to deductible
Physician Charges
  Inpatient

  Outpatient Primary Care Visit
  Outpatient Specialist Visit
  Outpatient Urgent Care Visit
  MDLIVE Telehealth Consultation
Covered 85%* of CC subject to deductible

Covered 85%* of CC subject to deductible
Covered 85%* of CC subject to deductible
Covered 85%* of CC subject to deductible
$0 copay ($10** copay waived through 03/31/26)
Covered 75%* of MAB subject to deductible

Covered 75%* of MAB subject to deductible
Covered 75%* of MAB subject to deductible
Covered 75%* of MAB subject to deductible
Not Covered
Wellness Benefit
  Physical / GYN Exam		Covered in full
Deductible & copayment waived

Covered 75%* of MAB subject to deductible
Wellness Benefit
Pap Smear Screening &
Mammogram Screening
Covered 100% of CC
Deductible & coinsurance waived

Covered 75%* of MAB subject to deductible
Wellness Benefit
Adult Flu Vaccination		Covered in full
Deductible & copayment waived

Covered 75%* of MAB subject to deductible
Injection ExpensesCovered 85%* of CC subject to deductible
Covered 75%* of MAB subject to deductible
Chiropractic Expenses24 spinal manipulations per person annually covered 85%* of CC subject to deductible. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit.24 spinal manipulations per person annually covered 75%* of MAB subject to deductible. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit.
Physical, Speech &
Occupational Therapy Expenses
Covered 85%* of CC subject to deductible

Covered 75%* of MAB subject to deductible
Home Health Care ExpensesCovered 85%* of CC subject to deductible
Covered 85%* of MAB subject to deductible
Skilled Nursing Facility Expenses85%* eligible expenses subject to deductible for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital.
85%* eligible expenses subject to deductible for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital.
Hospice Care ExpensesCovered 85%* of CC subject to deductible
Covered 85%* of MAB subject to deductible
Durable Medical Equipment
and Medical Supplies Expenses
Covered 85%* of CC subject to deductible

Covered 85%* of scheduled amount subject to deductible
Prosthetic Devices and
Orthotics Expenses
Covered 85%* of CC subject to deductible

Covered 85%* of MAB subject to deductible
Prescription Drug BenefitCaremark Pharmacy Network
Prescription Drug Rx1Participating Retail: Up to 34 day supply, covered in full after $5** copay for generic and $15** copay for brand name drugs. 90 day supply covered in full after $10** copay for generic and $30** copay for brand name drugs.

Participating Mail Order: Up to 90 day supply. Covered in full after $10** copay for generic and $30** copay on brand name drugs.
OtherCoverage Information
Member ContributionContribution required; see SPD for details.
Qualifying AgeAge 57 to age 65 with certain prior plan participation requirements.
Age 50 to age 65 with certain prior plan participation requirements for
"30-and-out Pension" participants only (excluding I&S participants who must be at least age 57).
Dependent CoverageCoverage is provided only to your spouse under age 65 and not eligible for Medicare

CC (Contracted Charges) means the agreed upon fees between MCTWF and in-network providers.

MAB (Maximum Allowable Benefit) means the portion of the amount billed by an out-of-network provider that has been established as the benefit package maximum payable amount, subject to deductible, coinsurance and co-payments.

* The coinsurance payments for these services apply toward the out-of-pocket maximum.
** The co-payments and/or coinsurance payments for these services do not apply towards the annual out-of-pocket maximum.

Eligibility for auto-related accidental injuries or illnesses under your MCTWF benefit package will be available only to the extent that claims resulting from the accident are in excess of the greater of (1) the required insurance coverage or other financial protection required under applicable state law, or (2) the benefit limits of any other insurance under which the individual is entitled to coverage. MCTWF will provide benefits pursuant to a signed MCTWF Assignment, Subrogation and Reimbursement Agreement, contingent upon the submission of proof that benefits have been exhausted through the auto carrier and/or other insurance available. MCTWF does not provide Qualified Health Coverage.

If you are the operator or occupant of a rental vehicle and other medical coverage is available, no MCTWF benefits will be paid for auto-related accidental injuries or illnesses.

This Schedule of Benefits is not a full statement of covered services under your benefit package. As a general rule, all procedures or services not deemed experimental by the medical community are covered. Contact MCTWF's Member Services Call Center for any benefit questions you may have.