Page 126 - Touching All the Bases- Power point 2023 v2_Neat

out-of-network expenses after a $9,000 individual and $18,000 family deductible.

There is an annual $6,350 individual and $12,700 family out-of-pocket limit for in-network
covered services and an annual $12,700 individual and $25,400 family out-of-pocket limit
for out-of-network covered services. When you or your family members reach the
applicable out-of-pocket limit, the program begins to pay 100% of all coinsurance for
covered expenses (except applicable copayments), including prescription drug copayments
(described below).

In addition, there is an annual $6,350 individual and $12,700 family total maximum out-
of-pocket for in-network covered services. The total maximum out-of-pocket (“TMOOP”)
is the most you and your family members pay for in-network covered services during the
policy year. Once you or any of your covered family members reach the individual
TMOOP limit, the program begins to pay 100% of all in-network covered expenses
incurred for the remainder of the year (including covered prescription drug expenses
described below), and no additional coinsurance, copayments, and deductibles will be
incurred, even if the family TMOOP limit has not been met. Once the family TMOOP
limit is reached, the program will pay 100% of all in-network covered expenses for you
and all of your covered family members, no matter how much each individual has
accumulated in TMOOP expenses. The TMOOP does not include amounts in excess of the
plan allowance, and there is no TMOOP for out-of-network benefits.

The program also includes a prescription drug benefit that covers certain prescriptions
filled at in-network pharmacies. Prescriptions filled at an out-of-network pharmacy are not
covered. After satisfying the annual in-network deductible described above, the program
covers 70% of the cost of covered prescription drugs. You will have an option to purchase
prescription drugs at a retail pharmacy or via mail order. Covered preventive drugs are
covered at 100%, and the deductible does not apply. Please refer to the benefits booklet
for more information.

• Grandfathered PPO Option – 100/80 PPO

This program generally provides 100% payment of reasonable and customary physician
and hospital costs for in-network covered expenses with no annual deductible and $15
copayments for certain services. The program also provides 80% payment of all reasonable
and customary physician and hospital costs for out-of-network expenses after satisfaction
of a $500 individual and $1,000 family deductible.

There is an annual $1,000 individual and $2,000 family out-of-pocket limit for out-of-
network covered services. The out-of-pocket limit, under this benefit option, refers to the
specified dollar amount of expenses incurred for covered services; the deductible does not
count toward this limit. When you or your family members reach an out-of-pocket limit,
the program begins to pay 100% coinsurance with the exception of applicable copayments.

The program also includes prescription drug coverage, requiring the use of network
pharmacies, with various copayments depending upon the type of drug (i.e., generic, brand

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