Page 127 - Touching All the Bases- Power point 2023 v2_Neat

formulary, or brand non-formulary) and whether it is purchased at a retail pharmacy or via
mail order. The program covers prescriptions as long as they are listed on the prescription
drug formulary for the plan. If you choose to purchase a brand-name drug when a generic
drug is available, you will pay the difference between the brand and generic prices in
addition to the applicable copayment. Prescriptions filled at an out-of-network pharmacy
are not covered. Please refer to the benefits booklet for more information.

Please note:

The Plan and Highmark Blue Cross Blue Shield believe this coverage is a
“grandfathered health plan” under the Patient Protection and Affordable Care Act
(“ACA”). As permitted by the ACA, a grandfathered health plan can preserve certain
basic health coverage that was already in effect when that law was enacted. Being a
grandfathered health plan means that your policy may not include certain consumer
protections of the ACA that apply to other plans, for example, the requirement for the
provision of preventive health services without any cost sharing. However,
grandfathered health plans must comply with certain other consumer protections in the
ACA, for example, the elimination of lifetime limits on benefits.

Questions regarding which protections apply and which protections do not apply to a
grandfathered health plan and what might cause a plan to change from grandfathered
health plan status can be directed to the Office of the Commissioner’s Human
Resources Department, 1271 Avenue of the Americas, New York, NY 10020, (212)
931-7852. You may also contact the Employee Benefits Security Administration, U.S.
Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply to
grandfathered health plans.

Dental Option Offered: MetLife PDP

This program allows you visit both MetLife network dentists and out-of-network dentists.
Generally, for in-network services, the Plan provides 100% of costs up to the maximum allowable
charge for in-network Type A Services (preventive services) with no deductible, 90% of costs up
to the maximum allowable charge for in-network Type B Services (basic restorative services) after
deductible, and 60% of costs up to the maximum allowable charge for in-network Type C Services
(major restorative services) after deductible. For Orthodontic Services, the Plan covers 50% of the
maximum allowable charge, payable as follows: up to 20% of the total benefit will be paid for the
initial placement, with the remaining benefit paid in quarterly installments over the course of
treatment.

Out-of-network coverage is available based on the reasonable and customary charge rather than
the maximum allowable charge. This means that if an out-of-network dentist performs a covered
service, you will be responsible for paying the deductible, any part of the reasonable and customary
charge that is not covered, and any amount charged by the out-of-network dentist in excess of the
reasonable and customary charge. Out-of-network Type A Services are covered at 100% of the
reasonable and customary charge, without deductible; Type B Services are covered at 80% of the

DB1/ 116795505.8