Page 121 - 2022 Washington Nationals Flipbook

MLB LWIP & Nationals Welfare
Plans and Summary Plan Description

brand formulary, or brand non-formulary) and whether it is purchased at a retail
pharmacy or via mail order. The program covers only generic drugs when available
and authorized by your doctor. If you choose to purchase a brand-name drug, you
will pay the difference between the brand and generic prices in addition to the
applicable copayment. Preventive medications are covered without participant cost
sharing. Prescriptions filled at an out-of-network pharmacy are not covered. Please
refer to the benefits booklet for more information.

 PPO Option 2 – High Deductible Health Plan (HDHP 80/60 PPO)

After satisfaction of a $1,300 individual (for participants enrolled in employee-only
coverage) or a $2,600 family (for participants who enroll one or more family
members) deductible, this program generally provides 80% payment of all reasonable
and customary physician and hospital cost for in-network covered expenses, and 60%
payment of all reasonable and customary physician and hospital costs for out-of-
network expenses. The program covers 100% of all reasonable and customary costs
for in-network routine preventative care services with no participant cost sharing.

There is an annual $1,500 individual (for participants enrolled in employee-only
coverage) or $3,000 family (for participants who enroll one or more family members)
out-of-pocket maximum for in-network covered services, and an annual $3,000
individual (for participants enrolled in employee-only coverage) or $6,000 family (for
participants who enroll one or more family members) out-of-pocket maximum for
out-of-network covered services. The out-of-pocket limit, under this benefit option,
refers to the specified dollar amount of coinsurance and deductible you or your family
members incur for covered services and covered medications. When you or your
family members reach the applicable out-of-pocket limit, the program begins to pay
100% of all covered expenses with the exception of deductibles and amounts in
excess of the plan allowance.

In addition, there is an annual $1,500 individual (for participants enrolled in
employee-only coverage) or $3,000 (for participants who enroll one or more family
members) family total maximum out-of-pocket for in-network covered services. The
total maximum out-of-pocket (“TMOOP”) is the most you or your family members
pay for in-network covered services during the policy year. Once you reach the
individual TMOOP limit, or you or your family members reach the family dollar
amount, the program begins to pay 100% of all in-network covered expenses, and no
additional coinsurance, copayments or deductibles will be incurred for in-network
covered services and covered medicates in that benefit period. 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 deductible described above, the program
covers 80% of the cost of covered prescription drugs. Covered preventive drugs are
covered at 100%, and the deductible does not apply. Please refer to the benefits
booklet for more information.

See Benefit Booklets for additional details.

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