Page 55 - 2022 MLB Umpire Benefit Guide Flipbook 1

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. 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 amounts in excess of the plan
allowance.

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 for that individual (including covered prescription drug expenses described
below), and no additional coinsurance, copayments or deductibles will be incurred for in-
network covered services in that benefit period, 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. 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. 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% of reasonable and customary physician and
hospital costs for in-network covered expenses with no annual deductible and minimal
copayments for certain services. The program also provides 80% 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 coinsurance incurred for covered services in a benefit period.
When you or your family members reach an out-of-pocket limit, the program begins to
pay 100% of all out-of-network covered expenses (with the exception of applicable
copayments, deductibles, prescription drug expenses, amounts in excess of the plan
allowance).

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