Page 56 - 2022 MLB Umpire Benefit Guide Flipbook 1

The program also includes a prescription drug program requiring the use of network
pharmacies, with various copayments depending upon the type of drug (i.e., generic,
brand formulary, or brand non-formulary) and whether it is purchased at a retail
pharmacy or via mail order. No copayment is required for covered preventive drugs.
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: PPO Option

This program generally provides 100% of costs up to the maximum allowable charge for in-
network Type A Services (preventive services), 90% of costs up to the maximum allowable
charge for in-network Type B Services (basic restorative services), 60% of costs up to the
maximum allowable charge for in-network Type C Services (major restorative services), and
50% of costs up to the maximum allowable charge for in-network Orthodontic Services.

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. Please refer to the benefits booklet for more
information.

For participants that are not residents of Louisiana, Mississippi and Texas, this program also
generally provides 100% of costs up to the reasonable and customary charge for out-of-network
Type A Services, 80% of costs up to the reasonable and customary charge for out-of-network

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