Page 8 - 2022 MLB Umpire Benefit Guide Flipbook 1

Medical Plan Benefits Summary Continued

Benefit In-Network Out-of-Network
$30 Copay 70% after deductible
Physical Medicine
Combined Limit: 30 visits per calendar year
$30 Copay 70% after deductible
Speech Therapy
Combined Limit: 20 visits per calendar year
Occupational Therapy $30 Copay 70% after deductible
Combined Limit: 20 visits per calendar year
Durable Medical Equipment, Orthotics, 100% 70% after deductible
Prosthetics
100% 70% after deductible
Skilled Nursing Facility Care
Combined Limit: 100 days per calendar year
Home Health Care 100% 70% after deductible
Allergy Injections 100% 70% after deductible
Private Duty Nursing 100%
Hospice 100% 70% after deductible

Inpatient Mental Health 100% 70% after deductible
Outpatient Mental Health $30 Copay 70% after deductible
Inpatient Substance Abuse
Detoxification 100% 70% after deductible
Rehabilitation 100% 70% after deductible
Outpatient Substance Abuse $30 Copay 70% after deductible
Precertification is your responsibility, $1,000 penalty may apply
Precertification Requirements
if you don’t precertify your care
Premier Prescription Drug Program Retail Drugs (30-day Supply)
(Defined by Premier Gold Pharmacy $10 Copay / $35 Copay / $60 Copay
Network; not by the physician
network) Maintenance Drugs through Mail Order (90-day Supply)
(Generic / Brand-Formulary / Brand- $20 Copay / $70 Copay / $120 Copay
Formulary Mandatory Generic)

Click here for a detailed Medical Plan Summary

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