Page 162 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

• High Deductible Health Plan Option –HDHP 80/60 PPO

This program generally provides 80% payment of all reasonable and customary physician
and hospital costs for in-network covered expenses and 60% payment of all reasonable and
customary physician and hospital costs for out-of-network covered expenses after
satisfaction a $1,400 individual and $2,800 family deductible. The program covers 100%
payment of all reasonable and customary costs for in-network routine preventative care
services with no participant cost-sharing without regard to the deductible.

There is an annual $1,500 individual and $3,000 family out-of-pocket limit for in-network
covered services and an annual $3,600 individual and $6,000 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 expenses you incur for covered services; the
deductible does count toward this limit. When you reach the out-of-pocket limit, the
program begins to pay 100% of all covered expenses with the exception of applicable
copayments.

In addition, there is an annual $1,500 individual and $3,000 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. The TMOOP does not include amounts
in excess of the plan allowance, and there is no TMOOP for out-of-network benefits.

The program includes prescription drug coverage, requiring the use of network pharmacies.
After satisfying the annual in-network deductible described above, the program covers
80% of the cost of covered prescription drugs. Prescriptions filled at an in-network
pharmacy are covered as long as they are listed on the prescription drug formulary
applicable to your plan. Prescriptions filled at an out-of-network pharmacy are not
covered. Please refer to the benefits booklet for more information.

COBRA Contact:
Benefit Coordinators Corporation
Two Robinson Plaza
Suite 200
Pittsburgh, Pennsylvania 15205
1-800-978-7948
enterpriseservice@benxcel.com

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