Page 100 - Touching All the Bases- Power point 2023 Umpires_Neat

the specified dollar amount of expenses incurred for covered services. When you reach the out-of-
pocket limit, the program begins to pay 100% of all covered expenses. Copayments, prescription
drug, and amounts that are not considered “usual, customary, and reasonable” are excluded.

In addition, there is an annual $2,000 individual and $4,000 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, with
various co-payments 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. Prescriptions
are covered as long as they are listed on the prescription drug formulary applicable to your plan.
If you choose to purchase a brand-name drug when a generic drug is available, 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.

Dental Option Offered: MetLife PPO Option

This program generally provides 100% of costs up to the maximum allowable charge for in-
network Type A Services (preventive services), 80% of costs up to the maximum allowable charge
for in-network Type B Services (basic restorative services), 65% of costs up to the maximum
allowable charge for in-network Type C Services (major restorative services), 65% of costs up to
the maximum allowable charge for in-network Temporomandibular Joint Disorder (“TMJ”)
Services, and 50% of costs up to the maximum allowable charge for in-network Orthodontic
Services.

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 Type B Services, 65% of costs up to the reasonable and customary charge for out-
of-network Type C Services, 65% of costs up to the reasonable and customary charge for out-of-
network TMJ Services, and 50% of costs up to the reasonable and customary charge for out-of-
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

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