Selecting Your Plan

Is the Basic Plan a Good Match for You?
Within the indemnity and PPO plans administered by Aetna and Medical Mutual, you can choose from two coverage levels — Basic or Plus. Some of the features of the Basic Plans and Plus Plans are very similar. For example, both plans:

Cover the same hospital/medical services at the same coinsurance;
Require you to pay an annual deductible before the plan begins paying a portion of your hospital/medical costs;
Offer out-of-pocket protection for hospital/medical services, which means you pay nothing for covered services if you reach the out-of-pocket maximum; and
Cover the same prescription drugs at the same copayments until maximum limits are met.

With many equal features, it’s important to understand how the Basic Plans differ from the Plus Plans so you can select the coverage level that’s right for you.

Monthly Premiums and Hospital/Medical Coverage
Plan Feature	Basic Plan	Plus Plan	Difference
Monthly Premium	Lower	Higher	Basic Plan enrollees pay less each month for premiums.
Annual Deductible	$1,500 per enrollee for indemnity and in-network PPO	$500 per enrollee for indemnity and in-network PPO	Basic Plan enrollees pay more only if they use services.
Out-of-Pocket Maximum	$2,500 per enrollee/$5,000 per family for indemnity and in-network PPO	$1,500 per enrollee/$3,000 per family for indemnity and in-network PPO	Basic Plan enrollees pay more only if they use services.
Preventive Services	Enrollee pays no money out of pocket — no deductible or coinsurance — for designated in-network services (deductible and coinsurance will apply for out-of-network services).	Enrollee pays deductible and coinsurance for designated in-network and out-of-network services.	Basic Plan enrollees pay no deductible or coinsurance for designated in-network services, such as an annual physical, a mammogram and a colorectal cancer screening.
Prescription Drug Coverage
Basic Plan	Plan’s maximum annual payment: The Basic Plan has a maximum annual payment of $10,000 per enrollee for Tier 2 and Tier 3 drugs. This is the maximum amount that STRS Ohio will pay in retail and mail-order costs for Tier 2 and Tier 3 drugs for an enrollee in a calendar year, regardless of the amount that enrollee has paid in copayments. Once the maximum limit is met, the enrollee pays the full cost of Tier 2 and Tier 3 drugs for the remainder of the year. This feature provides no out-of-pocket protection for Tier 2 and Tier 3 drugs. Note: STRS Ohio’s costs for Tier 1 drugs and Prilosec OTC^®/OTC omeprazole do not count toward the $10,000 maximum annual payment limit. As a result, an enrollee continues to pay only the copayment for these drugs even after the $10,000 maximum limit is met.
Plus Plan	Enrollee’s maximum annual expense: The Plus Plan has a $2,000 maximum annual expense per enrollee for all covered drugs. This is the maximum amount an enrollee will pay in retail and mail-order costs for covered prescription drugs in a calendar year, regardless of the amount that STRS Ohio has paid. Once the maximum limit is met, the enrollee pays nothing for covered drugs for the remainder of the year. This feature provides out-of-pocket protection for all covered drugs.
Difference	Basic Plan enrollees could pay an unlimited amount for Tier 2 and Tier 3 drugs if the plan’s maximum annual payment limit is met. No out-of-pocket protection is provided for Tier 2 and Tier 3 drugs.

How the Basic Plan’s Maximum Annual Payment Works
In general, the Basic Plan’s maximum annual payment for prescription drugs is based on cost-sharing. You pay a portion of the total drug cost by paying a fixed copayment amount, and STRS Ohio pays the remaining balance. Once STRS Ohio’s share of the cost for retail and mail-order Tier 2 and Tier 3 drugs reaches $10,000, STRS Ohio stops paying for Tier 2 and Tier 3 drugs and you are responsible for the full cost of these drugs for the remainder of the calendar year.

For example, if a retail pharmacy charges $300 for a Tier 3 drug, you would pay a $50 copayment, and STRS Ohio would pay the remaining balance of $250. As a Basic Plan enrollee, the $250 that STRS Ohio paid is the amount you need to track. Once STRS Ohio has paid a total of $10,000 to make up the difference between the copayment you pay and the actual cost of Tier 2 and Tier 3 drugs, you are responsible for paying the full cost of Tier 2 and Tier 3 drugs for the remainder of the calendar year — regardless of the amount you have paid in copayments.

Keep in mind that STRS Ohio’s cost-share for Tier 1 drugs and Prilosec OTC^®/OTC omeprazole does not count toward the $10,000 maximum. As a result, you will continue to pay a fixed copayment amount for these drugs even after the $10,000 maximum annual payment limit is met.

For a more detailed look at how the Basic Plan’s maximum annual payment works, please see the example below.

BEFORE Basic Plan’s Maximum Annual Payment is Met
	Total Drug Cost	Enrollee Pays	STRS Ohio Pays
Drug A (Tier 2)	$275	$30 (retail copayment)	$245
Drug B (Tier 3)	$350	$50 (retail copayment)	$300
Drug C (Tier 3)	$725	$125 (mail-order copayment)	$600
Drug D (Tier 1)	$50	$25 (mail-order copayment)	$25 (amount does not accumulate)

Throughout the calendar year, the amount in the “STRS Ohio Pays” column accumulates for Tier 2 and Tier 3 drugs. Once this amount totals $10,000, STRS Ohio will stop paying its portion of drug costs for Tier 2 and Tier 3 drugs. When this occurs, you will be responsible for paying the full cost of all Tier 2 and Tier 3 drugs for the remainder of the calendar year. You will continue to pay only a fixed copayment amount for Tier 1 drugs and Prilosec OTC^®/OTC omeprazole.

Using the same drug costs above, the chart below shows the amounts you would be responsible for paying after the $10,000 maximum limit is reached.

AFTER Basic Plan’s Maximum Annual Payment is Met
	Total Drug Cost	Enrollee Pays	STRS Ohio Pays
Drug A (Tier 2)	$275	$275 (full cost at retail)	$0
Drug B (Tier 3)	$350	$350 (full cost at retail)	$0
Drug C (Tier 3)	$725	$725 (full cost at mail order)	$0
Drug D (Tier 1)	$50	$25 (mail-order copayment)	$25

How to Decide Which Plan is Right For You
In general, the Basic Plan offers a lower monthly premium in exchange for a higher annual deductible and out-of-pocket maximum for hospital/medical services. It also offers no out-of-pocket protection for Tier 2 and Tier 3 drugs.

If you have a chronic health condition that requires frequent care or your prescription drug expenses are high, the Basic Plan may not be the plan for you. However, the Basic Plan may be an option if you use health care services infrequently or for preventive purposes, or if you need family coverage and you and your family members are in good health. It may also be a good option if you use prescription drugs on a limited basis.

Here are a few questions you can ask yourself to determine if the Basic Plan is a good match for you:

Am I in good health?
How often do I use hospital and medical services?
How many prescription drugs do I take on a regular basis?
Can I afford to pay the full cost of Tier 2 and Tier 3 drugs if I reach the maximum payment limit under the Basic Plan?
Will I use preventive services at no cost to me?
Am I willing to pay a higher annual deductible and out-of-pocket maximum?

Keep in mind that prescription drug coverage is an important factor to consider when comparing plans. To check the tier status of medications you or your family members take on a regular basis, call Express Scripts toll-free at 1-866-685-2792 or visit www.express-scripts.com. This will help you calculate how much you will pay in copayments for prescription drugs under the Basic Plan or the Plus Plan.

In addition, if you take any Tier 2 or Tier 3 drugs on a regular basis, you should call Express Scripts to find out the amount STRS Ohio would pay for these medications. This will help you determine whether you might reach the plan’s $10,000 maximum annual payment for Tier 2 and Tier 3 drugs during the calendar year.

Only you can decide which plan is right for you. Knowing your health care needs and estimating your out-of-pocket expenses can help you determine if the Basic Plan is a good match for you. To learn more about plan, please read the publication: The Basic Plan: Making It Work for You.