Plans & Premiums for Enrollees Without Medicare
Premium information for this plan is listed after the plan features.

Preferred Provider Organization (PPO) Plans

AultCare PPO

Plan Features
	In-Network	Out-of-Network1
Annual Deductible per Enrollee2	$500	$1,000
Out-of-Pocket Maximum2 (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$800 per single enrollee $1,200 per family	$3,000 per single enrollee $6,000 per family
Lifetime Benefits Maximum per Enrollee	$2,000,000	$1,000,000
Health Provider Access	Use network provider	Use any provider
Physician, Hospital, Skilled Nursing & Home Health Care
Physician Office Visit	Enrollee pays 20%	Enrollee pays 50%
Hospital Inpatient Services
Hospital Charges for Outpatient Surgery and Preadmission Testing
Emergency Room Care	Enrollee pays 20% (no deductible)	Enrollee pays 20% (no deductible)
Skilled Nursing Facility	Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100%	Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100%
Inpatient Mental Health	Enrollee pays 20%; no limit on days	Enrollee pays 50%; no limit on days
Home Health Care	Enrollee pays 20%; 100-visit limit per calendar year	Enrollee pays 50%; 100-visit limit per calendar year
Preventive Services
Physical Exam	Enrollee pays $15 (no deductible); up to $200 per calendar year	Enrollee pays 50% (no deductible); up to $200 per calendar year
Colorectal Cancer Screening	Limited coverage
Prostatic Specific Antigen (PSA)	Enrollee pays 20% (no deductible); limit one per year	Enrollee pays 50% (no deductible); limit one per year
Pap Smear
Mammogram	Enrollee pays 20% (no deductible); up to $85 per year; limit one per year	Enrollee pays 50% (no deductible); up to $85 per year; limit one per year
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 20%	Enrollee pays 50%
Outpatient Mental Health	Enrollee pays 20%; no visit limit	Enrollee pays 50%; no visit limit
Additional Services
Dental Care	No coverage	No coverage
Vision Care
Prescription Drug Coverage
Retail Network Provider	AultCare Prescription Program
Retail Copayment/ Coinsurance	Generic: $10 or 20%, whichever is greater Formulary brand-name: $15 or 25%, whichever is greater Nonformulary brand-name: $30 or 30%, whichever is greater Nonparticipating pharmacy: Reimbursed the amount AultCare would have been charged at a participating AultCare pharmacy, less copayment
Maximum Day Supply at Retail	34
Mail-Order Provider	BioScrip
Mail-Order Copayment	Generic: $20 Formulary brand-name: $30 Nonformulary brand-name: $45
Maximum Day Supply at Mail Service	60

¹ Different copayments apply to proton pump inhibitor (PPI) medications under Express Scripts. Designated double-strength medications may be available for half the applicable copayment under Express Scripts.

² Applies to all medication classes unless otherwise specified. Designated double-strength medications are only available for half the maximum day supply under Express Scripts.

 

AultCare PPO
Monthly Premiums — Without Medicare

Eligibility Group	TOTAL COST: $590
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	543	47
29	525	65
28	507	83
27	489	101
26	471	119
25	453	137
24	434	156
23	416	174
22	398	192
21	380	210
20	362	228
19	344	246
18	326	264
17	308	282
16	290	300
15	272	318
Less than 15 Years of Service1	0	590
NOTE: The “Total Cost” listed above is the amount a benefit recipient would pay if he or she paid 100% of the premium cost for coverage under each plan.
Spouse	0	490
Dependent Children	0	172
Sponsored Dependent, Adult	N/A	N/A
Sponsored Dependent, Children	N/A	N/A
NOTE: The “Total Cost” for eligible dependent coverage varies by plan and is listed in the “You Pay” columns.

¹ Benefit recipients with a benefit effective date of Jan. 1, 2004, or later need 15 years of qualifying service credit to purchase health care coverage through STRS Ohio. Benefit recipients with a benefit effective date before Jan. 1, 2004, who have less than 15 years of service credit have access to coverage, but will pay 100% of their health care premium.