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); $200 limit per calendar year; bone density screening limit one per calendar year	Enrollee pays 50% (no deductible); $200 limit per calendar year; bone density screening limit one per calendar year
Bone Density Screening
Immunizations/Inoculations	Enrollee pays 20%	Enrollee pays 50%
Colorectal Cancer Screening	Limited coverage
Prostatic Specific Antigen (PSA)	Enrollee pays 20% (no deductible); limit one per calendar year	Enrollee pays 50% (no deductible); limit one per calendar year
Pap Smear
Mammogram	Enrollee pays 20% (no deductible); limit one per calendar year	Enrollee pays 50% (no deductible); limit one per calendar year
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 20%	Enrollee pays 50%
Outpatient Mental Health	Enrollee pays 20%; 30-visit limit per calendar year	Enrollee pays 50%; 30-visit limit per calendar year
Additional Services
Dental Care	No coverage	No coverage
Vision Care
Prescription Drug Coverage
Retail Network Provider	AultCare Prescription Program
Retail Copayment/ Coinsurance3	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 Out-of-network pharmacy: Reimbursed the amount AultCare would have been charged at a network pharmacy, less copayment
Maximum Day Supply at Retail4	34
Mail-Order Provider	BioScrip
Mail-Order Copayment3	Generic: $20 Formulary brand-name: $30 Nonformulary brand-name: $45
Maximum Day Supply at Mail Service4	60

¹Payments are based on reasonable charges or traditional amounts for medically necessary services as established by the health care plan administrator. If nonparticipating providers or providers that do not accept Medicare assignment charge in excess of these payments, the enrollee is responsible for the excess charges.

² Annual deductible must be met before benefits are payable, unless otherwise noted. In-network and out-of-network accumulations are separate.

³ 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.

⁴ 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: $639
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	599	40
29	599	40
28	579	60
27	558	81
26	538	101
25	517	122
24	496	143
23	476	163
22	455	184
21	434	205
20	414	225
19	393	246
18	372	267
17	351	288
16	331	308
15	310	329
Less than 15 Years of Service1	0	639
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	588
Dependent Children	0	185
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.