Plans & Premiums for Enrollees Without Medicare

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

Preferred Provider Organization (PPO) Plans

Aetna Basic PPO

Plan Features
	In-network	Out-of-network¹
Annual Deductible per Enrollee²	$1,500	$3,000
Out-of-Pocket Maximum² (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$2,500 per single enrollee $5,000 per family	$5,000 per single enrollee $10,000 per family
Lifetime Benefits Maximum per Enrollee	$2,500,000
Health Provider Access	Use network provider	Use any covered 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%
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%; no visit limit	Enrollee pays 50%; no visit limit
Preventive Services
Physical Exam	Enrollee pays 0% (no deductible); limit one per calendar year (colorectal cancer screening limit one per three calendar years)	Enrollee pays 50%; limit one per calendar year (colorectal cancer screening limit one per three calendar years)
Bone Density Screening
Immunizations/Inoculations
Colorectal Cancer Screening
Prostatic Specific Antigen (PSA)
Pap Smear
Mammogram
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	Discount on eyewear and exams at participating providers	Discount on eyewear and exams at participating providers
Prescription Drug Coverage
Retail Network Provider	Express Scripts
Retail Copayment/ Coinsurance³	Tier 1: $10 ($25 PPI) Tier 2: $30 ($50 PPI) Tier 3: $50 ($75 PPI) Prilosec OTC^®/OTC omeprazole: $5 with prescription If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Once STRS Ohio has paid $10,000 in retail and mail-order prescription costs for Tier 2 and Tier 3 drugs for an enrollee, that enrollee pays 100% of the full cost of Tier 2 and Tier 3 drugs for the remainder of the year. The enrollee continues to pay only the copayment for Tier 1 drugs and Prilosec OTC^®/OTC omeprazole, which are not subject to maximum annual payment. Out-of-network pharmacy: Reimbursed the amount STRS Ohio would have been charged at a network pharmacy, less copayment.
Maximum Day Supply at Retail⁴	30 (28 Prilosec OTC^®/OTC omeprazole)
Mail-Order Provider	Express Scripts
Mail-Order Copayment³	Tier 1: $25 ($65 PPI) Tier 2: $75 ($125 PPI) Tier 3: $125 ($190 PPI) Prilosec OTC^®/OTC omeprazole: Not covered If the cost of the drug is less than the copayment, the enrollee pays the cost of the drug. Once STRS Ohio has paid $10,000 in retail and mail-order prescription costs for Tier 2 and Tier 3 drugs for an enrollee, that enrollee pays 100% of the full cost of Tier 2 and Tier 3 drugs for the remainder of the year. The enrollee continues to pay only the copayment for Tier 1 drugs and Prilosec OTC^®/OTC omeprazole, which are not subject to maximum annual payment.
Maximum Day Supply at Mail⁴	90

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.

Aetna Basic PPO
Monthly Premiums — Without Medicare

Eligibility Group	TOTAL COST: $478
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	333	145
29	322	156
28	311	167
27	300	178
26	289	189
25	278	200
24	266	212
23	255	223
22	244	234
21	233	245
20	222	256
19	211	267
18	200	278
17	189	289
16	178	300
15	167	311
Less than 15 Years of Service¹	0	478
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	505
Dependent Children	0	135
Sponsored Dependent, Adult	0	505
Sponsored Dependent, Children	0	135
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.