Plans & Premiums for Enrollees Without Medicare

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

Commercial HMO Plans

Paramount Health Care

Plan Features
Annual Deductible Per Enrollee	No deductible
Out-of-Pocket Maximum (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$1,500 per single enrollee $3,000 per family
Lifetime Benefits Maximum per Enrollee	No benefit maximum
Health Provider Access	Use HMO provider
Physician, Hospital, Skilled Nursing & Home Health Care
Physician Office Visit	Enrollee pays $15 for primary care physician; $25 for specialists
Hospital Inpatient Services	Enrollee pays 10%
Hospital Charges for Outpatient Surgery and Preadmission Testing	Enrollee pays 10%
Emergency Room Care	Enrollee pays $100; waived if admitted
Skilled Nursing Facility	Enrollee pays 0% per benefit period for days 1–20; $75 for days 21–100; after 100 days, enrollee pays 100%
Inpatient Mental Health	Enrollee pays 10%; no limit on days
Home Health Care	Enrollee pays 10%; no visit limit
Preventive Services
Physical Exam	Enrollee pays $15 for primary care physician; $25 for specialists (age/gender coverage guidelines may apply to immunizations/inoculations)
Bone Density Screening
Immunizations/Inoculations
Colorectal Cancer Screening
Prostatic Specific Antigen (PSA)
Pap Smear
Mammogram	Enrollee pays 10% (no deductible); limit one per calendar year
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 10%
Outpatient Mental Health	Enrollee pays $25; no visit limit
Additional Services
Dental Care	No coverage
Vision Care	Enrollee pays $25 for annual eye exam at participating providers
Prescription Drug Coverage
Retail Network Provider	Express Scripts
Retail Copayment/ Coinsurance¹	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 the enrollee has paid a total of $2,000 out of pocket in retail and mail-order copayments, that individual pays nothing for covered drugs for the remainder of the year. Out-of-network pharmacy: Reimbursed the amount STRS Ohio would have been charged at a network pharmacy, less copayment.
Maximum Day Supply at Retail²	30 (28 Prilosec OTC^®/OTC omeprazole)
Mail-Order Provider	Express Scripts
Mail-Order Copayment¹	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 the enrollee has paid a total of $2,000 out of pocket in retail and mail-order copayments, that individual pays nothing for covered drugs for the remainder of the year.
Maximum Day Supply at Mail²	90

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.

Paramount Health Care
Monthly Premiums — Without Medicare

Eligibility Group	TOTAL COST: $735
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	620	115
29	600	135
28	579	156
27	558	177
26	538	197
25	517	218
24	496	239
23	476	259
22	455	280
21	434	301
20	414	321
19	393	342
18	372	363
17	351	384
16	331	404
15	310	425
Less than 15 Years of Service¹	0	735
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	685
Dependent Children	0	219
Sponsored Dependent, Adult	0	685
Sponsored Dependent, Children	0	219
NOTE: The “Total Cost” for eligible dependent coverage varies by plan and is listed in the “You Pay” columns.

¹Benefit 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.