Plans & Premiums for Enrollees With Medicare Parts A & B
Premium information for this plan is listed after the plan information.

Preferred Provider Organization (PPO) Plan

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	60

¹ Payments are based on usual, customary and reasonable fees for medically necessary services as established by the health care plan administrator.

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

 

AultCare PPO
Monthly Premiums — With Medicare Parts A & B

Eligibility Group	TOTAL COST: $246
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	206	40
29	201	45
28	194	52
27	187	59
26	180	66
25	173	73
24	166	80
23	159	87
22	152	94
21	145	101
20	139	107
19	132	114
18	125	121
17	118	128
16	111	135
15	104	142
Less than 15 Years of Service1	0	246
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	276
Dependent Children	0	276
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.