Plans & Premiums for Enrollees With Medicare Parts A & B

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

Commercial HMO Plan

Paramount Health Care

Plan Features
Annual Deductible per Enrollee¹	No deductible
Out-of-Pocket Maximum¹ (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
Colorectal Cancer Screening
Prostatic Specific Antigen (PSA)
Pap Smear
Mammogram	Enrollee pays 10% (no deductible); limit one per 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/ Coinsurance²	Tier 1: $10 ($25 PPI) Tier 2: $30 ($50 PPI) Tier 3: $50 ($75 PPI) Prilosec OTC^®: $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. Nonparticipating pharmacy: Reimbursed the amount STRS Ohio would have been charged at a participating Express Scripts pharmacy, less copayment.
Maximum Day Supply at Retail³	30 (28 Prilosec OTC^®)
Mail-Order Provider	Express Scripts
Mail-Order Copayment²	Tier 1: $25 ($65 PPI) Tier 2: $75 ($125 PPI) Tier 3: $125 ($190 PPI) Prilosec OTC^®: 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 Mail³	90

¹ Annual deductible must be met before benefits are payable, unless otherwise noted. In-network and out-of-network accumulations are separate.

² 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.

³ Applies to all medications unless otherwise specified. Designated double-strength medications are only available for half the maximum day supply under Express Scripts.

Paramount Health Care
Monthly Premiums — With Medicare Parts A & B

Eligibility Group	TOTAL COST: $316
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	208	108
29	201	115
28	194	122
27	187	129
26	180	136
25	173	143
24	166	150
23	159	157
22	152	164
21	145	171
20	139	177
19	132	184
18	125	191
17	118	198
16	111	205
15	104	212
Less than 15 Years of Service¹	0	316
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	350
Dependent Children	0	350
Sponsored Dependent, Adult	0	350
Sponsored Dependent, Children	0	350
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.