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 features.

Medicare HMO Plans

Kaiser Permanente Medicare Plus

Plan Features
Annual Deductible per Enrollee	No deductible
Out-of-Pocket Maximum (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$2,500 per single enrollee $6,000 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
Hospital Inpatient Services	Enrollee pays 0%
Hospital Charges for Outpatient Surgery and Preadmission Testing	Enrollee pays $15
Emergency Room Care	Enrollee pays $50; waived if admitted
Skilled Nursing Facility	Enrollee pays 0% for up to 100 days per benefit period; after 100 days, enrollee pays 100%
Inpatient Mental Health	Enrollee pays 0%; no limit on days
Home Health Care	Enrollee pays 0%; no visit limit
Preventive Services
Physical Exam	Enrollee pays $15 (age/gender coverage guidelines may apply to immunizations/inoculations)
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 0%
Outpatient Mental Health	Enrollee pays $15; no visit limit
Additional Services
Dental Care	No coverage
Vision Care	Enrollee pays $15 for annual eye exam at United Optical
Prescription Drug Coverage
Retail Network Provider	Kaiser Medical Facilities and other network pharmacies
Retail Copayment/ Coinsurance	Formulary generic: $15 Formulary brand-name: $30 Services must be received by pharmacies participating in the HMO network.
Maximum Day Supply at Retail	31
Mail-Order Provider	Kaiser Mail-Order
Mail-Order Copayment	Formulary generic: $15 Formulary brand-name: $30
Maximum Day Supply at Mail	90

Kaiser Permanente Medicare Plus
Monthly Premiums — With Medicare Parts A & B

Eligibility Group	TOTAL COST: $265
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	221	44
29	213	52
28	206	59
27	198	67
26	191	74
25	184	81
24	176	89
23	169	96
22	162	103
21	154	111
20	147	118
19	140	125
18	132	133
17	125	140
16	118	147
15	110	155
Less than 15 Years of Service¹	0	265
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	289
Dependent Children	0	289
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.