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 Enrollee¹	No deductible
Out-of-Pocket Maximum¹ (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
Colorectal Cancer Screening	Enrollee pays $15 for physician
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 participating pharmacies
Retail Copayment/ Coinsurance	Formulary generic: $15 Formulary brand-name: $30 Services must be received by pharmacies participating in the HMO.
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

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

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

Eligibility Group	TOTAL COST: $251
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	208	43
29	201	50
28	194	57
27	187	64
26	180	71
25	173	78
24	166	85
23	159	92
22	152	99
21	145	106
20	139	112
19	132	119
18	125	126
17	118	133
16	111	140
15	104	147
Less than 15 Years of Service¹	0	251
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	251
Dependent Children	0	251
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.