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

Medical HMO Plans

Paramount Elite

Plan Features
Annual Deductible Per Enrollee	No deductible
Out-of-Pocket Maximum (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	No annual maximum
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; $20 for specialists
Hospital Inpatient Services	Enrollee pays 0%
Hospital Charges for Outpatient Surgery and Preadmission Testing
Emergency Room Care	Enrollee pays $50; 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 0%; 190 lifetime days
Home Health Care	Enrollee pays 0%; no visit limit
Preventive Services
Physical Exam	Enrollee pays $15 for primary care physician; $20 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 0%; limit one per calendar year
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 0%
Outpatient Mental Health	Enrollee pays $25; no visit limit
Additional Services
Dental Care	No coverage
Vision Care	No coverage
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 Elite
Monthly Premiums — With Medicare Parts A & B

Eligibility Group	TOTAL COST: $264
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	221	43
29	213	51
28	206	58
27	198	66
26	191	73
25	184	80
24	176	88
23	169	95
22	162	102
21	154	110
20	147	117
19	140	124
18	132	132
17	125	139
16	118	146
15	110	154
Less than 15 Years of Service1	0	264
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	305
Dependent Children	0	305
Sponsored Dependent, Adult	0	305
Sponsored Dependent, Children	0	305
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.