Plans & Premiums for Enrollees With Medicare Part B Only

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

Indemnity Plans

Medical Mutual Basic Indemnity¹

Plan Features
Annual Deductible per Enrollee²	$1,500
Out-of-Pocket Maximum² (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$2,500 per single enrollee $5,000 per family
Lifetime Benefits Maximum per Enrollee	$2,500,000
Health Provider Access	Use any covered provider
Physician, Hospital, Skilled Nursing & Home Health Care
Physician Office Visit	Enrollee pays 20%
Hospital Inpatient Services
Hospital Charges for Outpatient Surgery and Preadmission Testing
Emergency Room Care
Skilled Nursing Facility	Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100%
Inpatient Mental Health	Enrollee pays 20%; no limit on days
Home Health Care	Enrollee pays 20%; no visit limit
Preventive Services
Physical Exam	Enrollee pays 0% (no deductible); limit one per calendar year (colorectal cancer screening limit one per three calendar years)
Colorectal Cancer Screening
Prostatic Specific Antigen (PSA)
Pap Smear
Mammogram
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 20%
Outpatient Mental Health	Enrollee pays 20%; no visit limit
Additional Services
Dental Care	No coverage
Vision Care	No coverage
Prescription Drug Coverage
Retail Network Provider	Express Scripts
Retail Copayment/ Coinsurance³	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 STRS Ohio has paid $10,000 in retail and mail-order prescription costs for Tier 2 and Tier 3 drugs for an enrollee, that enrollee pays 100% of the full cost of Tier 2 and Tier 3 drugs for the remainder of the year. The enrollee continues to pay only the copayment for Tier 1 drugs and Prilosec OTC^®. Tier 1 drugs and Prilosec OTC^® are not subject to maximum benefit. Nonparticipating pharmacy: Reimbursed the amount STRS Ohio would have been charged at a participating Express Scripts pharmacy, less copayment.
Maximum Day Supply at Retail⁴	30 (28 Prilosec OTC^®)
Mail-Order Provider	Express Scripts
Mail-Order Copayment³	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 STRS Ohio has paid $5,000 in retail and mail-service prescription costs for Tier 2 and Tier 3 drugs for an enrollee, that enrollee pays 100% of the full cost of Tier 2 and Tier 3 drugs for the remainder of the year. The enrollee continues to pay only the copayment for Tier 1 drugs and Prilosec OTC^®. Tier 1 drugs and Prilosec OTC^® are not subject to maximum benefit.
Maximum Day Supply at Mail⁴	90

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.

³ 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.

⁴ Applies to all medication classes unless otherwise specified. Designated double-strength medications are only available for half the maximum day supply under Express Scripts.

Medical Mutual Basic Indemnity
Monthly Premiums — With Medicare Part B Only

Eligibility Group	TOTAL COST: $297
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	257	40
29	257	40
28	253	44
27	250	47
26	246	51
25	242	55
24	239	58
23	235	62
22	231	66
21	228	69
20	224	73
19	220	77
18	217	80
17	213	84
16	209	88
15	206	91
Less than 15 Years of Service¹	151	146
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	146
Dependent Children	N/A	N/A
Sponsored Dependent, Adult	0	146
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.