Plans & Premiums for Enrollees With Medicare Part B Only

Plans & Premiums for Enrollees With Medicare Part B Only
Premium information for these plans are listed after the plan information.

Preferred Provider Organization (PPO) Plans

AultCare PPO

Plan Features
	In-Network	Out-of-Network¹
Annual Deductible per Enrollee²	$500	$1,000
Out-of-Pocket Maximum² (Annual amount enrollees pay excluding the annual deductible and prescription drug copayments)	$800 per single enrollee $1,200 per family	$3,000 per single enrollee $6,000 per family
Lifetime Benefits Maximum per Enrollee	$2,000,000	$1,000,000
Health Provider Access	Use network provider	Use any provider
Physician, Hospital, Skilled Nursing & Home Health Care
Physician Office Visit	Enrollee pays 20%	Enrollee pays 50%
Hospital Inpatient Services
Hospital Charges for Outpatient Surgery and Preadmission Testing
Emergency Room Care	Enrollee pays 20% (no deductible)	Enrollee pays 20% (no deductible)
Skilled Nursing Facility	Enrollee pays 20% (90 days per benefit period); after 90 days, enrollee pays 100%	Enrollee pays 50% (90 days per benefit period); after 90 days, enrollee pays 100%
Inpatient Mental Health	Enrollee pays 20%; 30-day limit per calendar year	Enrollee pays 50%; 30-day limit per calendar year
Home Health Care	Enrollee pays 20%; 100-visit limit per calendar year	Enrollee pays 50%; 100-visit limit per calendar year
Preventive Services
Physical Exam	Enrollee pays $15 (no deductible); $200 limit per calendar year; bone density screening limit one per calendar year	Enrollee pays 50% (no deductible); $200 limit per calendar year; bone density screening limit one per calendar year
Bone Density Screening
Immunizations/Inoculations	Enrollee pays 20%	Enrollee pays 50%
Colorectal Cancer Screening	Limited Coverage
Prostatic Specific Antigen (PSA)	Enrollee pays 20% (no deductible); limit one per calendar year	Enrollee pays 50% (no deductible); limit one per calendar year
Pap Smear
Mammogram	Enrollee pays 20% (no deductible); limit one per calendar year	Enrollee pays 50% (no deductible); limit one per calendar year
Outpatient Services
Diagnostic X-ray and Lab Testing	Enrollee pays 20%	Enrollee pays 50%
Outpatient Mental Health	Enrollee pays 20%; no visit limit	Enrollee pays 50%; no visit limit
Additional Services
Dental Care	No coverage	No coverage
Vision Care	No coverage	No coverage
Prescription Drug Coverage
Retail Network Provider	AultCare Prescription Program
Retail Copayment/ Coinsurance	Generic: $10 or 20%, whichever is greater Formulary brand-name: $15 or 25%, whichever is greater Nonformulary brand-name: $30 or 30%, whichever is greater Out-of-network pharmacy: Reimbursed the amount AultCare would have been charged at a network pharmacy, less copayment
Maximum Day Supply at Retail	34
Mail-Order Provider	BioScrip
Mail-Order Copayment	Generic: $20 Formulary brand-name: $30 Nonformulary brand-name: $45
Maximum Day Supply at Mail	60

¹ Payments are based on reasonable charges or traditional amounts for medically necessary services as established by the health care plan administrator. If nonparticipating providers or providers that do not accept Medicare assignment charge in excess of these payments, the enrollee is responsible for the excess charges.

² Annual deductible must be met before benefits are payable, unless otherwise noted. In-network and out-of-network accumulations are separate.

AultCare PPO
Monthly Premiums — With Medicare Part B Only

Eligibility Group	TOTAL COST: $474
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	422	52
29	414	60
28	407	67
27	399	75
26	392	82
25	385	89
24	377	97
23	370	104
22	363	111
21	355	119
20	348	126
19	341	133
18	333	141
17	326	148
16	319	155
15	311	163
Less than 15 Years of Service¹	201	273
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	297
Dependent Children	N/A	N/A
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.