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.

Medicare HMO Plan

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 Part B Only

Eligibility Group	TOTAL COST: $747
Benefit Recipient Years of Service	STRS OHIO PAYS	YOU PAY
30+	704	43
29	697	50
28	690	57
27	683	64
26	676	71
25	669	78
24	662	85
23	655	92
22	648	99
21	641	106
20	635	112
19	628	119
18	621	126
17	614	133
16	607	140
15	600	147
Less than 15 Years of Service¹	496	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	538
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.