This is the medical plan description for your STRS Ohio-sponsored health care plan effective Jan. 1, 2009. This document describes the features of the Plus Plans, Basic Plans and Health Care Assistance Plans (HCAPs) administered by Aetna and Medical Mutual. The information within this document applies to all of these plans, unless otherwise noted.

Many features of the Plus Plans, Basic Plans and HCAPs are the same. However, deductibles, out-of-pocket maximums, and out-of-pocket expenses for preventive care services and prescription drugs vary by plan. These differences are noted throughout this publication.

When reviewing this document, please refer to the descriptions that apply to the plan in which you are enrolled. If a description of a plan feature does not reference a specific plan, the information applies to all plans. If you are not sure which plan you are enrolled in, please call your plan administrator at the toll-free number listed on the back of your medical ID card or contact STRS Ohio’s Member Services Center toll-free at 1-888-227-7877.

It is important for you to read this document carefully. The charts in the Schedule of Coverage section detail your coverage for various medical and prescription drug expenses. Please keep this medical plan description in your permanent records for future reference.

If you have questions about your health care coverage, please call your plan administrator directly.

The medical plan description document can be viewed as a PDF either in its entirety or by sections:

Entire document

2009 Medical Plan Description

Medical Plan Description sections

Introduction

This section contains information on:

Authorization to Release Information

Fraud

Recovery of Costs

Definitions

Enrollment Provisions

Qualifying Events for Changing Plans

Schedule of Coverage

This section contains information on:

Schedule of Coverage — Enrollee Without Medicare

Schedule of Coverage — Enrollee With Medicare Parts A & B

Schedule of Coverage — Enrollee With Medicare Part B Only

Description of Coverage

This section contains information on:

Alcoholism and Drug Abuse	Mental Disorders (Nonbiologically Based)
Allergy Tests and Treatment	Mouth, Jaws and Teeth
Ambulance Services	National Medical Excellence (NME) Program® (Aetna Only)
Biologically Based Mental Illness	Other Covered Medical Expenses
Case Management	Outpatient Therapy Services
Certification for Hospital Admissions	Plastic, Reconstructive or Cosmetic Surgery
Certification for Other Services (Aetna Plans Only)	Precertification
Christian Science Practitioners, Nurses or Sanatoria	Preventive Health Care Services
Diagnostic Services	Prescription Drug Expenses
Emergency Services	Private Duty Nursing Services
Experimental Treatment	Skilled Nursing Facility Expenses
Home Health Care	Surgical Services
Hospice Care	Transplant Services
Hospital Expenses	Exclusions

Important Plan Provisions

This section contains information on:

Adjustment Rule	Subrogation and Right of Recovery Provision
Assignment	Recovery of Overpayment
Benefit Payment	Reporting Claims
Out-of-Pocket Maximum for Medical Plans	Automatic Claims-Filing by Medicare (Medicare Crossover)
Lifetime Benefit	Keeping Records of Expenses
Changes in Benefits or Provisions	Explanation of Benefits
Foreign Travel	Review of Benefit Determinations
Monthly Premiums	Termination of Coverage
Coordination of Benefits	Continuation of Medical Expense Benefits After Termination
Effect of Medicare	Continuing Dependent Coverage Upon the Death of Eligible Beneficiary
Effect of Prior Coverage

Continuation of Coverage Options

STRS Ohio Prescription Drug Program

This section contains information on:

Covered Drugs and Supplies	Covered Drug Limitations
Coverage Features and Financial Responsibilities	Step Therapy
Limitations	Medicare Part B-Covered Drugs and Supplies
Exclusions	Coordination of Benefits
Voluntary Tablet-Splitting Program	Appeals
Prior Authorization	Notice of Medicare Part D Creditable Coverage

 

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