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 |
Notice of Privacy Practices