Open Enrollment – Medical and Prescription Drug Plans - Human Resources at Ohio State

2019 Open Enrollment

November 1-14, 2018

Medical and Prescription Drug Plans

2019 Medical Benefits

Medical Plan Updates
  • Extended Care Facility services will be covered up to 60 days per plan year.
  • There will be no lifetime limit on the number of human organ transplants that may be covered.
  • Weight-loss surgery will be included in your plan’s annual deductible and out-of-pocket limit with no lifetime maximum.

Ohio State’s medical benefits provide comprehensive coverage for planned and emergency care.

All Ohio State medical plans provide coverage for the same types of medical services; however, the member’s out-of-pocket costs for each service varies based on how the plan pays for those services. You have the flexibility to decide which plan option is best for you and your family.

Related Information

When selecting a plan, think about how frequently you visit the doctor, whether you need out-of-network coverage and how you want to balance your employee payroll contributions with what you are required to pay out-of-pocket for medical services.

  • Prime Care Advantage provides coverage for most medical services only when you receive medical care from the plan’s statewide network of providers.
  • Prime Care Choice provides in-network and out-of-network coverage for medical services.
  • Prime Care Connect is available for individuals with limited household income to help reduce financial barriers with obtaining medical care. It provides coverage for most medical services only when you receive medical care from the plan’s statewide network of providers, and is available only to faculty and staff who meet specific income qualifications and requirements. Learn more about Prime Care Connect requirements
  • Out-of-Area Plan is available to employees and their dependents who:
    • Live in areas without adequate network access or
    • Are enrolled in a Prime Care plan but will be outside Ohio for at least 30 consecutive days. You must meet certain criteria to enroll temporarily in this plan, as detailed on the 2019 Out-of-Area Benefit Election Form.

Use the zip code eligibility tool to see if this plan is available to you.

The CoreSource mobile app is available to make it easier for you to manage your medical benefit. You can access information such as the status of your deductible and out-of-pocket maximum, view claims and show your ID card to providers. You may ask questions and receive answers from CoreSource through the “message center”. You can download the app for free from the app store from Apple or Google Play. Search for “myCoreSource mobile.”

Effective Jan. 1 – Dec. 31, 2019

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Benefit Component Prime Care Advantage1 Prime Care Choice1 Prime Care Connect4 Out-of-Area Plan5
Network Network Out-of-Network3 Network Non-Network
Annual Deductible2 Individual: $450
Family: $900 for most services
Individual: $950
Family: $1,900 for most services
Individual: $1,900
Family: $3,800 for most services
Individual: $150
Family: $300 for most services
Individual: $450
Family: $900 for most services
Coinsurance Plan pays 80% for most services after deductible Plan pays 80% for most services after deductible Plan pays 60% for most services after deductible Plan pays 85% for most services after deductible Plan pays 80% for most services after deductible
Annual Out-of-Pocket Maximum Individual: $2,600
Family: $5,200
Individual: $3,750
Family: $7,500
Individual: $7,500
Family: $15,000
Individual: $1,500
Family: $3,000
Individual: $2,600
Family: $5,200
Preventive Care Plan pays 100% Plan pays 100% Plan pays 60% after deductible Plan pays 100% Plan pays 100%
Office Visit – Primary Care Provider (PCP)6 Plan pays 100% Plan pays 100% Plan pays 60% after deductible Plan pays 100% Plan pays 100%
Office Visit – Behavioral Health Provider Plan pays 80%, no deductible Plan pays 80% after deductible Plan pays 60% after deductible Plan pays 100% Plan pays 80% after deductible
Office Visit – All Other Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible You pay $20 copay Plan pays 80% after deductible
Immediate Care – Convenient Care Plan pays 100% Plan pays 100% Plan pays 60% after deductible Plan pays 100% Plan pays 100%
Immediate Care – Urgent Care Plan pays 80%, no deductible Plan pays 80% after deductible Plan pays 60% after deductible You pay $35 copay Plan pays 80% after deductible
Immediate Care – Emergency Care Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 80% after deductible You pay $100 copay Plan pays 80% after deductible
Inpatient Hospitalization Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible You pay $200 copay Plan pays 80% after deductible
Outpatient Surgery Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible You pay $150 copay Plan pays 80% after deductible
Lab and X-ray Plan pays 80% after deductible Plan pays 80% after deductible Plan pays 60% after deductible Plan pays 85%, no deductible Plan pays 80% after deductible

1 With application, an individual enrolled in this plan may qualify for the Out-of-Area Plan’s non-network benefits.
2 A separate deductible applies for infertility treatment.
3 Out-of-pocket costs that you incur when receiving services from out-of-network providers will apply to the network out-of-pocket maximum.
4 Special application is required. For faculty and staff who have applied and been approved for enrollment in this plan, the network restriction will be removed if your permanent home address is outside Ohio or in select areas of Ohio without adequate network access. Review eligibility by zip code.
5 Must meet eligibility criteria. Review eligibility by zip code.
6 A PCP is a generalist physician designated as a family medicine, general internal medicine, geriatric medicine or general pediatrics provider. PCP services also can be provided by a Primary Care Nurse Practitioner who practices with a PCP. This benefit also applies to University Health Connection and clinics in a retail setting (convenience care).
NOTE: This medical plan comparison chart should be used as a general guide only. Refer to the 2019 Faculty and Staff Health Plans Specific Plan Details (SPD) Document for further information. If the information provided in this summary chart differs from the Specific Plan Details Document, the Specific Plan Details Document will govern.

Under the Affordable Care Act, group health plans and insurance companies must provide participants with SBCs and a glossary of terms commonly used in health insurance coverage. All group health plans and insurance companies use the same standard format for their SBCs and glossary. Our SBCs and glossary are available below and paper copies are available free of charge by contacting OHR Customer Service at HR@osu.edu, (614) 292-1050, or (800) 678-6010.

To compare 2018 and 2019 SBCs, go to the Notices page.

1Summary of Benefits and Coverage

2019 Prescription Drug Benefits

Prescription Plan Updates
Preventive vitamin D medication will no longer be covered at 100% based on updated recommendations from the U.S. Preventive Services Task Force. Most prescriptions for vitamin D are generic and will be subject to the applicable pharmacy benefit copay.

All of the university’s medical plans include prescription drug benefits through Express Scripts, with no need to enroll in a separate prescription drug plan.

Prescription medications are available via home delivery mail-order service and nationwide retail pharmacy locations. You choose which option is most convenient for you and your family. You may obtain a 90-day prescription for maintenance medications through Express Scripts Home Delivery or at an eligible retail preferred pharmacy. The Express Advantage Network allows members to take advantage of higher savings at a preferred retail network pharmacy. You may use retail pharmacies that are not preferred pharmacies in the Express Advantage Network, but your out-of-pocket costs will be higher. Examples of pharmacies in the preferred retail network include, but are not limited to:

  • Costco*
  • Discount Drug Mart*
  • Giant Eagle
  • Kmart
  • Kroger*
  • Marc’s
  • Meijer*
  • OSU Outpatient Pharmacy*
  • Rite Aid
  • Sam’s Club
  • Wal-Mart*
*Retail90 available

With the Express Scripts mobile app, you can manage your prescriptions on-the-go. Features include refilling and tracking the status of home delivery prescriptions, viewing lower-cost medications available and setting reminders. You can also compare your out-of-pocket costs based on the days’ supply of medication, as well as where you are purchasing it.

Go to express-scripts.com and select “Register” or download the Express Scripts mobile app for free from your mobile device’s app store and select “Register Now” in the app.

Effective Jan. 1 – Dec. 31, 2019

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Prescription Drug Plan
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Annual Out-of-Pocket Maximum1 $2,500 per person, $5,000 per family $2,000 per person, $4,000 per family
Deductible2 $50 per person, $100 per family No deductible
Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3
Supply Limitations 30-day supply 30-day supply 90-day supply 30-day supply 30-day supply 90-day supply
Generic Drug $10 copay $20 copay $25 copay $8 copay $18 copay $20 copay
Formulary Brand Name Drug 30% coinsurance, up to $100 35% coinsurance, up to $110 30% coinsurance, up to $250 30% coinsurance, up to $40 35% coinsurance, up to $50 30% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum

1 The Prescription Drug Program annual out-of-pocket maximum is based on plan enrollment and is separate from the medical plan annual out-of-pocket
maximum.
2 The deductible applies to brand name medications only.
3 Retail90 is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.

NOTE: The Prescription Drug Plan, Value-Based Drug Plan and Specialty Medication Plan designs have a combined deductible and annual out-of-pocket maximum.

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication.

For greater details about the Prescription Drug Program, refer to the 2019 Faculty and Staff Health Plans Specific Plan Details (SPD) Document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Faculty, staff and their dependents who are participating in Prime Care Advantage, Prime Care Choice, Out of-Area or Prime Care Connect and are actively participating in the Care Coordination Program for management of asthma, chronic obstructive pulmonary disease (COPD), diabetes and/or heart disease (coronary artery disease or congestive heart failure) are eligible for the VBD. The copay for certain eligible generic drugs taken for the chronic condition(s) will be waived and the member cost-share for certain eligible formulary brand- name drugs taken for the chronic condition(s) will be reduced by 50 percent for eligible participants. If you choose not to actively participate in the Care Coordination Program, you are not eligible for the VBD. Eligible VBD medications obtained at a non-preferred pharmacy will not receive the VBD discount and will be subject to the applicable benefit copay/coinsurance. (see the 2019 Value-Based Prescription Drug Plan Medication Guide)

Effective Jan. 1 – Dec. 31, 2019

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Value Based Drug Plan1, 2, 3
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Home Delivery or Retail90 Pharmacy3
Supply Limitations 30-day supply 90-day supply 30-day supply 90-day supply
Generic Drug $0 $0 $0 $0
Formulary Brand Name Drug 15% coinsurance, up to $50 15% coinsurance, up to $125 15% coinsurance, up to $20 15% coinsurance, up to $50
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum

1 The Value-Based Drug Plan eligibility is based on actively participating in the Care Coordination Program for management of specific chronic conditions (asthma, chronic obstructive pulmonary disease (COPD), diabetes, and heart disease). Visit yp4h.osu.edu to learn more about the Care Coordination Program.
2 Non-Formulary Brand Name Drugs are not eligible for the Value-Based Drug Plan.
3 The Value-Based Drug Plan is not available at Non-Preferred Pharmacies.

NOTE: The Prescription Drug Plan, Value-Based Drug Plan and Specialty Medication Plan designs have a combined deductible and annual out-of-pocket maximum.

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication.

For greater details about the Prescription Drug Program, refer to the 2019 Faculty and Staff Health Plans Specific Plan Details (SPD) Document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Specialty medications are usually high-cost pharmaceutical products that are generally, but not exclusively, biotechnological in nature. The Ohio State Wexner Medical Center Outpatient Pharmacy and Accredo Specialty pharmacy through Express Scripts are the only pharmacies in the exclusive specialty network. If you do not have your specialty medication filled at one of these two pharmacies, it will not be covered.

Effective Jan. 1 – Dec. 31, 2019

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Specialty Medication Plan
Feature Retail Delivery OSUWMC Pharmacy and Accredo
Supply Limitations 30-day supply
Generic Drug Not Available 20% coinsurance, up to $50
Formulary Brand Name Drug 20% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication.

For greater details about the Prescription Drug Program, refer to the 2019 Faculty and Staff Health Plans Specific Plan Details (SPD) Document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Effective Jan. 1 – Dec. 31, 2019

PDF Version

Infertility Medication Plan1, 2, 3, 4
Feature Retail Delivery Home Delivery
Lifetime Maximum Benefit $15,000
Supply Limitations 30-day supply
Generic Drug 20% coinsurance, up to $50 20% coinsurance, up to $50
Formulary Brand Name Drug 30% coinsurance, no maximum 30% coinsurance, no maximum
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum

1 The infertility treatment medical benefit includes the cost of prescription medications and requires prior authorization from OSU Health Plan.
2 The Prescription Drug Program annual out-of-pocket maximum does not apply to infertility medications.
3 Infertility treatment has a separate lifetime maximum benefit.
4 The infertility drug coinsurance does not have a maximum coinsurance per prescription for formulary and non-formulary brand name medications.

For greater details about the Prescription Drug Program, refer to the 2019 Faculty and Staff Health Plans Specific Plan Details (SPD) Document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

PDF Version

Preventive Drug List
Drug Category Eligibility Criteria
Aspirin for cardiovascular disease Men age 45 to 79 years AND
Women age 55 to 79 years
Aspirin for preeclampsia Women of child-bearing years, who are at increased risk of preeclampsia after 12 weeks gestation
Oral fluoride supplementation Children from birth through 5 years old
Iron supplementation in children Children from birth to 12 months of age
Folic acid supplementation All women planning or capable of pregnancy
Breast cancer prevention Subject to prior authorization:

  • Tamoxifen (generic)
  • Raloxifene (generic)
  • Soltamox (Tamoxifen liquid) (brand)
Vaccines See OSU Health Plan Forms & Downloads
Bowel Preparations Certain bowel preparation agents for screening colonoscopy for men and women ages 50 to 75 years
Statin drugs for the primary prevention of cardiovascular disease Low- to moderate-dose statins for men and women age 40-75 years. These medications include:

  • Atorvastatin
  • Fluvastatin IR and XL
  • Lovastatin
  • Pravastatin
  • Simvastatin
  • Rosuvastatin

 

Women’s Health/Contraceptive Coverage
Drug/Device Category Eligibility Criteria
At least one form of women’s contraception in each of the 18 “methods” of contraception outlined in the FDA birth control guide. See OSU Health Plan Forms & Downloads Women only. No age restriction.

 

Tobacco Cessation Coverage
Drug Category Eligibility Criteria
Prescription and Over-the-Counter products with a physician prescription. Men and women age 18 and older.

Open Enrollment Information