Medical and Prescription Drug Coverage
If you are not eligible for Medicare, you can enroll in:
- HOP Pre-65 Medical Plan only (no prescription drug coverage)
- HOP Pre-65 Medical Plan with prescription drug coverage
- Pre-65 Managed Care Plan (Highmark, Aetna, Independent Blue Cross, Capital Blue Cross, or UPMC)
HOP Pre-65 Medical Plan
The HOP Pre-65 Medical Plan covers hospital, surgical, and medical services. Plan highlights:
- You must meet a $1,500 annual deductible before the Plan pays benefits, except for a free physical exam each year that requires no deductible.
- Once you meet the deductible, you pay 25% for providers in the Private Healthcare Systems (PHCS) national network and 40% for out-of-network providers.
- If you spend $5,500 out of pocket in a calendar year, the Plan will pay 100% of covered medical expenses for the rest of the year, up to a $300,000 annual maximum benefit.
- The Plan includes access to the SilverSneakers® fitness program.
Prescription drug coverage
You can elect to enroll in the HOP Pre-65 Medical Plan with or without prescription drug coverage, but you cannot enroll for prescription drug coverage only.
The prescription drug option is administered by OptumRx. It covers prescription drugs dispensed on an outpatient basis. (Drugs you receive in a hospital are covered under the medical portion of the Plan.) You must meet a $350 deductible each year before the Plan pays benefits (separate from the medical deductible). Once you meet the deductible, you pay 50% of the cost for most generic and brand-name drugs that you purchase either at a local network pharmacy or by mail.
Prescription drug coverage under the HOP Pre-65 Medical Plan provides coverage for Critical Care Drugs, which are specific high-cost brand-name drugs with no generic equivalent in their therapeutic class and that are used to treat serious conditions.
Pre-65 Managed Care Plans
The Pre-65 Managed Care Plans provide benefits designed especially for the Health Options Program and include both medical and prescription drug coverage. Managed care plans are available through Highmark, Aetna, Independent Blue Cross, Capital Blue Cross, and UPMC.
You must use an in-network provider to receive the maximum benefit. See the regional managed care plan guides for descriptions of the managed care plans that are available where you live, the benefits they provide, and their rates.
Comparable coverage for your spouse
If you and your spouse are both PSERS retirees, you may individually enroll in any option. If your spouse is NOT a PSERS retiree and is Medicare-eligible, he or she must enroll in the same plan in which you are enrolled. If your spouse is not eligible for Medicare, he or she must enroll in the same type of plan in which you are enrolled (the HOP Pre-65 Medical Plan if you enroll in the HOP or Value Medical Plan, or a managed care plan offered by the same insurance company if you enroll in a Medicare Advantage plan).
Last Modified: February 14, 2024