Medical Insurance - CareFirst Administrators
Schuster offers two medical plan options. Each plan accesses the National BlueCross BlueShield provider
networks. The chart below is a brief outline of the Standard plan. Please refer to the Summary Plan Description for
complete plan details.
NOTE: Medical benefit deductions are taken on a pre-tax basis.
BENEFITS
STANDARD 80/60 PLAN
In-Network
Out-of-Network
Annual Deductible (calendar year)
Individual
$250
$500
Family
$750
$1,500
Maximum Out of Pocket (calendar year)
Includes deductible
Individual
$2,000
$3,000
Family
$4,000
$6,000
Preventive Care
Immunizations
100%
60% after deductible
Preventive Care
100%
60% after deductible
Physician Services
Office Visits
$25 copay, then 100%
60% after deductible
Specialist Visits
$25 copay, then 100%
60% after deductible
Urgent Care
$50 copay, then 100%
$50 copay, then 100%
Outpatient Diagnostic
Diagnostic Tests Minor
80% after deductible
60% after deductible
Diagnostic Tests Major
80% after deductible
60% after deductible
Hospital Services
Inpatient Care (pre-certification required)
80% after deductible
60% after deductible
Outpatient Surgery
$35 copay; then 100%
60% after deductible
Emergency room
$150 copay (waived if admitted) then 80%
Prescription Drugs—with Express Scripts
RX Deductible
None
RX Out-of-Pocket Max
None
Retail Generic
$10
Retail Preferred
$30
Retail Non Preferred
$50
Specialty Drugs
15% Coinsurance up to $150 Max per Fill
Retail/Mail Prescription
Retail - 34 day supply; Mail - 90 day supply; copay 2x retail
Smoking Cessation Products
$500/individual per lifetime