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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