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Compare Plan Benefits and Costs

Covered Services The Care Assured Value Plan
Cost-Sharing*:		 The Care Assured Premier Plan
Cost-Sharing*:
Monthly Premium $0 per month1 $49.40 per month1
Primary Physician Visit $15 copay per visit $0 copay per visit
Specialist Visit $30 copay per visit $15 copay per visit
Diagnostic Tests and X-rays 10% coinsurance $0 copay for most x-rays;
$75 copay for MRI, CTI, PET scans
Laboratory Services 10% coinsurance $0 copay — office/lab;
$25 copay — hospital outpatient
Inpatient Hospitalization $190 copay/day (days 1-10);
$0 copay (days 11-365)		 $250 per admission
Outpatient Surgery $240 copay in hospital;
$200 copay in surgical center		 $100 copay in hospital;
$50 copay in surgical center
Emergency Room Visit $50 copay2 per visit $50 copay2 per visit
Urgent Care Visit $35 copay per visit $35 copay per visit
Ambulance Services $50 copay $50 copay
Preventive Care
Annual Physical Exam, Immunizations, GYN Exam, Bone Mass Measurement, Mammogram, Colorectal Screening, Prostate Screening		 $0 copay3 $0 copay3
Maximum annual out-of-pocket for (medical) expenses $3,500 per year $1,500 per year
Routine Vision Services No insured benefits (see below) $50/year for routine eye exams;
$75/year for frames and lenses;
Routine Hearing Services No insured benefits (see below) $50/year for routine hearing exams
$500/year for hearing aids
Outpatient Prescription Benefits Refer to the prescription benefit comparison  when included in the plan purchased (additional premium applies) Refer to the prescription benefit comparison  when included in the plan purchased (additional premium applies)

HMCA members may see any provider who agrees to accept our terms and conditions of payment.

This may not be a complete description of coverage; for full information reference the Evidence of Coverage document.

*Balance Billing - If your doctor, provider, or supplier does not accept Medicare assignment, they may charge you a limited amount (9 percent) over the sum of the plan payment and your copayment responsibility. This applies only to certain services (such as physician services) and does not apply to hospital services, some supplies or for durable medical equipment.

1 You must continue to pay your Medicare Part B premium in addition to the Care Assured premium.
2 Waived if admitted to the hospital within 2 days for the same condition.
3 Medicare coverage guidelines apply.

Value Added Services

Our plans also include certain other value added services that are available through use of a discount card when the member uses the value-added network of providers. The products and services described below are neither offered nor guaranteed under our contract with the Medicare Program. In addition they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the Careington International Corporation and its third party providers’ grievance processes:

Service The Care Assured Value Plan The Care Assured Premier Plan
Dental Care Deep discounts on most routine dental procedures Deep discounts on most routine dental procedures
Routine Vision Services Deep discounts on eye exams, frames and lenses Deep discounts on eye exams, frames and lenses
Routine Hearing Services Deep discounts on hearing exams and hearing aids Deep discounts on hearing exams and hearing aids
CMS APPROVAL 11/24/2007
H7845_MM_NA_E_4006_3_ALL

Underwritten by

The Chesapeake Life Insurance CompanySM