MAY 2011 - Association of Marina Industries

Association of Marina Industries – HM Care Advantage Benet SummaryBenet Schedule Value Standard PremiumOce Visits – Physician/Licensed PractitionerDaily In-HospitalAdditional Daily Benet for FirstDay of Hospital ConnementSurgeryAnesthesiaOutpatient Diagnostic TestingProvider Network$60 per Visit5 Visits$100 per Day30 Days$100 First Day1 Admission$500 Max. per SurgeryBased on Schedule2 Surgeries20% of ScheduledSurgery Benet$100 per Testing Day3 DaysReduces Fees fromNetwork Providers$80 per Visit5 Visits$200 per Day30 Days$200 First Day1 Admission$500 Max. per SurgeryBased on Schedule2 Surgeries20% of ScheduledSurgery Benet$125 per Testing Day3 DaysReduces Fees fromNetwork ProvidersHospital Emergency Room Not Included $250 per Visit2 VisitsInpatient Visits – Physician Not Included $100 per Visit3 Visits$100 per Visit5 Visits$500 per Day30 Days$500 First Day1 Admission$1,000 Max. per SurgeryBased on Schedule3 Surgeries20% of ScheduledSurgery Benet$300 per Testing Day3 DaysReduces Fees fromNetwork Providers$500 per Visit3 Visits$100 per Visit3 VisitsDaily Intensive Care Unit Not Included Not Included $1,000 per DayReplaces In-Hospital DaysOutpatient Hospital Services Not Included $200 per Treatment Day2 DaysWellness Screening TestWellness ServiceOutpatient PrescriptionDrug Insurance*(Dependent-only coverage isnot available.)*Provided by Fidelity Security LifeInsurance Company.$150 per Test1 Test$75 per Service1 ServiceNot Included(See PharmacyDiscount Card)$150 per Test1 Test$75 per Service1 Service$10 Co-pay GenericFormulary$15 Co-pay Generic OralFormulary Contraceptives$50 Co-pay Brand NameFormulary$1,000 Max. Benet$250 per Treatment Day2 Days$150 per Test1 Test$75 per Service1 Service$10 Co-pay GenericFormulary$15 Co-pay Generic OralFormulary Contraceptives$50 Co-pay Brand NameFormulary$1,000 Max. BenetIndemnity Benefits shown are per calendar year per covered person. The calendar year is the employer-defined benefit cycle.This Benefit Summary is not intended to be a complete or legal description of the program of benefits. Certain exclusions andlimitations apply and may vary by state. HM Care Advantage pays a fixed amount for medical services. It does not provide majormedical or comprehensive medical coverage.Starting at less than $45per month per employee,the plans at the leftwere developed for theAssociation of MarinaIndustries .About HM Care AdvantageHM Care Advantage pays axed amount for medicalservices. The benets can bepaid directly to the provideror to the employee, whicheverthe employee prefers.Complementary discount andwellness programs round outthe coverage offering, and aprovider network helps reduceout-of-pocket expenses.Additional value-addedbenets include:• Health Information On-Call• Complementary WellnessDiscount Program• Health Information On-Line• Pharmacy Discount Card**• Vision Discount** Replaced by insured prescriptiondrug coverage when insured coverageis offeredMonthly Premium Costs Value Standard PremiumEmployee $44.11 $95.14 $114.70Employee + Spouse $80.12 $167.65 $264.31Employee + Children $81.16 $181.48 $278.14Family $117.05 $253.83 $397.59The rates shown above are contingent upon the employer contributing at least 100% of the premium for the lowest pricedemployee-only plan.About HM Life Insurance CompanyHM Life Insurance Company is a member of the HM Insurance Group, based in Pittsburgh, PA. HMInsurance Group, a Highmark Company, oers a product portfolio featuring HM Worksite Advantage —Critical Illness, Accident and Disability Income plans — and HM Care Advantage, a limited benetmedical plan. HM is a recognized leader in excess loss and reinsurance including Employer Stop Loss,Provider Excess and HMO Reinsurance. HM Life Insurance Company has received “A-” (Excellent)ratings from A.M. Best Company, one of the country’s oldest and most respected rating agencies.Interested inlearning more?Visit AMI's benets site,www.amiemployeebenets.com,or call 719.313.9578 to speak toShawn, your AMI benetsspecialist, who can addressyour particular needs.HM Care Advantage is an HM Life Insurance Company product administered by Key Benet Administrators (KBA). Based on the plan selected, Medical and Visioncoverages are underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HM905, HL902 or similar. For other insured products when available:Dental and Outpatient Prescription Drug coverages are underwritten by Fidelity Security Life Insurance Company, Kansas City, MO, under policy form series M-9037 andM-9031/M-9022. Administrative and/or customer support services when available are provided: for Health Information On-Call – Health Dialog Services Corporation; forComplementary Wellness Discount Program – Healthways Whole-Health Networks, Inc; for Health Information On-Line – HealthMedia® Inc.; for Pharmacy Discount Card– Caremark, Inc; for Vision – Davis Vision; for Provider Network Discount – MultiPlan and Indiana Health Network. Other administrative and/or customer support servicesmay be provided by HM Life Insurance Company and HM Benets Administrators. Certain exclusions and limitations may apply. See your certicate or other evidence ofcoverage for details. Coverage or service requested or the use of a specic association, franchise, trust or union may not be avail-able in all states.MTG - 1320 (08/14/09)24