Page 16 - Plainview Benefit Guide 4-1-24
P. 16

Limited Benefit Indemnity Plan Options

          Pan-American / Healtcare2U



         Semi Monthly 24 Pay Periods     Plan 1        Plan 2
                                                                       Employees can cover their spouse & dependent
         Employee Only                   $  14.36      $  49.72        children.  Children  can  remain  on  a  parent’s
                                                                       medical plan until age 26. When a child turns 26,
         Employee + Spouse               $  60.71      $148.22
                                                                       they will lose  medical coverage on the last day
         Employee + Child(ren)           $  65.65      $132.10         of their birth month. This is an automated process.
         Employee + Family               $120.58       $246.36

                                                     Plan 1                                                      Plan 2
          Summary of Benefits
                                          Reimbursement Amounts                     Reimbursement Amounts

          Term Accidental Death &                     $5,000                                   $10,000
          Dismemberment (AD&D)

          Accident Benefit per                     Up to $2,500                               Up to $5,000
          Occurrence (off the job)                $100 Deductible                           $100 Deductible

          Accident Death Benefit                      $5,000                                   $10,000

          Telehealth-Healthcare2U            UNLIMITED $0 Telehealth 24/7              UNLIMITED $0 Telehealth 24/7

          PCP Doctor Office Visit                   $10 Copay                                 $10 Copay
          (Healthcare2 U) Page 13 to 15        UNLIMITED PCP Visits                       UNLIMITED PCP Visits
          Urgent Care Visit                         $25 Copay                                 $25 Copay
          (Healthcare2 U) Page 13 to 15   UNLIMITED PCP / Urgent Care Visits         UNLIMITED PCP / Urgent Care Visits

          Preventative Care MEC                     Paid 100%                                $150 per day
          (First Health Network Only) Page 5   No Copay’s, Deductibles, Co-Ins            1 day per calendar year
          Specialist / PCP                             N/A                                   $100 per day
          Pan American Indemnity Benefit                                                  3 day per calendar year
          Hospital Admission                      $1,000 First Day                          $1,500 First Day
          Indemnity Benefit
          Hospital Indemnity                        $50 per day                              $500 per day
          Benefit –Inpatient        Up to 60 days calendar year (CY) max for any inpatient hospital stay  Up to 60 days calendar year (CY) max  for any inpatient   hospital stay
                                         $100 per day  Up to 30 days calendar year                 $1,000 per day  Up to 30 days calendar year
          Intensive Care
                                          maximum (applied to overall CY max)               maximum (applied to overall CY max)
          Emergency Room                           Up to $2,500                               Up to $2,500
          (Accident)                              $100 Deductible                           $100 Deductible
          Emergency Room                           $100 per day                              $100 per day
          (Sickness)                           1 day per calendar year                    1 day per calendar year
                                                                                             $2,500 per day
          Inpatient Surgical Benefit                   N/A
                                                                                          1 day per calendar year
          Specified Illness Benefit                                                         $5,000 Lump Sum
          First Diagnosis of invasive Cancer, Heart    N/A                               Spouse 50% of Lump Sum
          Attack and Stroke                                                              Children 25% of Lump Sum
                                           Generic: $15 Per Day Maximum Paid         Generic: $10 Per Day Maximum Paid
          Prescription Drugs                  Name Brand: Discount Only            Name Brand: $50 Per Day Maximum Paid
          See Policy for                   Monthly Maximum Limit Reimbursement:      Monthly Maximum Limit Reimbursement:
          Details*                        Monthly Limited to 2 per insured for Generic    Monthly Limited 2 Day per insured for Generic and 2 Brand

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                             *“Prescription benefits are provided by RxEDO's, Inc. www.rxedo.com.  Pan-American Life and RxEDO's, Inc. are not affiliated.”
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