Page 6 - Summit LTC Management LLC_Benefit Guide_GROUP 2 2019-2020_Revised 10-1-2020

Healthcare2U and

Pan-American (Group ID SE565)

How to Access (Non-Emergency) Benefits
For ANY non-emergency health care services – First Call: 800-496-2805
The Triage Operator will direct you to one of the following choices:
Option One – Direct Primary Care
Unlimited doctor visits with a $10 visit fee
Unlimited urgent care visits for a $25 fee
Option Two – In/Out of Network Providers
At your option, the plan also provides a $75 Allowance to use in any doctor’s office visit (in or out of network)
You have four visits per plan year in addition to the Option One unlimited choices above.
Option Three – Preventive Care for Adults, Children and Women
All preventive care benefits are covered at 100% with no cost to the member
All preventive care services MUST be provided by a *in-network provider
*Call (1-888-561-5759) or go online (www.providerlocator.com/palicfh) to locate an in-network provider

Healthcare2U Di- Pan American Life Pan American Life
Outpatient Services
rect Primary Care Panamed Indemnity MEC Plan

Unlimited $10 Copay Per $75 Per Visit 4 times a Year (See Healthcare2U or
Routine Office Visit
Office Visit Max Reimbursement Panamed Coverage)
(See MEC or Panamed 100% No Limit
Wellness/Preventive In-Network Only
Coverage) (In-Network Only)
Urgent Care Center N/A (Plan 1) $100 Benefit (See Healthcare2U or
Emergency
$25 Copay Fee (Plan 2) Panamed Coverage)
Urgent Care Center Emergency Room $2,500 - (See Healthcare2U or
Emergency Accident
$25 Copay Fee $100 Deductible applies Panamed Coverage)
Unlimited $0 Copay N/A (See Healthcare2U Cov-
Telehealth (See Healthcare2U Coverage)
Available 24/7/365 erage)
Chronic Disease Unlimited $10 Copay Per $75 Per Visit 4 times a Year (See Healthcare2U or
Management Office Visit Max Reimbursement Panamed Coverage)
Plan 1: Discount Plan
Plan 2:
Generic - $25 Per Day
Prescription Drugs (See Panamed Coverage) (See Panamed Coverage)
(Maximum 2 Per Month)
Brand - $50 Per Day
(Maximum 2 Per Month)
Testing and Treatment In-
Provides inpatient and outpa-
COVID 19 (See Panamed Coverage) cluded at 100% (medically
tient Therapies
necessary)
Inpatient Room &
(See Panamed Coverage) Limited Plan Benefits (See Panamed Coverage)
Board and Surgical
In Addition – Once Your Visit is Scheduled
1. Visit provider and present ID card
2. Provider files claim (In network doctors will not require payment up front)
3. PPO Network applies discounts and forwards claim to Pan-American Life (insurance carrier)
4. If the claim is less than the allowable benefit amount in your plan, you owe nothing
5. If the claim is more than the allowable benefit amount in your plan, you will owe the balance to the provider

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