Page 12 - Pampa 2024 Benefit Guide Final

Limited Benefit Indemnity Plan Options

Pan-American

Semi Monthly 24 Pay Periods Plan 1 Plan 2
Employees can cover their spouse & dependent
Employee Only $ 15.00 $ 50.00 children. Children can remain on a parent’s
medical plan until age 26. When a child turns 26,
Employee + Spouse $ 80.00 $160.00
they will lose medical coverage on the last day
Employee + Child(ren) $ 60.00 $120.00 of their birth month. This is an automated process.
Employee + Family $125.00 $235.00

Summary of Plan 1 Plan 2
Benefits Reimbursement Amounts Reimbursement Amounts

Term Life Insurance Member $5,000, Spouse $2,500, Children $1,250 Member $5,000, Spouse $2,500, Children $1,250

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

Accident Benefit per Up to $5,000 Up to $10,000
Occurrence (off the job) $100 Deductible $100 Deductible

Accident Death Benefit $10,000 $20,000

Unlimited $0 Telehealth 24/7 Unlimited $0 Telehealth 24/7
Telehealth-HealthiestYou
For Entire Family For Entire Family
$75 per day $100 per day
Doctor’s Office Visits
4 days per calendar year maximum 4 days per calendar year maximum
$100 per day $150 per day
Wellness Benefit
1 day per calendar year 1 day per calendar year
Hospital Admission $1,000 First Day $1,500 First Day
Indemnity Benefit
$500 per day $1,000 per day
Hospital Indemnity Up to 60 days calendar year (CY) max for any inpatient Up to 60 days calendar year (CY) max for any inpatient
Benefit –Inpatient hospital stay hospital stay

$1,000 per day Up to 30 days calendar year $2,000 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 $75 per day $75 per day
(Sickness) 4 days per calendar year 6 days per calendar year
Inpatient Surgical $500 per day $1,000 per day
Benefit 1 day per calendar year 1 day per calendar year
Generic: $25 Per Day Maximum Paid Generic: $25 Per Day Maximum Paid
Prescription Drugs Name Brand: Discount Only Name Brand: $50 Per Day Maximum Paid
See Policy for Monthly Maximum Limit : Monthly Maximum Limit :
Details* Monthly Limited to 1 per insured for Generic Monthly Limited 1 Day per insured for Generic and 1 Brand
There are No copayments, Deductibles, or Coinsurance There are No copayments, Deductibles, or Coinsurance

*“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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