Page 12 - Pampa 2024 Benefit Guide Final
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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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