Page 13 - Heritage Oaks_Benefit Guide 7-1-2020_Revised 09-25-2020

Limited Benefit Indemnity Plan Options

Pan-American (Group ID SE574)

Per Pay Period Plan 1 Plan 2 Plan 3
Employees can cover their spouse & dependent
Employee Only $ 11.70 $ 22.92 $ 36.99 children. Children can remain on a parent’s
medical plan until age 26. When a child turns 26,
Employee + Spouse $ 62.73 $ 84.96 $116.46
they will lose medical coverage on the last day
Employee + Child(ren) $ 50.73 $ 69.16 $ 94.53 of their birth month. This is an automated process.
Employee + Family $108.21 $138.29 $182.64

Summary of Benefits Plan 1 Plan 2 Plan 3
Group Medical Accident Up to $5,000 Up to $7,500 Up to $10,000
Benefit per Occurrence $100 Deductible $100 Deductible $100 Deductible
(off the Job
Telemedicine Doctor NO Cost. 24/7 Access to Doctors in lieu of office visits, urgent care, ER. Covers spouse and dependents.
Treatment See page 14 for more details
$75 per day $75 per day $75 per day
Doctor’s Office Benefit 4 days per calendar year max 4 days per calendar year max 6 days per calendar year max

Preventive Care Covered at 100% with NO deductibles, copays or co-insurance.
(Must use In-Network Providers) Please see your Pan American Booklet pages 3– 6 for complete details.
Hospital Admission $1,000 First Day $1,000 First Day $1,500 First Day
Indemnity Benefit (when admitted as Inpatient into Hospital Room) (when admitted as Inpatient into Hospital Room) (when admitted as Inpatient into Hospital Room)
$1,000 per day
$800 per day
$500 per day
Hospital Indemnity Up to 60 days calendar year (CY) Up to 60 days calendar year (CY) max Up to 60 days calendar year (CY)
Benefit –Inpatient max for any inpatient hospital stay for any inpatient hospital stay max for any inpatient hospital stay
$1,000 per day $1,600 per day $2,000 per day
Intensive Care Up to 30 days calendar year Up to 30 days calendar year Up to 30 days calendar year
maximum (applied to overall CY max) maximum (applied to overall CY max) maximum (applied to overall CY max)
Emergency Room $100 per day $100 per day $150 per day
Sickness 2 days per calendar year 4 days per calendar year 1 days per calendar year
Inpatient Surgical $500 per day $750 per day $1,000 per day
Benefit 1 day per calendar year 1 day per calendar year 1 day per calendar year
Outpatient Surgical $250 per day $375 per day $500 per day
Benefit 1 day per calendar year 1 day per calendar year 1 day per calendar year
Outpatient Diagnostic $35 per day $35 per day $45 per day
Lab Tests 3 days per calendar year 3 days per calendar year 3 days per calendar year
Outpatient Diagnostic $70 per day $70 per day $100 per day
Radiology Tests 4 days per calendar year 4 days per calendar year 2 days per calendar year
Outpatient Advance $300 per day $300 per day $400 per day
Studies (CT scans, MRI’s) 2 day’s per calendar year 2 day’s per calendar year 2 day’s per calendar year
Generic: $20 per day Generic: $15 per day
Prescription Drugs Generic: $30 per day Name Brand: $50 per day Name Brand: $50 per day
Name Brand: Discount Only
See Policy for Monthly Maximum Limited to 1 Day for Monthly Maximum Limited to 1 Day for Monthly Maximum Limited to 3 Days for
Details* Generic per insured person Generic and 1 Day for Name Brand per Generic and 3 Days for Name Brand per
insured person insured person
Group Term Life with Members Term Life—$5,000 Members Term Life—$5,000 Members Term Life—$5,000
Accidental Death and Members AD&D—$5,000 Members AD&D—$5,000 Members AD&D—$5,000
Dismemberment (AD&D Spouse Term Life—$2,500 Spouse Term Life—$2,500 Spouse Term Life—$2,500
members only) Children Term Life-$1,250 after 6 months Children Term Life-$1,250 after 6 months Children Term Life-$1,250 after 6 months

Group Accidental Death Death $10,000 Death $15,000 Death $20,000
and Dismemberment Dismemberment Up to $10,000 Dismemberment Up to $15,000 Dismemberment Up to $20,000
(AD&D) Members Only

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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.”