Page 10 - Benefit Guide Stamford Residence and Rehab

Limited Benefit Indemnity Plan Options

Pan-American

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

Summary of Benefits Plan 1 Plan 2
Group Medical Accident Benefit per Up to $5,000 Up to $7,500
Occurrence (off the Job $100 Deductible $100 Deductible
NO Cost. 24/7 Access to Doctors in lieu of office visits, urgent care, ER. Covers spouse and
Telemedicine Doctor Treatment dependents. See page 11 for more details

$75 per day $75 per day
Doctor’s Office Benefit 4 days per calendar year max 4 days per calendar year max
Preventive Care Covered at 100% with NO deductibles, copays or co-insurance.
(Must use In-Network Providers) (See page 4) Please see your Pan American Booklet pages 3-6 for complete details.
$1,000 First Day $1,000 First Day
Hospital Admission Indemnity Benefit
(when admitted as Inpatient into Hospital Room) (when admitted as Inpatient into Hospital Room)
$500 per day $800 per day
Hospital Indemnity Benefit –Inpatient Up to 60 days calendar year (CY) max for any Up to 60 days calendar year (CY) max for any
inpatient hospital stay inpatient hospital stay
$1,000 per day $1,600 per day
Intensive Care Up to 30 days calendar year maximum (applied Up to 30 days calendar year maximum (applied to
to overall CY max) overall CY max)
$100 per day $100 per day
Emergency Room - Sickness
2 days per calendar year 4 days per calendar year
$500 per day $750 per day
Inpatient Surgical Benefit
1 day per calendar year 1 day per calendar year
$250 per day $375 per day
Outpatient Surgical Benefit
1 day per calendar year 1 day per calendar year
$35 per day $35 per day
Outpatient Diagnostic Lab Tests
3 days per calendar year 3 days per calendar year
Outpatient Diagnostic Radiology $70 per day $70 per day
Tests 4 days per calendar year 4 days per calendar year

Outpatient Advance Studies (CT scans, $300 per day $300 per day
MRI’s) 2 day’s per calendar year 2 day’s per calendar year

Prescription Drugs Generic: $15 per day Generic: $25 per day
Name Brand: $50 per day
Name Brand: Discount Only
See Policy for Details* see Page 10 Monthly Maximum Limited to 1 Day for Generic per Monthly Maximum Limited to 1 Day for Generic and 1
and 11 Pan American Booklet insured person Day for Name Brand per insured person
Members Term Life—$5,000 Members Term Life—$5,000
Group Term Life with Accidental Members AD&D—$5,000 Members AD&D—$5,000
Death and Dismemberment (AD&D 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
Infant Term Life—$200 (10 days to 6 months) Infant Term Life—$200 (10 days to 6 months)

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

*“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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The limited benefit indemnity coverage is issued by Pan-American Life Insurance Company on policy form number PAN-POL-13. There are no exclusions for pre-existing conditions. The plan will not pay benefits for any care provided prior to the coverage
effective date or if the insured is confined in a hospital at the time the coverage is effective. Hospital does not include a nursing home, convalescent home or extended care facility. Like most group benefit programs, our products have exclusions, limitations, waiting
periods and terms for keeping them in force. The preventive care coverage is offered under a self-funded plan maintained by the plan sponsor. Pan-American Life Insurance Company does not insure benefits under these self-funded plans. See Page 20 for