Page 10 - Benefit Guide Austin Healthcare & Rehabilitation Final 101420
P. 10

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
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