ValueMed Program Brochure

L I M I T E D  H E A LT H  B E N E F I T S  P R O G R A M

…Because our People Count!

We are proud to offer the

ValueMed program to our

employees. This program gives you the

opportunity to purchase voluntary medical,

prescription, Dental, Vision and

Short-Term Disability coverage.

Please review this brochure carefully to

learn more.

All benefits provided by Pan American

Life Insurance Company

ValueMed

Plan

Highlights of all the Plans Include:

• Medical indemnity benefits, provided by Pan American

Life Insurance Company, include: office visits, maternity,

accidents, diagnostic, x-ray and lab.

• In-hospital benefit program

• Two Medical plan options

• Optional benefits

• No health questions - Guaranteed Coverage

• No pre-existing condition limitations

• No copays- no deductibles on medical plans

• Best Benefits Network Discount Card which includes

a national physicians PPO discount network provided

by Beech Street Network.

Best Benefits Network Discount Card*

Best Benefits, one of the most extensive health benefit discount

programs in the country, provides you and all the members

of your household with significant savings on health services

through its national network of over 100,000 providers.

Your membership provides significant savings on the following

coverages:

• Dental (10%)

• Vision (10%)

• Hearing (10-20%)

• Chiropractic (20-40%)

• Physicians (15-30%)

• Prescription (Up to 30%)

In addition to this extensive discount plan, optional

Dental/Vision benefits may be purchased for more comprehensive

coverage. See page 3 for more details.

Prescription Coverage

The following prescription coverage, provided by Member

Health Rx, is included with both Medical Plans:

• Preferred Generic Drugs - $10 or $20 copay

• Preferred Brand Name Drugs - $20 copay

• Non-Preferred Drugs - Discounts averaging 19% off of

average wholesale price.

The MemberHealth Rx prescription card is accepted at over

45,000 pharmacies throughout the United States. The network

includes pharmacy chains, such as CVS, Rite Aid, Medicine

Shoppe, Walgreens, Wal-Mart and thousands of independent

pharmacies throughout the country. Pharmacy location information

can be obtained by contacting customer service at

1-888-868-5854. If a neighborhood pharmacy is not already

participating in our network, please have them call us at

1-888-868-5854. We will send them information about how

they can participate in the network so that you can take advantage

of the savings as soon as possible.

The following benefits, except the Best Benefits Discount Card and Criterion Select Rx Card, are offered by the Pan American

Life Insurance Company

ValueMed Plans

The following optional benefits will be offered separately along with the Two Medical Offerings. If you do not participate in one of the Two Medical

plans you can still participate in the Dental/Vision, STD, and Life /AD&D programs.

Plan Design Standard Plan Premier Plan

Doctor's Office Visits Plan Pays $50 per visit Plan Pays $50 per visit

• Calendar Year Maximum $300 maximum per person, per year $300 maximum per person, per year

Preventive Care Plan Pays $50 per visit Plan Pays $50 per visit

• Calendar Year Maximum $150 maximum per person, per year $150 maximum per person, per year

Accident Benefit Pays 100% of charges incurred up to a maximum Pays 100% of charges incurred up to a maximum

of $300 per occurrence of $500 per occurrence

Diagnostic, X-ray & Lab Plan Pays $30 per visit Plan Pays $50 per visit

• Calendar Year Maximum $300 maximum per person, per year $300 maximum per person, per year

Hospital Indemnity Plan Pays $100 per day Plan Pays $200 per day

500 days lifetime maximum 500 days lifetime maximum

Surgical Benefit N/A Plan Pays $1,000 per year

(according to surgical schedule)

Intensive Care Benefits Pays $200 per day first 30 days, then coverage Pays $400 per day first 30 days, then coverage

reverts to Hospital Indemnity Benefit reverts to Hospital Indemnity Benefit

Substance Abuse Pays $50 per day Pays $100 per day

• Calendar Year Maximum 30 days per calendar year maximum 30 days per calendar year maximum

Skilled Nursing Benefits Pays $50 per day Pays $100 per day

60 days maximum per stay 60 days maximum per stay

Mental Health (Inpatient) Pays $50 per day Pays $100 per day

• Calendar Year Maximum $5,000 calendar year maximum $5,000 calendar year maximum

Life and AD&D Insurance

• Employee $5,000 $5,000

• Spouse (Life only) $2,500 $2,500

• Child (Life only) $1,250 $1,250

• Infant (Life only) $200 $200

Rx Card (Criterion Select)**

• Preferred Generic Drugs $10 or $20 copay $10 or $20 copay

• Preferred Brand Name $20 copay $20 copay

• Non-preferred Drugs Discounts averaging 19% off average wholesale price Discounts averaging 19% off average wholesale price

ER Sickness Benefit Plan Pays $75 per visit $300 max. pp Plan Pays $75 per visit $300 max. pp

Best Benefits Discount Card*

Includes Beech Street Physicians Network and Includes Beech Street Physicians Network and

discounts on vision, dental, hearing, chiro and Rx services discounts on vision, dental, hearing, chiro and Rx services

BI-Weekly Rates (100% Voluntary)

Employee $20.98 $32.01

Employee + One $41.40 $66.96

Employee + Family $45.90 $74.58

ValueMed Plans Optional Benefits

BI-Weekly Rates (100% Voluntary) Optional Pricing

Dental/Vision Benefits

Employee $11.49 Dental $50 deductible/ $500 Annual Max.,$250 Orthodontia No waiting periods/ No pre-X

Employee + One $26.59 Vision $300 Annual Max, 80% coverage, One Exam every 12 months, Frames/Lenses every 24 months

Family + Family $29.83

Disability Benefits

Employee (Only) $8.34 (Waiver of Premium) Up to $300 per week up to 26 weeks.(8/8/26) Pregnancy Covered

*LIFE/AD&D $20,000 additional Flat Amount

Employee (Only) $3.95

This benefit summary is for illustrative purposes only. Please refer to the Certificate of Coverage for details. All Calendar year and Lifetime Maximums are Per Covered Person.

•Included in the ValueMed plans is the Best Benefits Network Discount Card and Criterion Select Rx. These programs are not insurance and are provided by companies unaffiliated with Pan American Life.

•Insurance Company. Pan American is not a marketer for, nor an agent of, these companies, and is not responsible for any services/benefits provided by them.

** In the event that you are not able to find a network pharmacy, please contact 1.800.656.4577.

Optional

Benefits

You have the choice of selecting

Optional Dental/Vision, Disability

benefits and Life/AD&D benefits. If you

do not enroll in a medical plan, you

are still eligible for optional coverage.

If you are ready to enroll or if you

have questions about your plan choices,

contact the ValueMed service center

at 1.800.656.4577.

Disability

The ValueMed disability income plan is designed

to offset the loss of the income when you become

disabled due to a non-occupational injury or illness.

This coverage includes:

• Payments up to $300 per week for up to 26

weeks for the covered employee only (after a 7

day waiting period for sickness or accident; not to

exceed 66-2/3% of salary, excluding bonuses and

overtime).

• The disability plan includes a waiver of premium

rider. This rider provides an employee with a

payment of premium on all their selected

ValueMed benefits when an employee is out on

covered disability. This rider includes payment on

Medical, Dental/Vision and Life/AD&D benefits.

• Includes coverage for Disability due to pregnancy

or childbirth.

Annual $300 per person

Maximum

Routine Exam One every 12 months at 80%

Lenses, Frames One pair every 24 months at 80%

or Contacts

This benefit summary is for illustrative purposes only.

Please refer to the Certificate of Coverage for details.

Employee Only $20,000 flat amount

This benefit summary is for illustrative purposes only.

Please refer to the Certificate of Coverage for details.

Dental/Vision

With the ValueMed Dental/Vision plan, you can receive coverage

for both your preventive care as well as basic and major

Dental/Vision treatments. For a summary of benefits, see the

chart below.

Annual Deductible $50 per covered member

Preventive and Diagnostic Covered at 80%

TYPE I (routine exams and cleanings, (usual, customary and reasonable)

fluoride treatment sealants,

bitewing x-rays, full-mouth x-rays)

Basic Treatment Covered at 80%

TYPE II (extractions, (usual, customary and reasonable)

fillings, root canals)

Major Treatment Covered at 50%

TYPE III (crowns, dentures) (usual, customary and reasonable)

Orthodontia Covered at 50%

(braces for children to age 19) (usual, customary and reasonable)

Orthodontia Lifetime Maximum $250

Annual Maximum $500 per covered member

Vision

Dental

Please see page 3 for all ValueMed optional plan pricing.

Life/AD&D

Life /AD&D

??

What happens when I go to the doctor?

Example 1: You have elected the Standard Plan and your

child becomes sick and needs to go to the doctor. Your

ValueMed benefit pays $50 toward this visit (to an annual

maximum of $300).

Example 2: You have elected the Premier Plan and are

expecting a baby. The chart below outlines the benefits

you would receive toward delivery and hospital charges

under your ValueMed medical plan.

When you are ready to enroll or have questions

about your coverage choices, call the ValueMed

enrollment center at 1.800.656.4577. If you decide

to enroll, please save this brochure for future reference

along with the enrollment kit you will be

receiving.

Si necesita informacion o ayuda en espanol, por

favor comuniquese con el centro de beneficion

al 1.800.656.4577.

Pan American

Frequently Asked

Questions

Please read below to learn more about the

ValueMed Program.

1. Which insurance company pays my medical

insurance claims on ValueMed? Pan American

Life Insurance Company,* founded 1911.

2. Who do I call for more information? Contact

a ValueMed representative to assist you, Mon.-Thur.,

9am-6pm Central time and Friday 9am-5pm Central

time at 1.800.656.4577.

3. Who is eligible for this program? All part-time

employees who are at least 19 years old and their eligible

dependents (see question 9 for definition).

4. Will I receive an insurance card? Yes, you will

receive two separate cards:

1. Your Pan American Medical Insurance Card will

include MemberHealth Rx and all optional

coverages.

2. Your Best Benefits Network discount card with the

Beech Street name and logo on it (this is not

insurance).

5. When does my ValueMed coverage begin?

Your ValueMed coverage will begin on the day following

your first payroll deduction.

6. When will I receive my insurance ID cards?

Your ID cards will be delivered within two weeks after

your effective date (once we have confirmed that

your first payroll deduction has been taken). If you go

to a provider after your effective date but before you

receive your ID card, you will need to pay the doctor

in full and file the claim for reimbursement directly

with the insurance company.

7. When I go to the doctor, can the doctor bill

Pan American directly so I don’t have to pay at

the time of service and then get reimbursed?

Yes, if you present your Pan American insurance card,

most doctors will bill Pan American directly.

8. Can I use any physician or hospital? Yes, you

can use any accredited physician you choose and you

will still receive the same benefits from Pan American

Life Insurance Company. However, you will receive a

negotiated discount if you use your Best Benefits discount

card. To find a doctor in the Beech Street

Physician Network, call the Best Benefits customer service

line at 1-800-308-0374.

9. What is the definition of a dependent with

respect to medical benefits? A dependent is defined

as a plan participant’s spouse or unwed child from birth to

age nineteen (19). An unwed child who is a full-time student

may be covered until age twenty-six (26).

*Included in the ValueMed plans is the Best Benefits Network Discount Card and Criterion Select

Rx. These programs are not insurance and are provided by companies unaffiliated with Pan

American Life Insurance Company. Pan American is not a marketer for, nor an agent of, these

companies, and is not responsible for any services/benefits provided by them.

Premier

Plan Pays ...

Global Fee (office visits, lab services $420

delivery charges)

Hospital Fee — 3-day inpatient $600

stay (mother)

Hospital Fee — 3-day inpatient stay $600

(baby - if added to the plan within 30 days)

Total Benefits Payment: $1,620

ValueMed Checklist

My employer is: Washington Inventory Service.

My location is: City/State

My name is:

My Social Security Number is:

My date of birth is:

My home address is: Street Address/State/Zip

My hire date or status change date (part-time ) is:

My Life Insurance beneficiary is: Legal name

I want coverage for: EMPLOYEE ONLY EMPLOYEE + 1* FAMILY

My coverage choices: For ValueMed Plans See Page 3

My deduction options: For Post Tax VS. Pre Tax See Page 7

My dependents are:

Name/birth date

Name/birth date

Name/birth date

Name/birth date

This is NOT an enrollment form. You must call the ValueMed Enrollment Center at 1.800.656.4577

to enroll.

Si necesita información o ayuda en español, por favor comuníquese con el centro de Beneficios

al 1.800.656.4577.

* Employee + 1 coverage can be employee + spouse or employee + child.

What You Will

Need To Enroll

To enroll, contact the ValueMed Enrollment Center at

1.800.656.4577.

Please make sure you have the following information

before you call.

Pre-Tax vs. Post-Tax Elections

Employees will have the option of choosing to have their ValueMed premium deducted on a pre-tax or post-tax basis.

The decision made will have to remain the entire plan year, per I.R.S code. By having premium deducted on a pre-tax

basis, the following considerations apply: (i) Employees will not have to pay taxes on the money deducted to pay for

their benefits. This will make the benefits less expensive, but actual savings will vary based on the tax bracket the

employee is in. (ii) When an employee chooses to participate in the Pre-Tax plan, they are obligated to remain in the

plan for the entire plan year, unless a status change occurs. (iii) If an employee chooses for deductions to be taken pretax

and they choose the Short Term Disability benefit, the weekly income benefits received will be subject to income

tax. (iv) Because employees' premium payments are deducted before your social security taxes are calculated, employees'

social security benefits may be affected. If deductions are taken post-tax, benefits will cost the employee more

money, but the employee is allowed to cancel their policy at any time. However, the employee cannot re-enroll until

the next open enrollment period.

*Included in the ValueMed plans is the Best Benefits Network Discount Card and Criterion Select Rx. These programs are not insurance and are provided by companies unaffiliated with Pan American Life Insurance

Company. Pan American is not a marketer for, nor an agent of, these companies, and is not responsible for any services/benefits provided by them.

All of the ValuMed plan information is also available at www.wispeople.com.

This program is not intended to replace, nor

do we recommend that it replace any comprehensive

program of insurance in which

you currently participate, or are considering

participation in. This plan is not designed to

replace or provide major medical or catastrophic

coverage.

Coverage must be applied for within 60 days

of date of hire. If you do not enroll during

this time you will be unable to enroll until

the next annual enrollment period unless

you experience a qualified life status change

during the policy year.

This brochure is for illustrative purposes

only. A detailed Certificate of Coverage will

be provided upon enrollment in the

Program. The insurance benefits for the

medical indemnity plan are offered by Pan

American Life Insurance Company. For costs

and further details of coverage, including

exclusions, restrictions or limitations and the

terms under which the policy may be continued

in force, write to Pan American Life

Insurance Company.

Reference form number GER-1991-C

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