Pechanga 2013-2014 Benefits Guide

Framework Health Plan

Framework Health plan is a limited medical plan insured by Pan American Life. It is available to part-time Team Members, full-time Team Members during their 90 day waiting period, and to full-time Team Members not meeting the 30 hours per week requirement. You pay for the full cost of this coverage directly with pre-tax payroll contributions. Plan Option The following chart illustrates some of the benefits available under the Framework Health Plan option.

Benefits

Coverage

Life / AD&D Insurance • Team Member Only

$5,000

Life Insurance • Spouse • Child over 6 months • Child 14 days to 6 months

$2,500 $1,250 $200

Doctor’s Office Visit

Pays $60 per visit / $300 calendar year maximum per person Pays $50 per visit / $150 calendar year maximum per person Pays $35 per lab test / $105 calendar year maximum per person Pays $100 per x-ray / $200 calendar year maximum per person Pays $75 per visit / $300 calendar year maximum per person

Preventive Care

Outpatient Diagnostic Lab

Outpatient X-ray

Emergency Room Indemnity Daily In-Hospital Indemnity

Pays $100 per day / 60 days per calendar year maximum / 500 days lifetime maximum

Tiered-Pricing Pharmacy Program The Tiered-Pricing Pharmacy card is accepted at over 48,000 pharmacies in the U.S. including Rite Aid, Medicine Shoppe, Walgreens and thousands of independent pharmacies. Benefits are available for brand and generic drugs. The program segments brand and generic drugs into three price classifications (Tiers I, II, and III). A listing of the most commonly prescribed medications in the tier program is available online at www.rxpricequotes.com and is included with your ID cards after you enroll in the program. Discounts are available for drugs not listed in one of the three tiers as well as maintenance medications purchased through the mail order program. Retail Prescriptions

• Tier I • Tier II • Tier III • Non-Tiered Drugs

$10 or less for the scheduled quantity and dose $20 or less for the scheduled quantity and dose $40 or less for the scheduled quantity and dose Contract price (average discount of approximately 16%) or the pharmacy’s price, whichever is less. Discounts available for mail order medications. All completed orders processed and shipped within 48 hours. Orders are shipped free of charge via First Class Mail. Mail order form is included in your fulfillment kit.

Mail Order (90-day supply)

5