MEDICAL SERVICES What’s covered Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 $100 $200 time per benefit year) Diagnostic Exam - X-ray (1 time per covered accident) $25 $30 Accident Emergency Treatment, non-emergency room (once per $25 $50 covered accident) Physician's Follow-up Treatment office visit (per visit, up to 6 times per $25 $25 covered accident) Physical Therapy (per visit up to 10 visits per covered accident) $25 $25 Medical Devices $100 $125 Epidural Pain Management (up to 2 times per covered accident) $25 $50 Prescription drug $15 $25 Prosthesis (one) $250 $500 Prosthesis (two) $500 $1,000 Blood, Plasma, or Platelet Transfusion $100 $200 HOSPITAL Hospital Admission (once per benefit year) $500 $1,000 Hospital Confinement (per day up to 365 days per covered accident) $150 $250 Intensive Care Unit Admission (once per Benefit Year; payable instead of $750 $1,500 Hospital Admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement (per day up to 15 days, payable in $300 $500 addition to any Hospital Confinement benefit) Ambulance (Ground) $100 $200 Ambulance (Air) $750 $1,500 Emergency Room Admission $100 $150 Family Lodging (per day up to 30 days per benefit year) $50 $100 Transportation (100 or more miles up to 3 times per covered accident) $250 $500 Rehabilitation Unit (per day up to 30 days per covered accident) $50 $100 SURGERY Miscellaneous Surgery requiring general anesthesia (not covered by any $150 $300 other benefit) Open Surgery $625 $1,250 Exploratory Surgery or Debridement $125 $250 Tendon/Ligament/Rotator Cuff Tear $300 $625 Torn Knee Cartilage $300 $625 Ruptured/Herniated Disc $300 $625 EMERGENCY DENTAL Emergency Dental extraction $30 $65 Emergency Dental crown $100 $200 WELLNESS Wellness Screening Benefit $50 $50 (once per benefit year) LIFE AND DISMEMBERMENT LOSSES* LOW PLAN HIGH PLAN Accidental Death $15,000 $25,000 Accidental Death Common Carrier (pays an additional benefit if accidental death occurs while traveling as a fare- $30,000 $100,000 paying passenger on a public conveyance) Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or one arm and one leg, $7,500 $15,000 or irrecoverable loss of sight of both eyes Loss of one hand, foot, leg, or arm $3,750 $7,500 Loss of sight of one eye or loss of one eye $3,750 $7,500 Two or more fingers or toes $750 $1,500 One finger or one toe $375 $750 800-247-6875 • sunlife.com/us Accident Insurance