ALL COVERAGE LEVELS Plan Benefit Highlights BENEFITS LEVEL 4 TREATMENTS Initial Treatment $300 Follow-up Treatment Up to six treatments $50 MEDICAL IMAGING CT, CAT, MRI, PET, US, SPECT $200 X-Rays Up to two days $200 HOSPITAL ICU Admission $2,500 Hospital Admission $2,000 ICU Confinement Up to 30 days $1,600 Hospital Confinement Up to 365 days $400 Rehabilitation Up to 30 days $200 AMBULANCE Ground/Water $500 Air $1,500 SURGICAL Anesthesia $300 Exploratory Surgery $400 Internal Injuries Surgery Open abdominal/thoracic surgery $2,500 Miscellaneous Surgery $250 Outpatient Hospital or Ambulatory Surgical Center $450 Ruptured Disc or Torn Knee Cartilage Surgery $500 Tendons, Ligaments, and Rotator Cuff Surgery One tendon, ligament, or rotator cuff More than one tendon, ligament, or rotator cuff $500 $750 FAMILY SUPPORT Transportation Up to 3 round trips per Covered Person per Covered Accident $300 Family Member Lodging and Meals Per day per accident; Up to 30 days per Covered Accident $100 ALL COVERAGE LEVELS MONTHLY PREMIUMS LEVEL 4 Individual $41.80 Individual & Spouse $48.90 Individual & Child(ren) $63.10 Family $71.10 BENEFITS LEVEL 4 INJURY TREATMENTS Fractures Depending on open or closed reduction and bone involved Chip fracture - 25% of closed reduction amount $375 to $10,000 Dislocations Depending on open or closed reduction and joint involved With local or no anesthesia - 25% of closed reduction amount $375 to 10,000 Lacerations Not requiring sutures Sutured lacerations less than two inches Sutured lacerations totaling two but less than six inches Sutured lacerations totaling six inches or more $100 $250 $350 $700 2nd & 3rd Degree Burns Skin grafts are 50% of benefit $150 to $15,000 Appliances Crutches, leg braces, etc. $250 Blood, Plasma, and Platelet $400 Concussion $350 Coma $20,000 Emergency Dental Work Broken teeth repaired with crown or extraction of a broken natural tooth $300 Epidural Pain Management $250 Eye Injury Injury with surgical repair or removal of foreign body by physician, for one or both eyes $350 Gunshot Wound $2,000 Paralysis Paraplegia/Uniplegia Quadriplegia $25,000 $50,000 Physical, Occupational, or Speech Therapy Per day of treatment up to eight days combined $25 Prosthesis Up to two devices $500 Traumatic Brain Injury $2,500