ALL COVERAGE LEVELS Plan Benefit Highlights BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 TREATMENTS Initial Treatment $150 $200 $250 Follow-up Treatment Up to six treatments $50 $50 $50 MEDICAL IMAGING CT, CAT, MRI, PET, US, SPECT $200 $200 $200 X-Rays Up to two days $50 $100 $150 HOSPITAL ICU Admission $1,000 $1,500 $2,000 Hospital Admission $500 $1,000 $1,500 ICU Confinement Up to 30 days $400 $800 $1,200 Hospital Confinement Up to 365 days $100 $200 $300 Rehabilitation Up to 30 days $50 $100 $150 AMBULANCE Ground/Water $500 $500 $500 Air $1,500 $1,500 $1,500 SURGICAL Anesthesia $150 $200 $250 Exploratory Surgery $250 $300 $350 Internal Injuries Surgery Open abdominal/thoracic surgery $1,000 $1,500 $2,000 Miscellaneous Surgery $250 $250 $250 Outpatient Hospital or Ambulatory Surgical Center $150 $250 $350 Ruptured Disc or Torn Knee Cartilage Surgery $500 $500 $500 Tendons, Ligaments, and Rotator Cuff Surgery One tendon, ligament, or rotator cuff More than one tendon, ligament, or rotator cuff $500 $750 $500 $750 $500 $750 FAMILY SUPPORT Transportation Up to 3 round trips per Covered Person per Covered Accident $300 $300 $300 Family Member Lodging and Meals Per day per accident; Up to 30 days per Covered Accident $100 $100 $100 ALL COVERAGE LEVELS MONTHLY PREMIUMS LEVEL 1 LEVEL 2 LEVEL 3 Individual $19.90 $26.10 $33.40 Individual & Spouse $28.30 $34.90 $41.90 Individual & Child(ren) $31.50 $41.00 $51.30 Family $39.90 $49.80 $59.90 BENEFITS LEVEL 1 LEVEL 2 LEVEL 3 INJURY TREATMENTS Fractures Depending on open or closed reduction and bone involved Chip fracture - 25% of closed reduction amount $150 to $4,000 $225 to $6,000 $300 to $8,000 Dislocations Depending on open or closed reduction and joint involved With local or no anesthesia - 25% of closed reduction amount $150 to $4,000 $225 to $6,000 $300 to $8,000 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 $25 $100 $200 $400 $50 $150 $250 $500 $75 $200 $300 $600 2nd & 3rd Degree Burns Skin grafts are 50% of benefit $150 to $15,000 $150 to $15,000 $150 to $15,000 Appliances Crutches, leg braces, etc. $100 $150 $200 Blood, Plasma, and Platelet $250 $300 $350 Concussion $200 $250 $300 Coma $5,000 $10,000 $15,000 Emergency Dental Work Broken teeth repaired with crown or extraction of a broken natural tooth $150 $200 $250 Epidural Pain Management $100 $150 $200 Eye Injury Injury with surgical repair or removal of foreign body by physician, for one or both eyes $200 $250 $300 Gunshot Wound $500 $1,000 $1,500 Paralysis Paraplegia/Uniplegia Quadriplegia $10,000 $20,000 $15,000 $30,000 $20,000 $40,000 Physical, Occupational, or Speech Therapy Per day of treatment up to eight days combined $25 $25 $25 Prosthesis Up to two devices $500 $500 $500 Traumatic Brain Injury $1,000 $1,500 $2,000