BENEFITS BASIC ENHANCED ENHANCED PLUS HOSPITAL Hospital Admission 1 day/Covered Person $500 $1,000 $1,500 Hospital Confinement Pays up to 30 days/Covered Person $100 $150 $200 ICU 10 days/Covered Person $200 $300 $400 Rehab 10 days/ Covered Person $50 $75 $100 ACCIDENT Accident Treatment - ER 3 days/Covered Person $200 $300 $400 Accident Treatment - Physician’s Office or Urgent Care 6 days/Covered Person $50 $75 $100 Accident Surgery - Hospital or Ambulatory Surgical Center 3 days/Covered Person $1,000 $1,500 $2,000 Accident Surgery - Physician’s Office or Urgent Care 6 days/Covered Person $125 $125 $250 Hospital Benefits If hospitalized, you can get paid directly for the costs. Basic Enhanced Enhanced Plus Accident Benefits Weekend warrior? Active family? Or a long daily commute? No matter your situation, accidents happen. Basic Enhanced Enhanced Plus Benefits Hypothetical Example with Enhanced Plan You are traveling in your car and are hit by a driver running a red light. Your arm is broken and requires an ER visit, surgery, admission to the hospital, and two nights’ stay. The deductible in this example is based on a 2020 IRS minimum family medical HSA High Deductible Health Plan (HDHP). Cost of Care Your Deductible $2,800 Payable Plan Benefits ER Visit5 $827 Surgery6 $16,000 ER Visit $300 Surgery $1,500 Hospital Admission $1,000 Hospital Confinement $300 Total out-of- pocket cost7 $5,605 Total Cost of Care $16,827 Total benefit payment to you $3,100 Hypothetical Example with Enhanced Plan You have a car accident and are rushed to the ER. You’re admitted and stay 3 days for a back injury. Then, you complete 10 days of rehabilitation. The deductible in this example is based on Preferred Provider Organization (PPO) plan option Cost of Care Your Deductible $500 Payable Plan Benefits Confinement3 $11,728 Rehab4 $1,620 Admission $1,000 Confinement $450 Rehab $750 Total $13,348 Total out of pocket cost7 $3,069 Total benefit payment to you $2,200 Refer to the Plan Benefit Highlights section for additional information. Benefits are paid on a calendar year basis.