AFLAC GROUP HOSPITAL INDEMNITY INSURANCE G Policy Series C80000 HI BENEFIT TREATMENT BENEFITS AMOUNT OUTPATIENT DOCTOR’S OFFICE VISIT (maximum of 6 visits per calendar year for each insured) We will pay the amount shown for each day that an insured visits a doctor’s of昀椀ce. This bene昀椀t is not payable for visits to $50 a chiropractor’s of昀椀ce. TELEMEDICINE SERVICES (maximum of 6 per calendar year for each insured) We will pay the bene昀椀t amount shown for each day that, because of a covered accidental injury or covered sickness, an $20 insured seeks medical advice from a doctor via telemedicine services. The telemedicine services must be provided in lieu of an outpatient doctor’s of昀椀ce visit. CHIROPRACTOR VISIT (maximum of 4 visits per calendar year for each insured) We will pay the amount shown for each day that an insured receives services from a chiropractor for treatment of a $30 covered accidental injury or because of a covered sickness. Visits to a chiropractor’s of昀椀ce are not payable under the outpatient doctor’s of昀椀ce visit bene昀椀t. MAJOR DIAGNOSTIC EXAMS (once per covered sickness or accident per calendar year) We will pay the amount shown for each day that, due to a covered accidental injury or covered sickness, an insured requires one of the following exams: · Computerized Tomography (CT/CAT scan) $200 · Magnetic Resonance Imaging (MRI) · Electroencephalography (EEG) OUT OF HOSPITAL PRESCRIPTION DRUG (maximum of $100 per calendar year for each insured) We will pay the amount shown for each day an insured has a prescription 昀椀lled. Prescription drugs must meet three criteria: (1) be ordered by a doctor; (2) be dispensed by a licensed pharmacist; and (3) be medically necessary for the care and treatment of the insured. $20 This bene昀椀t does not include bene昀椀ts for: (a) therapeutic devices or appliances; (b) experimental drugs; (c) drugs, medicines or insulin used by or administered to a person while he is con昀椀ned to a hospital, rest home, extended-care facility, convalescent home, nursing home or similar institution; (d) immunization agents, biological sera, blood or blood plasma; or (e) contraceptive materials, devices or medications or infertility medication, except where required by law. HOSPITAL EMERGENCY ROOM VISIT (maximum of 5 visits per calendar year for each insured) We will pay the amount shown for each day that an insured visits a hospital emergency room due to a covered accidental $125 injury or for treatment due to a covered sickness. EMERGENCY ROOM OBSERVATION (1 visit for each covered sickness or accident per calendar year, maximum of 5 total visits per calendar year $150 for each insured) Each 24 hour We will pay the amount shown for each period of observation that, because of a covered accidental injury or covered period sickness, an insured: $75 · Receives treatment in a hospital emergency room, and Less than 24 · Is held in a hospital for observation without being admitted as an inpatient. hours, but at least 4 hours REHABILITATION FACILITY per day (maximum of 15 days per con昀椀nement, no more than 30 days total per calendar year for each insured) We will pay the amount shown for each day that, due to a covered accidental injury or a covered sickness, an insured receives treatment as an inpatient at a rehabilitation facility. For this bene昀椀t to be payable, the insured must be transferred $100 to the rehabilitation facility for treatment following an inpatient hospital con昀椀nement. We will not pay the rehabilitation facility bene昀椀t for the same days that the hospital con昀椀nement bene昀椀t is paid. AG80075TH R2 IV (1/19)