BENEFIT AMOUNTS: Eligible for Plan B PLAN B Type of Benefit Benefit Amount Ambulance Air Ambulance Transportation $1,000 Ground Ambulance Transportation $200 Blood, Plasma and $300 Platelets Burns 2nd Degree Burns Covering less than 10% of the body $200 Covering 10% but less than 25% of the body $400 Covering 25% but less than 35% of the body $800 Covering 35% or greater of the body $1,600 3rd Degree Burns Covering less than 10% of the body $1,600 Covering 10% but less than 25% of the body $3,200 Covering 25% but less than 35% of the body $6,400 Covering 35% or greater of the body $12,800 Skin Grafts due to Burns 50% of the benefit payable for Burns Chiropractic Services $50 per visit Coma $7,500 Concussion $200 Dental Injury Extraction $100 Crown $300 Diagnostic Examination $200 LRS-9548-0318-IN Page 1.1