Page 4 Benefit plan and Features - Low Plan Lacerations Employee Spouse Child Laceration(s) with no sutures and treated by a physician $50 $50 $50 Single laceration under 5 cm with sutures $75 $75 $75 Lacerations 5–15 cm with sutures (total of all lacerations) $250 $250 $250 Lacerations greater than 15 cm with sutures (total of all lacerations) $500 $500 $500 Surgery Employee Spouse Child Miscellaneous surgery requiring general anesthesia not otherwise listed (once per 24- hour period, even though multiple surgical procedures may be performed) $500 $500 $500 Open surgery $1,500 $1,500 $1,500 Exploratory surgery or debridement $400 $400 $400 Laparoscopic surgery or hernia repair $500 $500 $500 Tendon/Ligament/Rotator cuff tear $750 $750 $750 Torn knee cartilage $750 $750 $750 Ruptured/herniated disc $750 $750 $750 Burns Employee Spouse Child 21–40 sq. cm second degree $200 $200 $200 21–40 sq. cm third degree $500 $500 $500 41–65 sq. cm second degree $400 $400 $400 41–65 sq. cm third degree $1,000 $1,000 $1,000 66–160 sq. cm second degree $600 $600 $600 66–160 sq. cm third degree $3,000 $3,000 $3,000 161–225 sq. cm second degree $800 $800 $800 161–225 sq. cm third degree $7,000 $7,000 $7,000 More than 225 sq. cm second degree $1,000 $1,000 $1,000 More than 225 sq. cm third degree $10,000 $10,000 $10,000 Skin graft 50% of the applicable burn benefit Medical services Employee Spouse Child Diagnostic exam (one-time per benefit year): Arteriogram, angiogram, CT, CAT, EKG, EEG or MRI $150 $150 $150 X-ray (twice per covered accident) $50 $50 $50 Accident emergency treatment (non-ER or non-urgent care facility) (one time per covered accident) $50 $50 $50