Page 5 Benefit plan and Features - Low Plan Medical services Employee Spouse Child Physician’s follow-up treatment office visit (per visit, up to 10 times per covered accident) $50 $50 $50 Physical and occupational therapy (per visit, up to 10 times per covered accident) $50 $50 $50 Medical devices $250 $250 $250 Epidural pain management (up to 2 times per covered accident) $50 $50 $50 Prescription drug $25 $25 $25 Prosthesis (one) $750 $750 $750 Prosthesis (two) $1,500 $1,500 $1,500 Anesthesia $50 $50 $50 Blood, plasma or platelet transfusion $250 $250 $250 Hospital Employee Spouse Child Hospital admission (once per benefit year) $500 $500 $500 Hospital confinement (per day up to 365 days per covered accident) $200 $200 $200 Intensive care unit admission (once per benefit year; payable instead of hospital admission benefit if confined immediately to ICU) $1,000 $1,000 $1,000 Intensive care unit confinement (per day up to 15 days; payable in addition to any hospital confinement benefit) $400 $400 $400 Ambulance (Ground) $400 $400 $400 Ambulance (Air) $2,000 $2,000 $2,000 ER admission or urgent care facility $100 $100 $100 Family Lodging Maximum Lodging night stays: one benefit per day, 30 days per benefit year $150 $150 $150 Transportation (100 or more miles up to three times per covered accident) $500 $500 $500 Rehabilitation unit (per day, up to 30 days per covered accident) $50 $50 $50 Emergency dental Employee Spouse Child Emergency dental extraction $100 $100 $100 Emergency dental crown $200 $200 $200 Wellness benefit Employee Spouse Child Wellness screening benefit (once per benefit year) $50 $50 $50