Page 14 Benefit plan and Features - High Plan Medical services Employee Spouse Child Physician’s follow-up treatment office visit (per visit, up to 10 times per covered accident) $75 $75 $75 Physical and occupational therapy (per visit, up to 10 times per covered accident) $100 $100 $100 Medical devices $500 $500 $500 Epidural pain management (up to 2 times per covered accident) $100 $100 $100 Prescription drug $50 $50 $50 Prosthesis (one) $1,500 $1,500 $1,500 Prosthesis (two) $3,000 $3,000 $3,000 Anesthesia $100 $100 $100 Blood, plasma or platelet transfusion $500 $500 $500 Hospital Employee Spouse Child Hospital admission (once per benefit year) $1,500 $1,500 $1,500 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) $3,000 $3,000 $3,000 Intensive care unit confinement (per day up to 15 days; payable in addition to any hospital confinement benefit) $400 $400 $400 Ambulance (Ground) $250 $250 $250 Ambulance (Air) $1,300 $1,300 $1,300 ER admission or urgent care facility $200 $200 $200 Family Lodging Maximum Lodging night stays: one benefit per day, 30 days per benefit year $300 $300 $300 Transportation (100 or more miles up to three times per covered accident) $1,000 $1,000 $1,000 Rehabilitation unit (per day, up to 30 days per covered accident) $100 $100 $100 Emergency dental Employee Spouse Child Emergency dental extraction $200 $200 $200 Emergency dental crown $400 $400 $400 Additional Benefits Employee Spouse Child Acupuncture (per visit, up to 10 times per Covered Accident) $100 $100 $100