Benefit Gold Plan Silver Plan Bronze Plan Accidental Death Primary: $75,000 Spouse: $15,000 Child(ren): $3,000 Primary: $50,000 Spouse: $10,000 Child(ren): $2,000 Primary: $25,000 Spouse: $5,000 Child(ren): $1,000 Dismemberment Primary: up to $45,000 Spouse: up to $22,500 Child(ren): up to $7,500 Primary: up to $30,000 Spouse: up to $15,000 Child(ren): up to $5,000 Primary: up to $15,000 Spouse: up to $7,500 Child(ren): up to $2,500 Emergency Treatment $150 $100 $50 Accident Follow-Up $45 per treatment 3 per accident $30 per treatment 3 per accident $15 per treatment 3 per accident Ambulance Ground: $225; Air: $1,500 Ground: $150; Air: $1,000 Ground: $75; Air: $500 Burns (30% or more of the body) Up to $7,500 Up to $5,000 Up to $2,500 Dislocation Open Reduction: Closed Reduction:   Up to $5,100 Up to $1,350   Up to $3,400 Up to $900   Up to $1,700 Up to $450 Family Lodging $150 per day (30 days max) $100 per day (30 days max) $50 per day (30 days max) Fracture Open/Compound: Closed:   Up to $6,000 Up to $3,000   Up to $4,000 Up to $2,000   Up to $2,000 Up to $1,000 Lacerations $150 $100 $50 Diagnostic Exams $225 $150 $75 Paralysis Quadriplegia: $7,500 Hemiplegia: $4,500 Paraplegia: $3,000   Quadriplegia: $5,000 Hemiplegia: $3,000 Paraplegia: $2,000 Quadriplegia: $2,500 Hemiplegia: $1,500 Paraplegia: $1,000 Physical Therapy $30 per treatment (10 max) $20 per treatment (10 max) $10 per treatment (10 max) Prosthesis $750 $500 $250 Surgery Up to $1,200 Up to $800 Up to $400 Transportation $450 round trip $300 round trip $150 round trip Hospital Cash Benefit Hospital Admission $1,750 per admission Hospital Confinement $375 per day 30 days per confinement, 365 days lifetime limit Intensive Care Unit $375 per day 15 days per injury Rehabilitation Unit $100 per day 30 days per injury, up to 60 days per year

2280 E. Bidwell Street, Suite 200 Folsom, CA 95630