What Are My Benefits? © 2026 Surest. All Rights Reserved . 20 • Eyeglasses or contacts after cataract surgery or for aphakia is limited to one frame and one pair of lenses and one pair of contact lenses or a one-year supply of disposable contact lenses. • Hearing aids are limited to $2,500 per hearing impaired ear per Plan Year for in-network and out-of-network Providers combined. • Communication aids or devices; equipment to create, replace, or augment communication abilities, including but not limited to communication board or computer or electronic-assisted communication, speech processors, and receivers. Speech generating device, digitized speech, and using pre-recorded messages are eligible. • Purchase of one standard breast pump, either manual or electric, per pregnancy. Participant may have to pay a surcharge to the Provider if they purchase enhanced models. • Enteral Nutrition and low protein modified food products administered either orally or by tube feeding as the primary source of nutrition, for certain conditions which require specialized nutrients or formulas. The formula or product must be administered under the direction of a Physician or registered dietitian. (Example conditions include, but are not limited to, metabolic disease such as phenylketonuria (PKU) and maple syrup urine disease severe food allergies, and impaired absorption of nutrients caused by disorders affecting the gastrointestinal tract.) • Shoes as prescribed by a Provider for a Participant. Limited to one pair per Plan Year. • Coverage is provided for eligible durable medical equipment that meets the minimum medically appropriate equipment standards needed for the patient’s medical condition. • Select Durable Medical Equipment (DME) may require Prior Authorization and Medical Necessity review. Emergency Room Services In - Network Out - of - Network Emergency Room Visit $450 copayment / visit $450 copayment / visit Observation Stay $450 copayment / stay $450 copayment / stay Notes: • Refer to the Surest mobile app for additional coverage information. • Out-of-network Emergency Room Visit copayment applies to the in-network out-of-pocket maximum. • Out-of-network Observation Stay copayment applies to the in-network out-of-pocket maximum. • Copayment applies to Emergency room facility, professional expenses, and includes related expenses. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Emergency Room visit copayment. When the routine diagnostic service is prescribed by a doctor and received on a different date of service and location, the service is $0 copayment. • Returning home from an Emergency Room visit or hospital with durable medical equipment, such as crutches, may result in an additional copayment. • If the Emergency Room facility is unable to treat you, you may be referred to another Emergency Room facility or other Provider, you will be responsible for both Emergency Room copayments. • If you are admitted as an inpatient directly from the second Emergency Room facility or admitted for observation, then the second Emergency room visit copay is waived and you will be responsible for either the Inpatient Hospital or Observation Stay copayment. • If the Emergency Room facility is unable to treat you, you may be referred to another Emergency Room facility or other Provider, you will be responsible for both Emergency Room copayments. If you are admitted as an inpatient directly from the second Emergency Room facility or admitted for observation, then the second Emergency room visit copay is waived and you will be responsible for either the Inpatient Hospital or Observation Stay copayment. • Refer to Hospital Services section for additional coverage notes. Gender D ysphoria Services In - Network Out - of - Network Mental Health Office Visit $10 copayment / visit $100 copayment / visit Gender Dysphoria Surg ery $75 to $1,200 copayment / visit $225 to $3,600 copayment / visit Gender Dysphoria Reconstructive Services $75 copayment / visit $225 copayment / visit Gender Dysphoria Voice Therapy $10 copayment / visit $30 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • The following are covered for Gender Dysphoria services: − Psychotherapy for Gender Dysphoria and associated co - morbid psychiatric diagnoses.