What Are My Benefits? © 2026 Surest. All Rights Reserved . 12 • As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS). • As indicated in the most recent editions of the Healthcare Common Procedure Coding System (HCPCS), or Diagnosis-Related Group (DRG) Codes. • As reported by generally recognized professionals or publications. • As used for Medicare. • As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the Claims Administrator accepts. In-network Providers are reimbursed based on contracted rates. Out-of-network Providers are reimbursed at a percentage of the published rates allowed by CMS for Medicare for the same or similar service within the geographic market. When Covered Health Services are received from an out-of-network Provider as described below, Eligible Expenses are determined, as follows : • For non-Emergency Covered Health Services received at certain in-network facilities from out-of-network Providers when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act with respect to a visit as defined by the Secretary, the Eligible Expense is based on either:  The reimbursement rate as determined by applicable federal or state law or by an applicable state All Payer Model Agreement.  The reimbursement rate as determined by state law.  The initial payment made by the Claims Administrator or the amount subsequently agreed to by the out-of-network Provider and the Claims Administrator.  The amount determined by Independent Dispute Resolution (IDR). For the purpose of this provision, "certain network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act ), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act ), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act , and any other facility specified by the Secretary . IMPORTANT NOTICE : For Ancillary Services, and for non-Ancillary Services provided without notice and consent, you are not responsible, and an out-of-network Provider may not bill you, for amounts in excess of your applicable copayment which is based on the Recognized Amount as defined in Section 12 (Glossary). • For Emergency health care services provided by an out-of-network Provider , the Eligible Expense is based on either:  The reimbursement rate as determined by applicable federal or state law or by an applicable state All Payer Model Agreement.  The reimbursement rate as determined by state law.  The initial payment made by us or the amount subsequently agreed to by the out- of-network Provider and us.