What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 22 • Occupational therapy, physical therapy, and/or speech therapy visits performed in the home, not administered by a Home Health Agency will apply to the Rehabilitative/Habilitative Services visit limits. • Select Home Health Services may require Prior Authorization and Medical Necessity review. Hospice Care In-Network Out-of-Network Home Hospice Visit $35 copayment / visit $105 copayment / visit Inpatient Hospice Care $1,600 copayment / stay $4,800 copayment / stay Notes: • Refer to the Surest mobile app for additional coverage information. • Hospice care is an integrated program recommended by a Physician which provides comfort and support services for the terminally ill. • Hospice care can be provided in the home or an inpatient setting and includes physical, psychological, social, spiritual, and respite care for the terminally ill person, and short-term grief counseling for immediate family members while the Participant (terminally ill person) is receiving hospice care. • Benefits are available only when hospice care is received from a licensed hospice agency, which can include a hospital. • Inpatient Hospice Care may require Prior Authorization and Medical Necessity review. Hospital Services - Other In-Network Out-of-Network Outpatient Hospital Visit $75 to $525 copayment / visit $1,575 copayment / visit Inpatient Hospital $1,600 copayment / stay $4,800 copayment / stay Notes: • Other Hospital Services: The above copayments apply for Covered Health Services not specifically listed in this SPD, Surest mobile app or Benefits.Surest.com website. Copayments may vary based in Provider and location. • Refer to the Surest mobile app for additional coverage information. • Multiple copayments may apply if more than one treatment or procedure is performed during a visit/stay. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Hospital Services 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. • Inpatient hospitalization/stay Benefits include: − Physician and non-Physician services, supplies, and medications received during an inpatient stay. − Facility charges, including room and board in a semi-private room (a room with two or more beds). − Physician services for lab tests, anesthesiologists, pathologists, radiologists, and Emergency room Physicians. − The Surest Plan will allow the difference in cost between a semi-private room and a private room only if a private room is necessary according to generally accepted medical practice. • If you are admitted to inpatient from the Emergency department or from observation, the Emergency room copayment or Observation Stay copayment will be waived, and you will be responsible for the Inpatient Hospital Services copayment. • Outpatient hospital care includes services such as radiation device placement, outpatient pulmonary function testing, esophageal dilation, and hip dysplasia treatment. • Returning home from an outpatient visit or hospital with durable medical equipment, such as crutches, may result in an additional copayment. • All inpatient services require Pre-Admission Notification if planned, and notification within 24 hours of admission if emergent. Laboratory Services, X-Rays, and Diagnostic Tests - Outpatient In-Network Out-of-Network Non-Routine Tests $10 to $775 copayment / visit $90 to $2,325 copayment / visit Routine Diagnostic Laboratory Services / X-Rays / Ultrasounds $0 copayment / visit $0 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information and the copayment that has been assigned to your procedure/service. • Copayments for Non-Routine Tests may vary based on Provider, location, and procedure.