What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 32 − Level 5 is a category of major surgeries and procedures that require intensive monitoring and typically performed in an inpatient hospital setting. Transplant services must be rendered at a location specified as a Designated Provider. • Copayments for office visits or outpatient hospital visits may vary based on Provider and location. Refer to the Surest mobile app or call Surest Member Services to determine the copayment assigned to your procedure/service. • 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. • Returning home from an outpatient visit or hospital with durable medical equipment, such as a walker, may result in an additional copayment. • All inpatient services require Pre-Admission Notification if planned, and notification within 24 hours of admission if emergent. • Select office-based and outpatient procedures may require Prior Authorization and Medical Necessity review. Urgent Care In-Network Out-of-Network Urgent Care Visit $35 copayment / visit $105 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Benefits include visits at a walk-in Urgent Care center that treats illnesses and injuries requiring immediate care, but not serious enough to require an Emergency department visit. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Urgent Care 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. • If the Urgent Care facility is unable to treat you, you may be referred to the Emergency Room or other Provider, you will be responsible for both the Urgent Care and Emergency Room Copayments. • Returning home from a visit with durable medical equipment, such as crutches, may result in an additional copayment. Virtual Care – Designated Provider In-Network Out-of-Network Virtual Primary and Urgent Care $0 copayment / visit Not Covered Virtual Mental Health and Substance Use Disorder Care $10 to $40 copayment / visit Not Covered Virtual Specialty Care $0 to $65 copayment / visit Not Covered Notes: • Refer to the Surest mobile app for additional coverage information. • Please see the Behavioral Health and Office Visit sections for additional information on Telehealth Visits with your Provider. • Virtual care is for Covered Health Services that include the diagnosis and treatment of medical and mental health conditions for Participants that can be appropriately managed virtually within the scope of practice of the virtual providers, through the use of interactive audio and video telecommunication and transmissions, and audio-visual communication technology, or through federally compliant secure messaging applications with, or supervised by, a licensed and qualified practitioner. Virtual care provides communication of medical information between the patient and a Provider, through use of interactive audio and video communications equipment or through federally compliant secure messaging applications outside of a medical facility (for example, from home or from work). • Copayments will vary based on Provider. If you choose a Provider that is not a Designated Virtual Network Provider, see the Office Visit section for additional Telehealth Visit copayment information. Benefits are available only when services are delivered through a Designated Virtual Network Provider that are specified by your Surest Plan.