What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 18 Dental and Oral Services In-Network Out-of-Network • Orthognathic (Jaw) Surgery $2,200 copayment / visit $6,600 copayment / visit • Temporomandibular Joint (TMJ) Dysfunction Surgery $450 copayment / visit $1,350 copayment / visit Accidental and Medical Dental: • Oral Surgery (removal of impacted teeth) $350 copayment / visit $1,050 copayment / visit Accidental and Medical Dental - All Other Services: • Office Visit $10 to $65 copayment / visit $195 copayment / visit • Outpatient Hospital Visit $75 to $525 copayment / visit $1,575 copayment / visit • Inpatient Hospital $1,600 copayment / stay $4,800 copayment / stay Notes: • Refer to the Surest mobile app for additional coverage information. • Copayments for office visits may vary based on Provider and location. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Dental 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. • Returning home from a visit with durable medical equipment, such as an oral appliance, may result in an additional copayment. • The Surest Plan provides Benefits for dental services to treat and restore damage done to a sound, natural tooth as a result of an accidental injury. Coverage is for external trauma to the face and mouth only. A sound, natural tooth is a tooth, including supporting structures, that is healthy and would be able to continue functioning for at least one year. Primary (baby) teeth must have a life expectancy of one year before loss. Treatment and repair for services required due to an accidental injury must be started within six months and completed within twelve months of the date of the injury. • Benefits are provided for the following limited oral surgical procedures determined to be Medically Necessary and appropriate: − Oral surgery and anesthesia for removal of impacted teeth, removal of a tooth root without removal of the whole tooth, and root canal therapy. − Mandibular staple implant provided the procedure is not done to prepare the mouth for dentures. − Facility Provider and anesthesia services rendered in a Provider facility setting in conjunction with non- covered dental procedures when determined by the Claims Administrator to be Medically Necessary and appropriate due to your age and/or medical condition. − The correction of a non-dental physiological condition which has resulted in a severe functional impairment. • Treatment for tumors and cysts requiring pathological examination of the jaw, cheeks, lips, tongue, roof, and floor of the mouth. • The Surest Plan also covers dental services, limited to dental services required for treatment of an underlying medical condition such as a cleft palate or other congenital defect, oral reconstruction after invasive oral tumor removal, preparation for or as a result of radiation therapy for oral or facial cancer. • Eligible Expenses for hospitalizations are those incurred by a Participant who: (1) is a child under age five; (2) is severely disabled; or (3) has a medical condition, unrelated to the dental procedure that requires hospitalization or anesthesia for dental treatment. Coverage is limited to facility and anesthesia charges. Oral surgeon/dentist or dental Specialist professional fees are not covered for dental services provided. The following are examples, though not all-inclusive, of medical conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction, or hemophilia. Care must be directed by a Physician, dentist, or dental Specialist. • Accidental Dental Services may require Prior Authorization and Medical Necessity review. The Surest Plan provides Benefits for services for orthognathic surgery and the evaluation and treatment of TMJ and associated muscles. • Includes orthodontic services and supplies, and surgical and non-surgical options for the treatment of TMJ. Benefits for surgical services also include FDA-approved TMJ prosthetic replacements when all other treatments have failed. • Returning home from a visit with durable medical equipment, such an oral appliance, may result in an additional copayment.