What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 27 • Refer to the Surest mobile app for additional coverage information and the copayment assigned to your procedure/service. • Copayments for Radiation Therapy and Other High Intensity Therapy may vary based on Provider and location. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Radiation Therapy 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. • Benefits include Physician services and facility charges, and services such as, but not limited to: − Actinotherapy. − Apheresis. − Blood Transfusion. − Brachytherapy. − Conventional External Beam Radiation Therapy (EBRT). − Hyperbaric Oxygen Therapy (HBOT). − Non-Oral Radiopharmaceutical Therapy. − Oral Radiopharmaceutical Therapy. − Proton Therapy. − Radiation Therapy Simulation and Planning. − Radiopharmaceutical Therapy. − Stereotactic Radiation Therapy. • Select Radiation Therapies may require Prior Authorization and Medical Necessity Review. • See notes under Hospital Services – Other for services related to Radiation Device Placement. • See Dialysis Services for services for dialysis and home. Reconstructive Surgery In-Network Out-of-Network Office Visit $10 to $65 copayment / visit $195 copayment / visit Outpatient Hospital $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 or outpatient hospital visits may vary based on Provider and location. • 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 Reconstructive Surgery 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 outpatient visit or hospital with durable medical equipment, such as a walker, may result in an additional copayment. • Reconstructive procedures are services performed when the primary purpose of the procedure is either to treat a medical condition or to improve or restore physiologic function for an organ or body part. Reconstructive procedures include surgery or other procedures which are associated with an illness, injury, or congenital anomaly. The primary result of the procedure is not a changed or improved physical appearance. • Improving or restoring physiologic function means that the organ or body part is made to work better. An example of a Reconstructive procedure is surgery on the inside of the nose so that a person’s breathing can be improved or restored. • Benefits for Reconstructive procedures include breast reconstruction following a mastectomy and Reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the Surest Plan if the initial breast implant followed a mastectomy. Other services required by the Women’s Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any other Covered Health Services. You can contact Surest Member Services at the number on your member ID card for more information about Benefits for mastectomy-related services. • There may be times when the primary purpose of a procedure is to make a body part work better. However, in other situations, the purpose of the same procedure is to improve the appearance of a body part. Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered Cosmetic procedures. An example is upper eyelid surgery. At times, this procedure will be done to improve vision, which is considered a Reconstructive procedure. In other cases, if improvement in appearance