What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 16 − “Short-term acute care facility” means a facility or Hospital that provides care to people with medical needs requiring short-term hospital stay in an acute or critical setting such as for recovery following a surgery, care following sudden sickness, injury, or flare-up of a chronic sickness. − “Sub-acute facility” means a facility that provides intermediate care on short-term or long-term basis. • Non-Emergency air ambulance services require Prior Authorization and Medical Necessity review. Behavioral Health: Mental Health and Substance Use Disorder Services In-Network Out-of-Network Mental Health Office Visit (including Telehealth Visit) $10 copayment / visit $100 copayment / visit Applied Behavioral Analysis (ABA) Therapy $10 copayment / visit $100 copayment / visit Mental Health Habilitative, Cognitive, Occupational Therapy $10 copayment / visit $30 copayment / visit Mental Health Physical Therapy $5 copayment / visit $15 copayment / visit Mental Health Speech Therapy $10 copayment / visit $30 copayment / visit Electroconvulsive Therapy (ECT) $75 copayment / visit $225 copayment / visit Intensive Outpatient Treatment Program (IOP) $40 copayment / visit $120 copayment / visit Outpatient Alcohol and Drug Treatment Program $45 copayment / visit $135 copayment / visit Partial Hospitalization (PHP)/Day Treatment $75 copayment / day $225 copayment / day Substance Use Disorder Medication Therapy $30 copayment / visit $90 copayment / visit Transcranial Magnetic Stimulation (TMS) Therapy $75 copayment / visit $225 copayment / visit Residential Treatment Facility Care $1,200 copayment / stay $3,600 copayment / stay Outpatient Mental Health $75 copayment / visit $225 copayment / visit Inpatient Hospital $1,200 copayment / stay $3,600 copayment / stay Virtual Care See Virtual Care section for details Not Applicable Notes: • Refer to the Surest mobile app for additional coverage information. • Benefits include: − Diagnostic evaluations, assessment, and treatment planning. − Other treatments and/or procedures. − Medication management and other associated treatments. − Methadone Maintenance. − Individual, family, and group therapy. − Provider-based case management services. − Crisis intervention. − Intensive Outpatient Treatment program (IOP) (a structured outpatient mental health or substance use treatment program at a freestanding or hospital-based facility and provides services for at least three hours per day, two or more days per week). − Residential treatment. − Partial hospitalization (PHP)/Day treatment (a structured ambulatory program that may be freestanding or hospital-based and provides services for at least 20 hours per week). − Other Outpatient treatment. • Returning home from a visit with durable medical equipment, such as a walker, may result in an additional copayment. • Mental Health Office Visit refers to a face-to-face visit with your Provider. • Mental Health Telehealth Visit refers to a non-face-to-face visit with your Provider. • Nutritional counseling for mental health or substance use disorder does not have visit limits. • All inpatient services require Pre-Admission Notification if planned, and notification within 24 hours of admission if emergent. • Inpatient residential and partial hospitalization services may require Prior Authorization and Medical Necessity review. • Refer to the Gender Dysphoria Services section for additional coverage information.