What Are My Benefits? © 2026 Surest. All Rights Reserved. 17 The Surest Plan provides Benefits for behavioral services for Autism Spectrum Disorder, including Intensive Behavioral Therapies (IBT) such as Applied Behavior Analysis (ABA) that are the following: − Focused on the treatment of core deficits of Autism Spectrum Disorder. − Focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others, property, or impairment in daily functioning. − Provided by a Board-Certified Applied Behavior Analyst (BCBA) or other qualified Provider under the appropriate supervision. • Intensive Behavioral Therapy (IBT) is outpatient behavioral care services that aim to reinforce adaptive behaviors, reduce maladaptive behaviors, and improve the mastery of functional age-appropriate skills in Participants with Autism Spectrum Disorder. • These Benefits describe only the behavioral component of treatment for Autism Spectrum Disorder. Medical treatment of Autism Spectrum Disorder is a Covered Health Service for which Benefits are available under the applicable medical Covered Health Services categories as described in this section. • Visit limits do not apply to therapies provided for a mental health condition, such as autism disorders. • Applied Behavioral Analysis for Autism Spectrum Disorder services may require Prior Authorization and Medical Necessity review. Colonoscopy - Non-Screening In-Network Out-of-Network Colonoscopy – Non-Screening $0 to $800 copayment / visit $2,400 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Copayments may vary based on Provider and location. • Benefits include Physician services and facility charges. • Coverage is available for a non-screening colonoscopy received on an outpatient basis at a hospital, alternate facility, or in a Physician’s office. • A non-screening colonoscopy is a procedure performed to diagnose disease symptoms. • Services for preventive screenings are provided under the Preventive Care Services section. Complex Imaging In-Network Out-of-Network MRI (Magnetic Resonance Imaging) $75 to $525 copayment / visit $1,425 copayment / visit CT (Computed Tomography) $75 to $450 copayment / visit $1,350 copayment / visit Nuclear Imaging $75 to $725 copayment / visit $2,175 copayment / visit PET scan $75 to $950 copayment / visit $2,850 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Copayments may vary based on Provider and location. • Benefits include Physician services and facility charges. • If imaging occurs on multiple areas of the body, such as the lumbar spine and the cervical spine, on the same date of service, one copayment applies. • If imaging occurs using different types of imaging machines (e.g., MRI and a CT), on the same date of service, more than one copayment applies. • If your Physician suggests a low-dose CT Scan (LDCT) for lung cancer screening, refer to Preventive Care Services, in this section, for coverage notes.