What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 24 Maternity Care and Delivery In-Network Out-of-Network Routine Prenatal and Postnatal Office Visits, including Labs and Tests $0 copayment / visit $100 copayment / visit Newborn Nursery Care $0 copayment / test $0 copayment / test Amniocentesis $300 copayment / test $900 copayment / test Chorionic Villus Sampling (CVS) $325 copayment / test $975 copayment / test Inpatient Delivery $625 to $1,600 copayment / stay $4,800 copayment / stay Home Birth/Delivery $625 copayment / visit $1,875 copayment / visit Elective Non-Surgical Abortion $60 copayment / visit $180 copayment / visit Elective Surgical Abortion $100 copayment / visit $300 copayment / visit Medically Necessary Non-Surgical Abortion $60 copayment / visit $180 copayment / visit Medically Necessary Surgical Abortion $100 copayment / visit $300 copayment / visit All Other Outpatient Services Based on place of services Based on place of services Notes: • Refer to the Surest mobile app for additional coverage information. • The copayments for inpatient delivery may vary based on Provider and location; this includes a birthing center. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Maternity Care and Delivery 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 fetal monitor, may result in an additional copayment. • Routine prenatal and postnatal maternity services include evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force and Health Resources and Services Administration. • Home visit limited to one visit immediately following discharge of mother and newborn. • Hospital visits or admissions that do not result in delivery including false labor and tests or services not considered “routine” will follow the inpatient or outpatient hospital services Benefit. • There will be one copayment for all Covered Health Services related to childbirth/delivery, including the newborn, unless discharged after the mother. If a newborn baby is discharged after the mother, another copayment will apply to the baby’s services. See Hospital Services section for Benefits. • Home Birth/Delivery copayment includes medical supplies used for a home delivery of an infant. Birthing tubs are not covered. • Inpatient deliveries do not require Prior Authorization or notification unless the mother is hospitalized more than 48-hours following a normal vaginal delivery and 96-hours following a normal cesarean section delivery. Stays beyond these time periods may require Prior Authorization and Medical Necessity review. Medical Infusions, Injectables, and Chemotherapy In-Network Out-of-Network Cancer Chemotherapy $10 to $550 copayment / visit $165 to $1,650 copayment / visit Provider Administered Drugs $20 to $2,000 copayment / visit $375 to $6,000 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information and for the copayment assigned to your procedure/service. • Copayments may vary based on Provider and location. • Benefits are available for certain medical infusions, and injectables, and cancer chemotherapy administered on an outpatient basis in a hospital facility, alternate facility, in a Physician’s office, or in the home. This includes intravenous chemotherapy or other intravenous infusion therapy. • Covered Health Services include medical education services that are provided in an office, outpatient hospital, or alternate facility by appropriately licensed or registered health care professionals. • The Medical Infusions and injectables require supervision and follow up with a medical professional. The Provider Administered Drugs will be dispensed and administered by a medical professional. Certain drugs are