What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 31 Treatment / Tests / Therapies – Go to Surest mobile app or Benefits.Surest.com website for additional information In-Network Out-of-Network • Level 1: Generally, minor procedures or treatments that are typically performed in an outpatient office setting (e.g., needle biopsy, pain management procedures, etc.) $15 to $2,300 copayment / visit $150 to $6,900 copayment / visit • Level 2: Generally, minor procedures, surgeries, or treatments that are typically performed in an outpatient hospital setting (e.g., bronchoscopy, etc.) $0 to $2,450 copayment / visit $480 to $7,000 copayment / visit • Level 3: Generally, major procedures, surgeries, or treatments that are typically performed in an outpatient hospital setting but may be performed in an inpatient hospital setting (e.g., thyroid surgery, prostate surgery, etc.) $50 to $2,500 copayment / visit / stay $900 to $7,000 copayment / visit / stay • Level 4: Generally, major procedures, surgeries, or treatments that are typically performed in an inpatient hospital but may be performed in an outpatient hospital setting (e.g., colon surgery, small bowel surgery, etc.) $200 to $2,500 copayment / visit / stay $4,350 to $7,000 copayment / visit / stay • Level 5: Generally, major procedures, surgeries, or treatments that require intensive monitoring and are performed in an inpatient hospital setting (e.g., bone marrow and solid organ transplant, brain tumor surgery, coronary artery bypass graft surgery, etc.) $800 to $2,500 copayment / visit / stay $5,100 to $7,000 copayment / visit / stay Other Treatments/Tests/Therapies: Refer to the Surest mobile app or Benefits.Surest.com website for coverage and copayment information or call Surest Member Services. Copayments may vary based on Provider, location and treatment, test, or therapy. • Office Visits $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 and for the copayment assigned to your procedure/service. • The copayments above apply unless a Benefit is specified in another section of this SPD, Surest mobile app or Benefits.Surest.com website. • Copayments for outpatient hospital visits may vary based on Provider and location. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Treatment / Tests / Therapies 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. • Treatment, tests, and therapies have been tiered based on type and level (minor vs. major) of care. Some minor treatments or procedures are either included in the office visit copayment or may have a specific copayment based on the Provider and location selected. Some surgical procedures also have specific copayments based on the Provider or location selected. • Multiple copayments may apply if more than one treatment or procedure is performed during a visit/stay. • Copayments for Procedures in Level 1 - Level 5 may vary based on Provider and location. Refer to the Surest mobile app or call Surest Member Services to determine the copayment assigned to your procedure/service. − Level 1 is a category of minor procedures typically performed in an outpatient office setting. − Level 2 is a category of minor surgeries and procedures or services typically performed in an outpatient hospital setting. − Level 3 is a category of major surgeries and procedures typically performed in an outpatient hospital setting. − Level 4 is a category of major surgeries and procedures typically performed in an inpatient hospital setting.