What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 25 dispensed by a medical professional and may require special handling and storage. Certain drugs may require special handling and storage and are generally considered Specialty Drugs administered by a medical professional. • Supportive drugs that are often unplanned for your diagnosis and treatment, such as IV fluids or antibiotic injections, have a $0 copayment. • Provider Administered Drugs and Cancer Chemotherapy that are typically for planned administration have their own copayments when given in a non-emergent outpatient setting. If a mixture of drugs is needed for a chemotherapy visit, the copayment of the highest cost drug will apply to that visit. • The copayments apply to specific drugs that must be administered in a medical setting or under medical supervision. Call Surest Member Services to learn which medical drug (e.g., infusions and injections) are subject to these copayments. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Medical Drug 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. • Select injectable drugs that can be safely self-administered may not be covered under the medical Benefit. These drugs or equivalent drugs are covered under the pharmacy Benefits (see Section 13 [Outpatient Prescription Drugs]). • Select Medical Infusions, Injectables and Chemotherapy may require Prior Authorization and Medical Necessity review. Office Visit and Diagnostic Visit In-Network Out-of-Network Office Visit (including Telehealth Visit) $10 to $65 copayment / visit $195 copayment / visit Mental Health Office Visit (including Telehealth Visit) $10 copayment / visit $100 copayment / visit Allergy Injection Visit $0 copayment / visit $100 copayment / visit Allergy Testing and Treatment $70 copayment / visit $210 copayment / visit Convenience Care / Retail Visit $15 copayment / visit Not Covered E-Visit and Telephone Consult with Your Physician $10 copayment / visit $195 copayment / visit Outpatient Anticoagulant Management $10 copayment / visit $30 copayment / visit Virtual Care See Virtual Care section for virtual visit details Not Applicable Notes: The Surest Plan provides Benefits for services provided in an office for the diagnosis and treatment of an illness or injury. • Refer to the Surest mobile app for additional coverage information. • Copayments for office visits may vary based on Provider and location. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Office Visit 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. • Office Visit refers to face-to-face visit or Telehealth Visit with your Provider. • Multiple copayments may apply if a treatment or procedure is also performed during a visit. • Hearing Services – Assessments with your Provider. • 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 does not have visit limits. • Virtual Care refers to a visit with a Designated Virtual Network Provider such as Doctor on Demand. See Virtual Care Section for details. • Convenience Care/Retail Clinics are walk-in clinics in retail stores, supermarkets, and pharmacies that treat uncomplicated minor illnesses and injuries, and provide preventive care services. • If your Provider refers you for a test or service within a hospital or other facility, the Outpatient Hospital copayment may apply. • Returning home from a visit with durable medical equipment, such as crutches, may result in an additional copayment.