What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 26 Palliative Care In-Network Out-of-Network Office Visit $10 to $65 copayment / visit $195 copayment / visit Home Health Care Visit $35 copayment / visit $105 copayment / visit Outpatient Hospital Visit $75 to $525 copayment / visit $1,575 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Copayments for office visits or outpatient hospital visits may vary based on Provider and location. • The Surest Plan provides Benefits for palliative care for Participants with a new or established diagnosis of progressive debilitating illness. • Includes services for pain management received as part of a palliative care treatment plan. • The services must be within the scope of the Provider’s license to be covered. • Select services performed in the office and outpatient hospital setting may require Prior Authorization and Medical Necessity Review. • Returning home from a visit with durable medical equipment, such as a walker, may result in an additional copayment. • See Home Health Services notes for services related to Home Health Care. • See Hospice Care notes for services related to Hospice. Preventive Care Services In-Network Out-of-Network Preventive Care Services $0 copayment / visit $100 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Routine diagnostic services, including diagnostic lab, x-ray, and ultrasound are included in the Preventive Care Services 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. • 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, Bright Futures, Health Resources and Services Administration, and Advisory Committee on Immunization Practices. • Examples include: − Pediatric preventive care services, developmental assessments, and laboratory services appropriate to the age of a child from birth to age six, and appropriate immunizations up to age 18. − Coverage includes at least five child health supervision visits from birth to 12 months, three child health supervision visits from 12 months to 24 months, and once-a-year visits from 24 months to age six. − Routine physical exams. − Routine screenings for certain cancers and other conditions. This includes mammography, breast ultrasounds and breast MRIs. − Routine screening colonoscopy is covered as preventive with a diagnosis of family history. − Routine immunizations. Age limits may apply. − Routine lab tests, pathology, and radiology. − Hearing and vision screening limited to one exam per Plan Year for children up to age of 21. − Routine pre-natal and post-natal services. − One routine postnatal care exam provided during the period immediately after childbirth that includes a health exam, assessment, education, and counseling. − Preventive contraceptive methods and counseling for women. ◦ Includes certain approved contraceptive methods for women with reproductive capacity, including contraceptive drugs, devices, and delivery methods. • For Prescription Drug Coverage see Section 13 (Outpatient Prescription Drugs). • Low-dose CT Scan (LDCT) for lung cancer screening may require Prior Authorization and Medical Necessity review. Radiation Therapy and Other High Intensity Therapy In-Network Out-of-Network $30 to $1,700 copayment / visit $120 to $5,100 copayment / visit Notes: • The Surest Plan provides Benefits for services received on an outpatient basis at a hospital, alternate facility, or in a Physician’s office.