What Are My Benefits? Property of Bind Benefits, Inc., d/b/a Surest. All rights reserved © 2026. 19 • Orthognathic surgery and select services for TMJ Disorder may require Prior Authorization and Medical Necessity review. Dialysis Services In-Network Out-of-Network Dialysis $30 to $180 copayment / visit $540 copayment / visit Home Dialysis $40 copayment / visit $120 copayment / visit Notes: • Refer to the Surest mobile app for additional coverage information. • Copayments for office visits may vary based on Provider and location. • The Surest Plan provides Benefits for therapeutic treatments received in an office, home, outpatient hospital, or alternate facility. • Benefit includes services and supplies for renal dialysis, including both hemodialysis and peritoneal dialysis. • Benefit also includes training of the patient. • Dialysis Services may require Prior Authorization and Medical Necessity review. Durable Medical Equipment (DME) and Supplies In-Network Out-of-Network Purchase: Tier 1 to Tier 12 $0 to $500 copayment $20 to $1,000 copayment Rental: Tier 1 to Tier 12 $0 to $50 copayment / month $2 to $100 copayment / month Notes: • Durable Medical Equipment (DME) and supplies are tiered based on average cost and allowed amount. Supplies such as tubing, syringes, and catheters are assigned to a lower tier and will result in a lower copayment. Equipment such as glucose monitors, pumps, and wheelchairs are assigned to a higher tier and will result in a higher copayment. • Each piece of durable medical equipment and supplies are assigned to a tier, which corresponds to a copayment. A breakdown of the tiers and corresponding copayments can be found on Surest mobile app or Benefits.Surest.com website. • Returning home from an appointment with a health care Provider or from the hospital with durable medical equipment, such as crutches, may result in an additional copayment. Copayments will be dependent on the tier the item falls into. • For Enteral Nutrition administered at home, multiple copayments will apply (such as for formula, nursing visit and administration). The Surest Plan provides the following Benefits for durable medical equipment, prosthetics, orthotics, and supplies (subject to any limitations noted below): • Refer to the Surest mobile app for additional coverage and copayment information. • This durable medical equipment and supplies list is subject to periodic review and modification (generally quarterly, but no more than six times per Plan Year). • You may also view which tier a particular DME item has been assigned to by using the Surest mobile app or Benefits.Surest.com website or calling Surest Member Services for assistance. • Coverage includes rental or purchase of DME if Medically Necessary, ordered or provided by a Physician for outpatient use primarily in a home setting, serves a medical purpose for the treatment of an illness or injury, and is not of use to a Participant in the absence of a disease or disability. If you need certain durable medical equipment for an extended period of time, there may be an option to rent. Length of rental may vary by DME item. The purchase copayment based on tier may be split over a period of time, at which point the DME may be considered “purchased” or coverage may end. Note that some equipment such as oxygen equipment, will be set to rental for the duration of time the equipment is needed. Surest generally follows Centers for Medicare and Medicaid Services (CMS) guidelines on rental vs purchase. Refer to Surest mobile app or Benefits.Surest.com website for additional information. • Oxygen and the rental of equipment to administer oxygen (including tubing, connectors, and masks). • Cranial orthoses such as head shaping helmets and head reconstruction are a set of orthotic devices and services to reshape the head. They may be medically indicated for plagiocephaly (head asymmetry) and craniosynostosis (abnormal head shape).