Surest Plan CY2026 Summary
| Category | Plan Design Element | In-Network | Out-of-Network |
|---|---|---|---|
| Deductible | None | ||
| Coinsurance (Plan Paid) | 100% | ||
| OOP Limit Individual | $5,000 | $10,000 | |
| OOP Limit Family | $10,000 | $20,000 | |
| Preventative Care | $0 | $160 | |
| Virtual Care | $0 to $70 | Up to $270 | |
| Office Visit | $20 to $105 | $215 | |
| Urgent Care | $60 | $180 | |
| Emergency Room | $600 | $600 | |
| Ambulance | $350 | $350 | |
| Observation Stay | $350 | $350 | |
| Maternity Delivery | |||
| Prenatal and Postnatal Care | $0 | $160 | |
| Delivery | $900 to $2,000 | $6,000 | |
| Procedures (Office, Outpatient, Inpatient) | $35 to $3,000 | Up to $9,000 | |
| Other outpatient hospital services | $150 to $825 | $2,475 | |
| Other inpatient hospital stay (inc. admission from ER) | $2,000 | $6,000 | |
| Bariatric Surgery | Not Covered | Not Covered | |
| Procedures (Inpatient and some Outpatient) | $200to $3,000 | Up to $9,000 | |
| Rehabilitative Therapies | $10 to $130 | Up to $240 | |
| Acupuncture | $45 | $135 | |
| Chiropractic | $25 | $75 | |
| Occupational Therapy | $15 to $90 | $175 | |
| Physical Therapy | $10 to $70 | $210 | |
| Speech Therapy | $15 to $90 | $175 | |
| Mental Health & Substance Use Disorder | |||
| In an office setting (inc. ABA therapy) | $20 | $160 | |
| Intensive Outpatient Treatment Program | $70 | $210 | |
| Partial Hospitalization Program | $130 | $390 | |
| In an outpatient setting | $130 | $390 | |
| In an inpatient setting | $2,000 | $6,000 | |
| Routine Diagnostic Test (Ex: X-ray, Lab, Ultrasound) | $0 | $0 | |
| Advanced Test[1] | $20 to $1,050 | Up to $2,400 | |
| Complex Imaging (Ex: MRI, CT, etc.) | $125 to $850 | Up to $1,650 | |
| Chemotherapy | $25-$625 | Up to $1,875 | |
| Medical Infusions | $40-$2650 | Up to $6,300 | |
| Therapeutic Treatments-All others[2] | $15-$2,100 | Up to $6,300 | |
| Durable Medical Equipment (including hearing aids) | $0-$1,000 | Up to $2,000 | |
| Home Health Aid | $60 | $180 | |
| Hospice | |||
| Home Hospice Visit | $60 | $180 | |
| Inpatient Hospice Care | $2,000 | $6,000 | |
| Skilled Nursing Facility | $1,500 | $4,500 | |
| Fertility Treatment | Not Covered | Not Covered | |
| OOP Limit Cross Application | In-Network copays accumulate toward both In- and Out-of-Network OOP limits | Out-of-Network copays do not count toward In-Network OOP Limit |
|---|---|---|
| OOP Limit Accumulator | ERISA Plan Year accumulator | ERISA Plan Year accumulator |
| Out of Network Reimbursement | N/A | 100% of Medicare Fee Schedule |
| Therapy Visit Limits |
|
|
| Acupuncture | 60 visits per plan year, not combined with other therapies | |
| Chiropractic | 60 visits per plan year, not combined with other therapies | |
| Physical Therapy | 60 visits per plan year, not combined with other therapies | |
| Occupational Therapy | 60 visits per plan year, not combined with cognitive therapies | |
| Cognitive Therapy | 60 visits per plan year, combined with occupational therapies | |
| Speech Therapy | 60 visits per plan year; INN, not combined with cognitive therapies | |
| Home Health Care | 120 visits limit per person per plan year | |
| Skilled Nursing Facility | 120 visits llimit per person per plan year | |
| Pharmacy Tier | In-Network | Out-of-Network |
|---|---|---|
| Retail and Mail Order Pharmacy - 30 day supply | ||
| Tier 1 | $10 | Not Covered |
| Tier 2 | $60 | Not Covered |
| Tier 3 | $90 | Not Covered |
| Retail and Mail Order Pharmacy - 90 day supply | ||
| Tier 1 | $25.00 | Not Covered |
| Tier 2 | $150.00 | Not Covered |
| Tier 3 | $225.00 | Not Covered |
| Specialty Retail Pharmacy | ||
| Tier 1 | $10 | Not Covered |
| Tier 2 | $150 | Not Covered |
| Tier 3 | $300 | Not Covered |
*Bariatric Surgery and Fertility Treatment services are not covered
[1] Advanced Tests are complex medical tests your doctor may order to learn more about your health; typically planned and separately scheduled. Examples include EKG or a Facility Based Sleep Study.
[2] Therapeutic Procedures are treatments for complex diseases and health needs that do not involve surgery. Examples include radiation therapy or dialysis.
**All visit and stay limits are per covered person per plan year and combined in-network and out-of-network.
This product grid is intended to highlight benefits and should not be used to fully understand exact coverage. If this grid conflicts with the Certificate of Coverage, Schedule of Benefits, Riders, and/or amendments, those documents govern. Review your COC for an exact description of the services and supplies that are not covered.