Surest Plan Document

Summary of Benefits and Coverage

Plan: Surest Plan C5000 RX_ALT_2
Coverage Period: 1/1/2026 - 12/31/2026
Coverage for: Family | Plan Type: PPO

This Summary of Benefits and Coverage (SBC) helps you understand what this plan covers and what you pay. For full plan details, visit Join.Surest.com or call 1-866-683-6440.

Important Questions

What this Plan Covers & What You Pay for Covered Services
Important Questions	Answers	Why This Matters
What is the overall deductible?	$0	See the Common Medical Events section below for costs for services this plan covers
Are there services covered before you meet your deductible?	Yes. This plan does not have a deductible	Some services are covered even if you haven’t met a deductible.
Are there other deductibles for specific services?	No	No extra deductibles apply.
What is the out-of-pocket limit?	Network: $5,000 Individual / $10,000 Family Out-of-Network: $10,000 Individual / $20,000 Family	This is the most you could pay in a year.
What is not included in the out-of-pocket limit?	Premiums, balance billing, excluded services, penalties	These costs do not count toward the limit.
Will you pay less if you use a network provider?	Yes. Call 1-866-683-6440 for a list of providers. See Join.Surest.com	You’ll pay less using in-network providers.
Do you need a referral to see a specialist?	No	You can see a specialist without a referral.

Common Medical Events

All costs shown are after any deductible, if applicable.

Cost Sharing for Common Medical Services
Medical Event	Services You May Need	Network Cost	Out-of-Network Cost	Limitations, Exceptions & Notes
If you visit a health care provider’s office or clinic	Primary care visit	$20–$105 copay	$215 copay	Copay varies by procedure and provider.
	Specialist visit	$20–$105 copay	$215 copay	Based on treatment outcomes and cost efficiency.
	Preventive care, screening, immunization	No charge	$160 copay	Non-preventive services may incur costs.
If you have a test	Diagnostic test (x-ray, blood work)	No charge or $20–$1,050 copay	No charge or up to $2,400 copay	Preauthorization may apply out-of-network.
If you have a test	Imaging (CT/PET scans, MRI)	$125–$850 copay	Up to $1,650 copay	Based on cost and outcomes.
If you need drugs to treat your illness or condition	Tier 1 (Generic)	$10 / $25 (90-day)	Not covered	Some generics $0. Preauthorization may apply.
	Tier 2 (Preferred)	$60 / $150 (90-day)	Not covered	To learn more visit Optumrx.com
	Tier 3 (Non-preferred)	$90 / $225 (90-day)	Not covered
	Specialty drugs	$10 / $150 / $300 (30-day)	Not covered	No 90-day supplies. Preauth may apply.
If you need immediate medical attention	Emergency room care	$600 copay	$600 copay	Waived if admitted within 24 hours.
	Emergency transportation	$350 copay	$350 copay	Counts toward in-network OOP limit.
	Urgent care	$60 copay	$180 copay
If you have a hospital stay	Facility fee (hospital room)	$200–$3,000 copay	Up to $9,000 copay	Preauthorization may apply out-of-network.
If you have a hospital stay	Physician/surgeon fees	No charge	No charge
Mental health, behavioral health, substance use services	Outpatient	$20 or $130 copay	$160 or $390 copay	Preauthorization may apply.
Mental health, behavioral health, substance use services	Inpatient	$2,000 copay	$6,000 copay
If you are pregnant	Office visits	No charge	$160 copay	Preventive only at no cost.
	Delivery professional services	No charge	No charge	Single copay for childbirth.
	Delivery facility services	$900–$2,000 copay	$6,000 copay
If you need help recovering	Home health care	$60 copay	$180 copay	Limited to 120 visits/year.
	Rehabilitation services	$10–$130 copay	Up to $240 copay	60 visits/year per therapy type.
	Habilitation services	$10–$130 copay	Up to $240 copay
	Skilled nursing care	$1,500 copay	$4,500 copay	120 days/year max.
	Durable medical equipment	$0–$1,000 copay	Up to $2,000 copay	Preauthorization may apply.
If your child needs dental or eye care	Eye exam	No charge	$215 copay	1 exam per year.
	Glasses	Not covered
	Dental check-up	Not covered

Excluded Services & Other Covered Services

Services Not Covered

Bariatric surgery
Cosmetic surgery
Dental care
Infertility treatment
Long-term care
Routine foot care (except certain conditions)
Weight loss programs
Non-emergency care outside the U.S.
Private-duty nursing

Other Covered Services (Limits May Apply)

Acupuncture (60 visits/year)
Chiropractic care (60 visits/year)
Hearing aids
Routine adult eye exam (1/year)

Your Rights and Assistance

For continuation coverage, contact the Department of Labor’s Employee Benefits Security Administration: 1-866-444-3272.

For complaints, appeals, or more information, contact Surest Member Services: 1-866-683-6440.