2026 Surest Plan 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 | |
| Maternity Delivery | |||
| Prenatal and Postnatal Care | $0 | $160 | |
| Delivery | $900 to $2,000 | $6,000 | |
| Procedures (Office, Outpatient, Inpatient) | $200 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 | |
| Skilled Nursing Facility | $1,500 | $4,500 | |
| Acupuncture | $45 | $135 | |
| Chiropractic | $25 | $75 | |
| Occupational Therapy | $15 to $90 | $175 | |
| Physical Therapy | $10 to $70 | $210 | |
| Speech Therapy | $15 to $90 | $175 | |
| Home Health Care | 120 visits per person | 120 visits per person | |
| Skille Nursing Facility | 120 day limit | 120 day limit | |
| Complex Imaging (Ex: MRI, CT, etc.) | $60 to $450 | Up to $1,350 | |
| Routine Diagnostic (Ex: X-ray, Lab, Ultrasound) | $0 | $0 | |
| Advanced Tests [1] | $20 to $1,050 | Up to $2,400 | |
| Medical Infusions and Chemotherapy | $40 to $2,650 | Up to $7,950 | |
| Therapeutic Treatments [2] | $15 to $2,100 | Up to $6,300 | |
| Durable Medical Equipment (including hearing aids) | $0 to $1,000 | Up to $2,000 | |
| Fertility Treatment | Not Covered | Not Covered | |
| Mental Health & Substance Use Disorder | |||
| Office Visit (inc. ABA therapy) | $20 | $160 | |
| Intensive Outpatient Treatment Program | $70 | $210 | |
| Partial Hospitalization Program | $130 | $390 | |
| Outpatient | $75 | $225 | |
| Inpatient | $2,000 | $6,000 | |
| Hospice | |||
| Home Hospice Visit | $60 | $180 | |
| Inpatient Hospice Care | $2,000 | $6,000 | |
| 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 |
| Emergency Services OOP accumulator | In-network and Out-of-network copays accumulate to In-network OOP Limit | Out-of-network copays accumulate to In-Network OOP Limit |
| Therapy Visit Limits |
|
|
| Acupuncture | 60 visits per plan year; INN; OON; Medical Only** | |
| Chiropractic | 60 visits per plan year; INN; OON; Medical Only** | |
| Physical Therapy | 60 visits per plan year; INN; OON; Medical Only** not combined with other therapies | |
| Occupational Therapy | 60 visits per plan year; INN; OON; Medical Only** not combined with other therapies | |
| Speech Therapy | 60 visits per plan year; INN; OON; Medical Only** not combined with other therapies | |
| Home Health Care | 120 visits per plan year; INN; OON; Medical Only** | |
| Skilled Nursing Facility | 120 visits per plan year; INN; OON; Medical Only** | |
| 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 |
| Specialty Retail Pharmacy | ||
| Tier 1 | $10 | Not Covered |
| Tier 2 | $150 | Not Covered |
| Tier 3 | $300 | Not Covered |
Member co-pays, including co-pay ranges, are listed below for some services. For specific pricing:
- Log in to your account via the Surest app or website; or use
- https://benefits.surest.com/preview/access-code
- Access Code FINV25268Alt2
- Start a search by symptom or condition to find doctors or treatment options.
- Select a name/care option and location to see the price for a visit, as well as what’s included in the visit.
[1] [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.
[1] [2] Therapeutic Procedures are treatments for complex diseases and health needs that do not involve surgery. Examples include radiation therapy or dialysis.
Bariatric Surgery and Fertility Treatment services are not covered.
**All visit and stay limits are per covered person per plan year and combined in-network and out-of-network.
Insurance coverage provided by UnitedHealthcare Insurance Company. Administrative services provided by United HealthCare Services, Inc. or its affiliates.
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, those that are excluded or limited, and other terms and conditions of coverage. Contact your Surest representative for plan design information.