2025 Surest Plan Summary
| Category | Plan Design Element | In-Network | Out-of-Network |
|---|---|---|---|
| Deductible | None | ||
| Coinsurance (Plan Paid) | 100% | ||
| OOP Limit Individual | $4,000 | $8,000 | |
| OOP Limit Family | $8,000 | $16,000 | |
| Preventative Care | $0 | $100 | |
| Virtual Care | $0 to $65 | Up to $195 | |
| Office Visit | $10 to $65 | $195 | |
| Urgent Care | $35 | $105 | |
| Emergency Room | $350 | $350 | |
| Ambulance | $160 | $160 | |
| Observation Stay | $350 | $350 | |
| Maternity Delivery | |||
| Prenatal and Postnatal Care | $0 | $100 | |
| Delivery | $625 to $1,600 | $4,800 | |
| Procedures (Office, Outpatient, Inpatient) | $15 to $2,500 | Up to $7,000 | |
| Other outpatient hospital services | $75 to $525 | $1,575 | |
| Other inpatient hospital stay (inc. admission from ER) | $150 to $2,500 | $4,800 | |
| Bariatric Surgery | Not Covered | Not Covered | |
| Gender Dysphoria Surgery | Covered | Covered | |
| Skilled Nursing Facility | $1,200 | $3,600 | |
| Home Health Care | $30 | $90 | |
| Acupuncture | $30 | $90 | |
| Chiropractic | $15 | $45 | |
| Occupational Therapy | $10 to $55 | $165 | |
| Physical Therapy | $5 to $45 | $135 | |
| Speech Therapy | $10 to $55 | $165 | |
| 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] | $10 to $750 | Up to $2,250 | |
| Medical Infusions and Chemotherapy | $15 to $1,850 | Up to $5,550 | |
| Therapeutic Treatments [2] | $30 to $1,750 | Up to $5,250 | |
| Durable Medical Equipment (including hearing aids) | $0 to $500 | Up to $1,000 | |
| Fertility Treatment | Not Covered | Not Covered | |
| Mental Health & Substance Use Disorder | |||
| In an office setting (inc. ABA therapy) | $10 | $100 | |
| Mental Health Telehealth | $10 | $100 | |
| Intensive Outpatient Treatment Program | $40 | $120 | |
| Partial Hospitalization Program | $75 | $225 | |
| In an outpatient setting | $75 | $225 | |
| Hospice | |||
| Home Hospice Visit | $30 | $90 | |
| Inpatient Hospice Care | $1,600 | $4,800 | |
| 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 | $35 | Not Covered |
| Tier 3 | $70 | Not Covered |
| Specialty Retail Pharmacy | ||
| Tier 1 | $10 | Not Covered |
| Tier 2 | $100 | Not Covered |
| Tier 3 | $200 | Not Covered |
*Fertility Treatment and Bariatric Surgery are not covered
*Place of Service - the Price (Copays) for some medical services and procedures are determined by the clinical setting in which the individual actually receives the care ("Place of Service"). For example, minor surgery in an office will incur an Office Visit price (copay), whereas minor surgery received in a hospital will incur an Outpatient Hospital Services and Surgery price (copay).
[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.
••• Retail and Mail Order 90-day ratio is 2.5
Insurance coverage is provided by All Savers Insurance Company (for FL, GA, OH, UT and VA), by UnitedHealthcare Insurance Company of IL (for IL), by United Healthcare of Kentucky, Ltd. (for KY), or by UnitedHealthcare Insurance Company (for AL, AR, AZ, CO, DC, DE, GA, IA, ID, IN, KS, LA, MI, MN, MO, MS, MT, NC, NE, NH, NV, OK, PA, RI, SC, SD, TN, TX, UT, VA, WV, and WY). These policies have exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact either your broker or the insuring company. Administrative services provided by Bind Benefits, Inc. d/b/a Surest, its affiliate United HealthCare Services, Inc., or by Bind Benefits, Inc. d/b/a Surest Administrators Services, in CA.
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.
Property of Bind Benefits, Inc. d/b/a Surest. Do not distribute without written permission. © 2023. Patent Pending.
For complete details, consult your Certificate of Coverage.