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Page 1 of 10 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2026 – 12/31/2026 City County Insurance Services dba CIS Benefits: Surest Plan Coverage for: Individual and Family I Plan Type: PPO Important Questions Answers Why This Matters What is the overall deductible? $0 See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Yes. Preventive Care. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copay or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific services? No You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? For network providers: $3,000 individual / $6,000 family For out-of-network providers: $6,000 individual / $12,000 family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Premiums, balance billing charges and health care this plan doesn’t cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See Join.Surest.com or call 1-[PHONE REDACTED] for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No You can see the specialist you choose without a referral. The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit Join.Surest.com, Surest mobile app or call Surest Member Services at 1-[PHONE REDACTED]. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copay, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at Healthcare.gov/sbc-glossary/ or call 1-[PHONE REDACTED] to request a copy. ---PAGE BREAK--- Page 2 of 10 Common Medical Event Services You May Need What You Will Pay In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information* If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $5 - $40 copay/visit $120 copay/visit Certain procedures performed in the office may have a higher office visit copay. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. *Cost share applies to any other Telehealth service based on provider type. If you receive services in addition to office visit, additional copays may apply. Specialist visit $5 - $40 copay/visit $120 copay/visit Preventive care/screening/ immunization No charge $60 copay/visit You may have to pay for services that are not preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Routine diagnostic test x-ray, blood work) Non-routine diagnostic test sleep study, genetic testing) Routine diagnostic test: No charge Non-routine diagnostic test: Up to $425 copay/visit Routine diagnostic test: No charge Non-routine diagnostic test: Up to $1,275 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for certain Non-routine diagnostic tests or there may be no coverage. Imaging (CT/PET scans, MRIs) $50 - $340 copay/visit Up to $1,020 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for certain imaging tests or there may be no coverage. *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. ---PAGE BREAK--- Page 3 of 10 What You Will Pay Common Medical Event Services You May Need In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you need drugs to treat your illness or condition Tier 1 drugs (Typically, generic drugs with highest overall value) $10 copay, deductible does not apply / 30-day retail; $20 copay, deductible does not apply / 90-day retail or home delivery; $10 copay, deductible does not apply / SACC* $10 copay, deductible does not apply / 30- day retail; $20 copay, deductible does not apply / 90-day retail or home delivery; $10 copay, deductible does not apply / SACC* Prescription drug coverage is provided through Regence. Please refer to the information below for specific coverage details for prescription drug questions. For more information about prescription drug coverage is available at Member Services: 1-[PHONE REDACTED] (back of member ID card) Pharmacy Help Desk: 1-[PHONE REDACTED] (back of member ID card) Prescriber Help Desk: 1-[PHONE REDACTED] (back of member ID card) Mail Order: www.Amazon.com/regenceORMYW or 1-[PHONE REDACTED] Specialty Mail Order: www.Accredo.com OR 1-[PHONE REDACTED] Preferred URL: Regence.com Pre-member preferred site: Regence.com Member preferred site: (all CIS groups except for Lake Oswego) (Lake Oswego only) *SACC means a self-administrable cancer chemotherapy prescription. Prescription drugs not on the Drug List are not covered, unless an exception is approved. No charge, deductible does not apply for drugs specifically designated as preventive for treatment of certain chronic diseases that are on the Optimum Value Medication List. Out-of-pocket limit: $2,500 individual / $7,500 family / year. 90-day supply / retail prescription 90-day supply / home delivery prescription 30-day supply / specialty drug prescription 30-day supply / compound medications Tier 2 drugs (Typically, generic drugs with moderate overall value) $10 copay, deductible does not apply / 30-day retail; $20 copay, deductible does not apply / 90-day retail or home delivery; $10 copay, deductible does not apply / SACC* $10 copay, deductible does not apply / 30- day retail; $20 copay, deductible does not apply / 90-day retail or home delivery; $10 copay, deductible does not apply / SACC* Tier 3 drugs (Typically, brand drugs with moderate overall value) $40 copay, deductible does not apply / 30-day retail; $80 copay, deductible does not apply / 90-day retail or home delivery $50 copay, deductible does not apply / SACC* $40 copay, deductible does not apply / 30- day retail; $80 copay, deductible does not apply / 90-day retail or home delivery $50 copay, deductible does not apply / SACC* ---PAGE BREAK--- Page 4 of 10 Tier 4 drugs (Typically, brand drugs with lower overall value) Tier 5 drugs (Typically, specialty drugs with moderate overall value) Tier 6 drugs (Typically, specialty drugs with lower overall value) $100 copay, deductible does not apply / 30-day retail; $200 copay, deductible does not apply / 90-day retail or home delivery; $50 copay, deductible does not apply / SACC* $50 copay, deductible does not apply / generic specialty drug; $100 copay, deductible does not apply / specialty drug or SACC* $200 copay, deductible does not apply / specialty drug; $100 copay, deductible does not apply / SACC* $100 copay, deductible does not apply / 30-day retail; $200 copay, deductible does not apply / 90-day retail or home delivery; $50 copay, deductible does not apply / SACC* $50 copay, deductible does not apply / generic specialty drug; $100 copay, deductible does not apply / specialty drug or $200 copay, deductible does not apply / specialty drug; $100 copay, deductible does not apply / SACC*SACC* Specialty drugs are not available through home delivery. Coverage includes compound medications at $40 copay, deductible does not apply. Cost shares for insulin will not exceed $35 / 30-day supply or $105 / 90-day supply. No charge, deductible does not apply for certain preventive drugs, contraceptives and immunizations at a participating pharmacy. If you fill a brand drug or specialty drug when there is an equivalent generic drug or specialty biosimilar drug available, you pay the difference in cost in addition to the copayment and/or coinsurance, unless your provider specifies "dispense as written." The first fill of specialty drugs may be provided by a retail pharmacy; additional refills must be provided by a specialty pharmacy. ---PAGE BREAK--- Page 5 of 10 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you have outpatient surgery Facility fee ambulatory surgery center) $10 - $2,000 copay/visit Up to $5,000 copay/visit Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for certain outpatient surgery or there may be no coverage. Physician/surgeon fees No charge No charge If you need immediate medical attention Emergency room care $200 copay/visit $200 copay/visit Copay is waived if admitted within 24 hours. Out- of-network emergency room care visit copay applies to the in-network out-of-pocket limit. Emergency medical transportation $120 copay/transport $120 copay/transport Prior authorization is required for non-emergency medical transportation or there may be no coverage. Out-of-network emergency medical transportation copay applies to the in-network out- of-pocket limit. Urgent care $20 copay/visit $60 copay/visit None If you have a hospital stay Facility fee hospital room) $75 - $2,000 copay/stay Up to $5,000 copay/stay Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Prior authorization is required for non-emergency facility admissions and inpatient surgery or there may be no coverage. Physician/surgeon fees No charge No charge *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com. ---PAGE BREAK--- Page 6 of 10 Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Common Medical Event In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need mental health, behavioral health, or substance abuse services Outpatient services Home/Office: $5 copay/visit Outpatient Facility: $50 copay/visit Home/Office: $60 copay/visit Outpatient Facility: $150 copay/visit Certain procedures/services in the outpatient setting may have a lower copay. Prior authorization is required for certain outpatient services or there may be no coverage. Inpatient services $1,000 copay/stay $3,000 copay/stay Certain procedures/services in the inpatient setting may have a lower copay. Prior authorization is required for certain inpatient services or there may be no coverage. If you are pregnant Office visits No charge $60 copay/visit Cost sharing does not apply to preventive services with network providers. Depending on the type of service, a copay may apply. Childbirth/delivery professional services No charge No charge One copay for all covered services related to childbirth/delivery, including the newborn, unless discharged after mother. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Cost sharing does not apply to certain preventive services. Prior authorization is required for inpatient stays beyond 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery or there may be no coverage. Childbirth/delivery facility services $350 - $1,025 copay/stay $3,075 copay/stay ---PAGE BREAK--- Page 7 of 10 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information* In-Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you need help recovering or have other special health needs Home health care $20 copay/visit $60 copay/visit 120 visit limit - combination of network providers and out-of-network providers per person per plan year. Prior authorization is required for certain home health care services or there may be no coverage. Rehabilitation services $5 - $50 copay/visit Up to $150 copay/visit 77 visit limit for occupational therapy 77 visit limit for physical therapy 77 visit limit for speech therapy Visit limits are a combination of network providers and out-of-network providers per person per plan year. Copays are listed as a range. Providers are assigned copays within the range based on treatment outcomes and cost information that identifies network providers that provide cost- efficient care. Habilitation services $5 - $50 copay/visit Up to $150 copay/visit Skilled nursing care $800 copay/stay $2,400 copay/stay 120 day limit per person per plan year. Prior authorization is required or there may be no coverage. Durable medical equipment $0 - $500 copay/equipment based on DME tier Up to $1,000 copay/equipment based on DME tier For durable medical equipment (DME) tiers and limitations, visit Join.Surest.com website. Prior authorization is required for certain DME or there may be no coverage. Hospice services Home: $20 copay/visit Inpatient: $1,000 copay/stay Home: $60 copay/visit Inpatient: $3,000 copay/stay None If your child needs dental or eye care Children’s eye exam No charge $120 copay/visit One exam per person per plan year. Children’s glasses Not covered Not covered None Children’s dental check-up Not covered Not covered None *For more information about limitations and exceptions, see the plan or policy document at Join.Surest.com. ---PAGE BREAK--- Page 8 of 10 Services Your Plan Generally Does NOT Cover (Check your plan document for more information and a list of any other excluded services.) Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) Excluded Services & Other Covered Services: • Cosmetic surgery • Dental care (Adult) • Infertility treatment • Long term care • Non-emergency care when traveling outside the U.S. • Prescription drugs • Private duty nursing • Weight loss programs • Acupuncture (12 visit limit per person per plan year) • Bariatric surgery • Chiropractic care (20 visit limit per person per plan year) • Hearing aids (limitations apply) • Routine eye care (Adult) (limited to one exam per person per plan year.) • Routine foot care (for certain conditions) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for the agency is the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at [PHONE REDACTED] x61565 or www.cms.gov/cciio. You may also contact Surest Member Services at 1-[PHONE REDACTED]. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1-[PHONE REDACTED]. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Surest Member Services at 1-[PHONE REDACTED]. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al [1-[PHONE REDACTED]]. Traditional Chinese (中文): 如果需要中文的幫助, 請撥打這個號碼 [1-[PHONE REDACTED]]. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' [1-[PHONE REDACTED]]. Dutch (Deitsch): Fer Hilf griege in Deitsch, ruf [1-[PHONE REDACTED]] uff. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa [1-[PHONE REDACTED]]. Samoan (Gagana Samoa): Mo se fesoasoani i le Gagana Samoa, vala’au mai i le numera telefoni [1-[PHONE REDACTED]]. Carolinian (Kapasal Falawasch): ngere aukke ghut alillis reel kapasal Falawasch au fafaingi tilifon ye [1-[PHONE REDACTED]]. Chamorro (Chamoru): Para un ma ayuda gi finu Chamoru, å’gang [1-[PHONE REDACTED]]. To see examples of how this plan might cover costs for a sample medical situation, see the next section. ---PAGE BREAK--- Page 9 of 10 copayment copayment About these Coverage Examples: Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care (a year of routine in-network care of (in-network emergency room visit and and a hospital delivery) a well-controlled condition) follow up care) ■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0 ■ The plan’s overall deductible $0 ■ Specialist copayment $5 - $40 ■ Specialist copayment $5 - $40 ■ Specialist copayment $5 - $40 ■ Hospital (facility) copayment $75 - $2,000 ■ Hospital (facility) $75 - $2,000 ■ Hospital (facility) $75 - $2,000 ■ Other coinsurance $0 ■ Other coinsurance $0 ■ Other coinsurance $0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments, and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Total Example Cost $2,800 Total Example Cost $5,600 Total Example Cost $12,700 In this example, Peg would pay: Cost sharing Deductibles $0 Copayments $400 Coinsurance $0 What isn’t covered Limits or exclusions $70 The total Peg would pay is $470 In this example, Joe would pay: Cost sharing Deductibles $0 Copayments $100 Coinsurance $0 What isn’t covered Limits or exclusions $4,300 The total Joe would pay is $4,400 In this example, Mia would pay: Cost sharing Deductibles $0 Copayments $500 Coinsurance $0 What isn’t covered Limits or exclusions $10 The total Mia would pay is $510 ---PAGE BREAK--- Page 10 of 10 The plan would be responsible for the other costs of these EXAMPLE covered services.