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CIS Surest Plan Benefits Summary Effective Jan. 1– Dec. 31, 2026 This medical plan is self-insured by CIS and administered by Surest (a UnitedHealthcare company). CIS, not Surest/UnitedHealthcare, pays for your covered medical services and supplies. This is a summary only and is subject to change. Any errors or omissions are unintentional. Plan Handbooks are available by request. DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM PER CALENDAR YEAR UHC CHOICE PLUS NETWORK OUT-OF-NETWORK Deductible $0 Individual Out-of-Pocket Max $3,000 $6,000 Family Out-of-Pocket Max $6,000 $12,000 Unless otherwise noted, copays accumulate toward the out-of-pocket maximum. BENEFIT FEATURES IN-NETWORK OUT-OF-NETWORK Office Visit $5 to $40 $120 Virtual Health Primary and Urgent $0 Not Covered Mental Health & Substance Use Disorder $5 to $30 Not Covered Specialty $0 to $40 Not Covered Preventive Care $0 $60 Routine Diagnostic Test X-ray, Lab, Ultrasound) $0 $0 Complex Imaging MRI, CT) $50 to $340 Up to $1,200 Emergency Room $200 $200 Observation Stay $200 $200 Ambulance $120 $120 Urgent Care $20 $60 Procedures Procedures (Inpatient and some Outpatient) $75 to $2,000 Up to $5,000 Other Outpatient Hospital Services $50 to $330 $990 Other Inpatient Stay (inc. admission from ER) $1,000 $3,000 Mental Health & Substance Use Disorder In an office setting $5 $60 Intensive Outpatient Treatment Program $30 $90 Partial Hospitalization Program $50 $150 In an outpatient setting $50 $150 In an inpatient setting $1,000 $3,000 Maternity Prenatal and Postnatal Care $0 $60 Delivery $350 to $1,025 $3,075 Home Health Care $20 $60 Rehabilitative Therapies Occupational Therapy ― Up to 77 visits (combined with PT & ST) $5 to $35 $105 Physical Therapy ― Up to 77 visits (combined with OT & ST) $5 to $30 $90 Speech Therapy ― Up to 77 visits (combined with OT & PT) $5 to $35 $105 Alternative Care Acupuncture ― Up to 12 visits $20 $60 Chiropractic ― Up to 20 visits $10 $30 Skilled Nursing Facility $800 $2,400 Durable Medical Equipment $0 to $500 Up to $1,000 Hospice Home Hospice Visit ― Up to 120 visits $20 $60 Inpatient Hospice Care $1,000 $3,000 Advanced Tests Facility-Based Sleep Study) Up to $425 Up to $1,275 ---PAGE BREAK--- Prescription Medication Benefit Prescription drug coverage under the CIS-Surest plan is self-insured by CIS but administered by Regence BlueCross BlueShield (BCBS) of Oregon. Members follow the same Regence pharmacy formulary and copay structure used by other CIS medical plans. Prescription Medication Benefit At the Pharmacy (30-day supply) Member Pays At the Pharmacy (90-day supply) or Mail Order thru Amazon (90- day supply) Member Pays Individual deductible per calendar year No deductible Out-of-pocket maximum per calendar year $2,500 Individual / $7,500 family Tier 1 (Preferred Generic) $10 copay $20 copay Tier 2 (Non-Preferred Generic) $10 copay $20 copay Tier 3 (Preferred Brand) $40 copay $80 copay Tier 4 (Non-Preferred Brand) $100 copay $200 copay Tier 5 (Generic and Preferred Brand Specialty) $50 copay Generic Specialty $100 copay Preferred Brand Specialty N/A Tier 6 (Non-Preferred Specialty) $200 copay N/A Compound Medications $40 copay N/A Limitations and Exceptions Prescription drugs not on the Drug List are not covered, unless an exception is approved. No charge for certain preventive medications and immunizations, including those specifically designated as preventive for treatment of chronic diseases that are on the Optimum Value Medication List. Cost shares for insulin will not exceed $35 / 30-day supply or $105 / 90-day supply. Covered drugs limited to: • Up to 90-day supply for retail prescription • Up to 90-day supply for home delivery prescription • Up to 30-day supply for specialty drug prescription • Up to 30-day supply for compound medications Specialty Medications must be filled through Accredo Specialty 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." More information about prescription drug coverage, including tier specific information, is available at