MMC Benefits Handbook
Detailed List of Covered Services
The Plan reimburses medically necessary covered services and supplies for the diagnosis and treatment for an illness or injury. The Claims Administrator determines whether the service or supply is covered and determines the amount to be reimbursed.
Most services and supplies are subject to a copay. The copays will vary based on the covered service, the provider and whether the provider is in-network. For additional coverage information, go to Benefits.Surest.com, the Surest mobile app or call Surest Member Services at +1 866 683 6440.
Your costs for out-of-network services apply toward the in-network out-of-pocket maximum. However, your costs for in-network services do not apply toward the out-of-network out-of-pocket maximum.
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Surest Copay Plan
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Services
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In-Network Coverage
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Out-of-Network Coverage
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Alcohol and substance use
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Inpatient and Residential Treatment:
$950 copay / visit.
Prior authorization may be required
Outpatient:
$45 copay / visit
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Inpatient and Residential Treatment:
$2,850 copay / visit.
Prior authorization may be required
Outpatient:
$135 copay / visit
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Allergy testing and treatment
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$45 copay / visit
(allergy injections covered at 100% when no office visit charged)
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$135 copay / visit
(allergy injections covered after $60 copay)
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Alternative medicine (Acupuncture)
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$20 copay / visit
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$60 copay / visit
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Coverage limitations:
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Ambulance charges
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$125 copay / transport
Non-Emergency ground and air ambulance services may require prior authorization.
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$125 copay / transport
Non-Emergency ground and air ambulance services may require prior authorization.
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Applied Behavioral Analysis (ABA)
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$5 copay / visit.
Prior authorization may be required
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$60 copay / visit.
Prior authorization may be required
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Artificial insemination
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$100 copay / service.
Limited to overall infertility maximum of $20,000 per lifetime.
Prior authorization is required.
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$200 copay / service.
Limited to overall infertility maximum of $20,000 per lifetime.
Prior authorization is required.
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CT / PET scans
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$50 to $310 copay / visit
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$930 copay / visit.
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Chiropractors
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$10 copay / visit.
30 visits per calendar year (combined in-network/out-of-network)
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$30 copay / visit.
30 visits per calendar year (combined in-network/out-of-network)
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Contraceptive devices (as defined as Preventive Prescriptions)
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Covered at 100%
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$60 copay
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Cosmetic surgery
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Not covered
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Not covered
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Dental treatment
(covered only for accidental injury to sound teeth within 12 months)
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$5 to $40 copay / visit (based on provider and location) for office visit.
$50 to $300 copay / visit (based on provider and location) for Outpatient Hospital
$950 copay / visit for Inpatient Hospital
Accidental dental services may require prior authorization.
$160 copay / visit for oral surgery (removal of impacted teeth).
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$120 copay / visit for office visit.
$900 copay / visit for Outpatient Hospital
$2,850 copay / visit for Inpatient Hospital
Accidental dental services may require prior authorization.
$480 copay / visit for oral surgery (removal of impacted teeth).
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Doctor delivery charge for newborns
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Included in Maternity Hospital Stay copay
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Included in Maternity Hospital Stay copay
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Durable medical equipment (DME)
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$0 to $500 copay (based on provider and location) for purchase.
$0 to $50 copay (based on provider and location) for rental.
Select DME may require prior authorization.
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$20 to $1,000 copay (based on provider and location) for purchase.
$2 to $100 copay (based on provider and location) for rental.
Select DME may require prior authorization.
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EKG Testing
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$10 to $80 copay / visit (based on provider and location).
Not considered preventive.
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$240 copay / visit.
Not considered preventive.
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Emergency room
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$250 copay / visit for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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$250 copay / visit for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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Gender Affirming Surgery (and related costs)
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$45 copay / visit for Outpatient Hospital.
$950 copay / visit for Inpatient Hospital.
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Select services for the treatment of Gender Dysphoria may require prior authorization.
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$135 copay / visit for Outpatient Hospital.
$2,850 copay / visit for Inpatient Hospital.
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Select services for the treatment of Gender Dysphoria may require prior authorization.
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Gynecology visits
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Covered at 100% (for one routine exam each calendar year)
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$60 copay / visit
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Hearing care
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$0 copay / visit.
Hearing and vision screening limited to one exam per Plan Year for children up to age of 21.
Covered hearing aids limited to $5,000 per covered person every 3 years (no coverage for hearing aids for degenerative hearing loss).
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$60 copay / visit.
Covered hearing aids limited to $5,000 per covered person every 3 years (no coverage for hearing aids for degenerative hearing loss).
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Home health care
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$15 copay / visit for up to 120 home health care aid visits per calendar year for homebound patients (up to 4 hours each visit)
Prior authorization may be required
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$45 copay / visit for up to 120 home health care aid visits per calendar year for homebound patients (up to 4 hours each visit)
Prior authorization may be required
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Hospice care
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$15 copay / visit for Home Hospice Care.
$950 copay / visit for Inpatient Hospice Care.
Inpatient Hospice Care may require prior authorization.
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$45 copay / visit for Home Hospice Care.
$2,850 copay / visit for Inpatient Hospice Care.
Inpatient Hospice Care may require prior authorization.
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Immunizations
(routine)
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Covered at 100%
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$60 copay
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Infertility Services
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$5 to $40 copay / visit (based on provider and location) for office visit.
$100 to $1,500 copay (based on provider and location) for fertility treatments.
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility.
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$120 copay / visit for office visit.
$200 to $3,000 copay (based on provider and location) for fertility treatments.
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility.
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Inpatient hospital services
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$950 copay / stay
Prior authorization is required
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$2,850 copay / stay
Prior authorization is required
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Laboratory charges
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$0 copay for routine diagnostic laboratory services/x-rays/ultrasounds.
$10 to $370 copay / visit (based on provider and location) for non-routine diagnostic.
Select laboratory services and diagnostic testing may require prior authorization.
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$0 copay for routine diagnostic laboratory services/x-rays/ultrasounds.
$90 to $1,110 copay / visit (based on provider and location) for non-routine diagnostic.
Select laboratory services and diagnostic testing may require prior authorization.
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Magnetic resonance imaging – MRI
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$50 to $310 copay / visit (based on provider and location).
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$930 copay / visit.
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Mammograms, including 3D mammograms (Routine)
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Covered at 100%
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Covered at 100%
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Mastectomy – reconstructive surgery
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$225 to $900 copay (based on provider and location) for partial mastectomy
$350 to $1,050 copay visit (based on provider and location) for mastectomy
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$2,700 copay for partial mastectomy
$3,150 copay for mastectomy
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Maternity hospital stay
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$275 to $950 copay / stay (based on provider and location).
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$2,850 copay / stay
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Mental health
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Inpatient and Residential Treatment
$950 copay / visit
Subject to prior authorization
Outpatient:
$45 copay / visit
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Inpatient and Residential Treatment
$2,850 copay / visit
Subject to prior authorization
Outpatient:
$135 copay / visit
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Musculoskeletal Surgery
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$100 to $1,800 copay (based on provider and location)
Prior authorization may be required
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$1,800 to $3,400 copay (based on provider and location)
Prior authorization may be required
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Obesity Surgery
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$100 to $700 copay (based on provider and location)
Once per lifetime
Prior authorization is required
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Not covered
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Occupational therapy
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$5 to $35 copay / visit1 (based on provider and location)
Medical Necessity Required.
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$105 copay / visit
Medical Necessity Required.
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Organ transplant
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$1,100 copay / visit for bone marrow and solid organ transplants.
$1,300 copay / visit for Corneal Transplant
Prior authorization may be required
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$3,300 copay / visit for bone marrow and solid organ transplants.
$3,900 copay / visit for Corneal Transplant
Prior authorization may be required
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Outpatient physician services
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Preventive: 100%
Office Visit: $5 to $40 copay / visit (based on provider and location)
Mental Health/Substance Use Disorder Medication Therapy: $5 copay / visit
Mental Health office visit: $5 copay / visit
Outpatient Hospital: $50 to $300 copay / visit (based on provider and location)
Outpatient Mental Health: $45 copay / visit
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Office Visit: $120 copay / visit
Mental Health/Substance Use Disorder Medication Therapy: $15 copay / visit
Mental Health office visit: $60 copay / visit
Outpatient Hospital: $900 copay / visit
Outpatient Mental Health: $135 copay / visit
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Physical exams for adults
(routine)
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Covered at 100% (not subject to copays) for one physical exam each calendar year
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$60 copay for one physical exam each calendar year
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Physical exams for children
(routine)
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Covered at 100% (not subject to copays)
Subject to Plan limits
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$60 copay
Subject to Plan limits
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Physical therapy
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$5 to $30 copay / visit2 (based on provider and location)
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$90 copay / visit
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Digital Physical Therapy (Sword Health)
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$29 copay per month for unlimited sessions per month
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Not covered – all services must be provided by Sword Health
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Pregnancy termination
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$50 copay / visit for medical
$80 copay / visit for surgical
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$150 copay / visit for medical
$240 copay / visit for surgical
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Prenatal visits
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No charge for Routine Prenatal Care; covered at 100%
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$60 copay
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Prescription drugs3 (see "Prescription Drugs")
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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Private Duty Nursing
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$15 copay / visit.
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Prior Authorization is required
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$45 copay / visit.
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Prior Authorization is required
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Prostate specific antigen test–PSA
(routine)
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Covered at 100%
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$60 copay / visit
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Skilled nursing facility
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$700 copay / stay for up to 120 days per calendar year (combined in-network/out-of-network)
Prior Authorization is required
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$2,100 copay / stay for up to 120 days per calendar year (combined in-network/out-of-network)
Prior Authorization is required
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Speech therapy
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$5 to $35 copay / visit4 (based on provider and location)
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$105 copay / visit
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Surgery
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$10 to $1,800 copay / visit (based on provider and location).
Select procedures may require prior authorization.
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$45 to $3,400 copay / visit (based on provider and location).
Select procedures may require prior authorization.
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Tubal ligation
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Covered at 100%
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$60 copay / visit
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Urgent Care
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$25 copay / visit
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$75 copay / visit
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Virtual Medicine
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$0 copay / visit for virtual primary, urgent and acute care.
$0 to $45 for virtual mental health and substance use disorder care.
$5 to $25 copay / visit for virtual specialty care.
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Not covered
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Vasectomy
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$30 to $210 copay / visit (based on provider and location)
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$630 copay / visit
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Vision care
(routine eye exam)
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Not covered
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Not covered
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Vision Therapy/
Orthoptics |
Not covered
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Not covered
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X-rays
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Covered at 100%
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Covered at 100%
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1 $5 for Occupational Therapy when primary diagnosis is autism spectrum disorder (ASD).
2 $5 per visit if primary diagnosis is for Autism Spectrum Disorder (ASD).
3 A mandatory program, the PrudentRx prescription drug program, will apply for eligible specialty medications for complex conditions on the PrudentRx Drug List. If you do not speak with PrudentRx, do not enroll in any copay assistance as required by a manufacturer, or do not choose to participate in the PrudentRx program, i.e. opt out, you'll be responsible for paying up to 30% coinsurance cost for each specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum. The PrudentRx Drug List is available at www.caremark.com. For drugs not on the PrudentRx Drug List, standard mail order copays will apply. For more information, refer to "Are there mandatory discount or copay assistance programs applicable for specialty prescription drugs? and "Prescription Drug Programs."
4 $5 per visit if primary diagnosis is for autism spectrum disorder (ASD).