2026 CODAC Benefit Summaries and Carrier Flyers

70. Self-Administered Services or procedures, including self-administered or self-infused medications, that can be performed by the Covered Person without the presence of medical supervision. This exclusion does not apply to medications that, due to their characteristics (as determined by the claims administrator), must typically be administered or directly supervised by a qualified provider or licensed/certified health professional in an Outpatient setting. This exclusion does not apply to hemophilia treatment centers contracted to dispense hemophilia factor medications directly to members for self-infusion. 71. Services at No Charge or Cost: Services for which the Covered Person would not be obligated to pay in the absence of this Plan or that are available to the Covered Person at no cost, or for which the Plan has no legal obligation to pay, except for care provided in a facility of the uniformed services as per Title 32 of the National Defense Code, or as required by law.

72. Services Provided By a Close Relative, unless covered elsewhere in this SPD. See the Glossary of Terms section of this SPD for a definition of Close Relative.

73.

Services Provided By a School.

74.

Sex Therapy.

75. Sexual Function: Diagnostic service, non-surgical and surgical procedures and Prescription drugs (unless covered under the Prescription Drug benefit) in connection with treatment for male or female impotence.

76.

Standby Surgeon Charges.

77. Subrogation. Charges for an Illness or Injury suffered by a Covered Person due to the action or inaction of any third party if the Covered Person fails to provide information as specified in the Right of Subrogation, Reimbursement, and Offset section. See the Right of Subrogation, Reimbursement, and Offset section for more information. 78. Surrogate Parenting and Gestational Carrier Services. Any services or supplies provided in connection with a surrogate parent, not including pregnancy and maternity charges Incurred by a covered Employee or covered spouse acting as a surrogate parent.

79. Telehealth. Consultations made by a Covered Person’s treating Physician to another Physician .

80.

Temporomandibular Joint Disorder (TMJ) Services:

Diagnostic services. Surgical treatment.

• •

• Non-surgical treatment (including intraoral devices or any other non-surgical method to alter occlusion and/or vertical dimension).

This Plan does not cover orthodontic services.

81. Tobacco Addiction: Diagnoses, services, treatment, or supplies related to addiction to or dependency on nicotine, unless covered elsewhere in this SPD.

82. Transportation: Transportation services that are solely for the convenience of the Covered Person, the Covered Person's Close Relative, or the Covered Person's Physician.

83. Travel: Travel costs, unless covered elsewhere in this SPD.

84. Vision Care, unless covered elsewhere in this SPD. (Refer to the Vision Care Benefits section of this SPD).

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