2026 CODAC Benefit Summaries and Carrier Flyers

MEDICAL SCHEDULE OF BENEFITS

Benefit Plan(s) 009

All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays, Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expenses and Maximums section of this SPD for more details.

Refer to the applicable section of the Schedule of Benefits that corresponds to the place of service to determine the appropriate coverage.

Benefits listed in this Schedule of Benefits are subject to all provisions of this Plan, including any benefit determination based on an evaluation of medical facts and covered benefits. Refer to the Provider Network, Covered Medical Benefits, and General Exclusions sections of this SPD for more details. Important: Prior authorization may be required before benefits will be considered for payment. Failure to obtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the Cost Management section of this SPD for a description of these services and prior authorization procedures. If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, it is a combined Maximum Benefit for services that the Covered Person receives from all tier 1 and tier 2 Providers and facilities.

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Annual Deductible Per Calendar Year Excluding The Prescription Benefit Deductible: • Per Person

$2,500 $5,000 $2,500

$5,000 $10,000 $5,000

Per Family

•

Individual Embedded Deductible

−

Note: Embedded Deductible Means That If You Have Family Coverage, Any Combination Of Covered Family Members May Help Meet The Maximum Family Deductible; However, No One Person Will Pay More Than His Or Her Embedded Individual Deductible Amount. Plan Participation Rate, Unless Otherwise Stated Below: • Paid By Plan After Satisfaction Of Deductible

70%

50%

-4-

7670-00-415125