2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Annual Total Out-Of-Pocket Maximum:

Note: Medical, And Pharmacy Expenses Are Subject To The Same Out-Of-Pocket Maximum. • Per Person

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

$10,000 $20,000 $10,000

Per Family

•

− Individual Embedded Out-Of-Pocket Maximum

Note: Embedded Out-Of-Pocket Maximum Means That If You Have Family Coverage, Any Combination Of Covered Family Members May Help Meet The Family Out-Of-Pocket Maximum; However, No One Person Will Pay More Than His Or Her Embedded Individual Out-Of-Pocket Maximum Amount. Acupuncture Treatment • Maximum Visits Per Calendar Year Note: Medical Necessity Will Be Reviewed After 20 Visits. Ambulance Transportation: • Paid by Plan After Tier 1 Deductible Augmentation Communication Devices: • Maximum Benefit Every 3 Calendar Years • Paid By Plan After Deductible

20 Visits

70%

50%

70%

70%

1 Augmentation Communication Device

70%

50%

Paid By Plan After Deductible

•

Breast Pumps: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Cardiac Pulmonary Rehabilitation: • Co-pay Per Visit Maximum Visits Per Calendar Year Paid By Plan After Deductible • •

$25

Not Applicable

20 Visits

100% (Deductible Waived)

50%

Note: Medical Necessity Will Be Reviewed After 20 Visits. Cardiac Rehabilitation Phase 1 & 2 • Co-pay Per Visit

$25

Not Applicable

36 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Note: Medical Necessity Will Be Reviewed After 36 Visits.

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