2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Cognitive Rehabilitation: • Co-pay Per Visit

$25

Not Applicable

20 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Note: Medical Necessity Will Be Reviewed After 20 Visits. Contraceptive Methods Approved By The FDA And Contraceptive Counseling:

For Men: •

70%

50%

Paid By Plan After Deductible

For Women: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Counseling Services:

Marriage Counseling That Is Part Of A Behavioral Health Treatment Plan: • Copay Per Visit

$25

Not Applicable

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Nutritional: • Co-pay Per Visit – Primary Care Physician

$25 $50

Not Applicable Not Applicable

Co-pay Per Visit - Specialist Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Dental Services – Refer To The Covered Medical Benefits Section For Details: • Paid By Plan After Deductible

70%

70%

Durable Medical Equipment: • Emergency Services / Treatment: Urgent Care: • Co-pay Per Visit Paid By Plan After Deductible

70%

50%

$75

Not Applicable

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Walk-In Retail Health Clinics: • Co-pay Per Visit

$25

Not Applicable

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

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