2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Emergency Room Only: • Co-pay Per Visit

$350

$350

(Waived If Admitted As Inpatient Within 24 Hour(s)) • Paid By Plan

100% (Deductible Waived)

100% (Deductible Waived)

Emergency Physicians Only: • Paid By Plan

100% (Deductible Waived)

100% (Deductible Waived)

Extended Care Facility Benefits, Such As Skilled Nursing, Convalescent, Or Subacute Facility: • Maximum Days Per Calendar Year

60 Days

70%

50%

Paid By Plan After Deductible

•

Gender Dysphoria: •

70%

50%

Paid By Plan After Deductible

Travel And Lodging: •

$10,000

Maximum Benefit Per Calendar Year

100% (Deductible Waived)

100% (Deductible Waived)

Paid By Plan After Deductible

•

Habilitative Services: •

$25 $50

Not Applicable Not Applicable

Co-pay Per Visit - PCP

Co-pay Per Visit - Specialist

• • •

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. Hearing Services:

Exams, Tests: •

70%

50%

Paid By Plan After Deductible

Hearing Aids: • Maximum Benefit Including Implantable Hearing Devices

1 Per Ear Every 3 Years

70%

50%

Paid By Plan After Deductible

•

Implantable Hearing Devices:

Included in Hearing Aids Maximum Paid By Plan After Deductible

70%

50%

•

Home Health Care Benefits: •

60 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

70%

50%

•

Note: A Home Health Care Visit Will Be Considered A Periodic Visit By A Nurse, Qualified Therapist, Or Qualified Dietician, As The Case May Be, Or Up To Four Hours Of Home Health Care Services. Hospice Care Benefits: • Paid By Plan After Deductible

70%

50%

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7670-00-415125