2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Hospital Services:

Pre-Admission Testing: •

70%

50%

Paid By Plan After Deductible

Inpatient Services / Inpatient Physician Charges; Room And Board Subject To The Payment Of Semi Private Room Rate Or Negotiated Room Rate: • Paid By Plan After Deductible

70%

50%

Outpatient Services / Outpatient Physician Charges: • Paid By Plan After Deductible

70%

50%

Outpatient Advanced Imaging Charges: • Paid By Plan After Deductible

70%

50%

Outpatient Lab Charges: •

100% Deductible Waived

50%

Paid By Plan After Deductible

Outpatient X-Ray Charges: • Co-pay Per Visit

$75

Not Applicable

100% Deductible Waived

50%

Paid By Plan After Deductible

•

Outpatient Surgery / Surgeon Charges: • Paid By Plan After Deductible

70%

50%

Physician Clinic Visits In An Outpatient Hospital Setting: • Paid By Plan After Deductible

70%

50%

Manipulations: •

$25

Not Applicable

Co-pay Per Visit

20 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Visit Maximums Are Applied Based On Provider Designation And Procedure Code.

If A Provider Bills For A Manipulation And A Therapy On The Same Claim, Only One Visit Will Be Applied To The Manipulation Maximum Based On The Provider’s Designation. Note: Medical Necessity Will Be Reviewed After 20 Visits. Medical Necessity Review Is Based On Chiropractic Designation And Procedure Code. Maternity:

Routine Prenatal Services: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

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7670-00-415125