2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Non-Routine Prenatal Services, Delivery, And Postnatal Care: • Paid By Plan After Deductible Mental Health And Substance Use Disorder Benefits:

70%

50%

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

70%

50%

Residential Treatment: •

70%

50%

Paid By Plan After Deductible

Outpatient Or Partial Hospitalization Services And Physician Charges: • Paid By Plan After Deductible

70%

50%

Office Visit: •

$25

Not Applicable

Co-pay Per Visit

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Nursery And Newborn Expenses: • Paid By Plan After Deductible

70%

50%

Note: Deductible And / Or Co-pay Will Be Waived For Newborn Charges, Initial Stay (Days 0-5). Oral Surgery: • Paid By Plan After Deductible Physician Office Visit. This Section Applies To Medical Services Billed From A Physician Office Setting:

70%

70%

This Section Does Not Apply To: ➢

Preventive / Routine Services

➢

Manipulation Services Billed By Any Qualifying Provider

➢ Dental Services Billed By Any Qualifying Provider ➢ Therapy Services Billed By Any Qualifying Provider ➢ Any Services Billed From An Outpatient Hospital Facility

Primary Care Physician Office Visit: • Co-pay Per Visit

$25

Not Applicable

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Specialist Visit: •

$50

Not Applicable

Co-pay Per Visit

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

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7670-00-415125