2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

The Co-pays Will Not Apply To: ➢ Independent Lab ➢

Services Billed By Radiologist Or Pathologist, Including Independent Radiology Facility (Freestanding Radiology Facility)

Physician Office Services: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Office Surgery: •

70%

50%

Paid By Plan After Deductible

Office Advanced Imaging: •

70%

50%

Paid By Plan After Deductible

Post-Cochlear Implant Aural Therapy: • Co-pay Per Visit Maximum Visits Per Calendar Year

$25

Not Applicable

30 Visits

• •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Note: Medical Necessity Will Be Reviewed After 30 Visits. Preventive / Routine Care Benefits. See Glossary Of Terms For Definition. Benefits Include: Preventive / Routine Physical Exams At Appropriate Ages: • Paid By Plan After Deductible

100% (Deductible Waived)

50%

Immunizations: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Foreign Travel Immunizations: • Paid By Plan After Deductible

100% (Deductible Waived)

50%

Preventive / Routine Diagnostic Tests, Lab, And X-Rays At Appropriate Ages: • Paid By Plan After Deductible

100% (Deductible Waived)

50%

Preventive / Routine Mammograms And Breast Exams: • Maximum Exams Per Calendar Year Including 3D Mammograms For Preventive Screenings

1 Exam

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

-10-

7670-00-415125