2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

➢ Counseling For Interpersonal And Domestic Violence For Women (Provided Annually)* • Paid By Plan After Deductible

100% (Deductible Waived)

50%

*These Services May Also Apply To Men. Preventive / Routine Care Benefits For Children Include:

Preventive / Routine Physical Exams: • 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 Screenings / Services At Appropriate Ages: • Paid By Plan After Deductible

100% (Deductible Waived)

50%

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

100% (Deductible Waived)

50%

Preventive / Routine Hearing Exams: • Paid By Plan After Deductible

100% (Deductible Waived)

50%

Sterilizations:

For Men: •

70%

50%

Paid By Plan After Deductible

For Women: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Teladoc Health Services:

24/7 Care: •

$20

Co-pay Per Occurrence

100% (Deductible Waived)

Paid By Plan

•

Dermatology: •

$20

Co-pay Per Occurrence

100% (Deductible Waived)

Paid By Plan

•

-12-

7670-00-415125