2026 CODAC Benefit Summaries and Carrier Flyers

TIER 1 FACILITY + PHCS VALUE DRIVEN HEALTH PLAN NETWORK

TIER 2 ALL OTHER PROVIDERS

Mental Health: •

$20

Copay Per Occurrence

100% (Deductible Waived)

Paid By Plan

•

Note: Multiple Co-pays Apply When Multiple Claims Are Billed On The Same Date Of Service. Telehealth: • Co-pay Per Visit – Primary Care Physician

$25 $50

Not Applicable Not Applicable

Co-pay Per Visit - Specialist Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Therapy Services:

Occupational Outpatient Hospital And Office Therapy: • Co-pay Per Visit

$25

Not Applicable

20 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Physical Outpatient Hospital And Office Therapy: • Co-pay Per Visit

$25

Not Applicable

20 Visits

Maximum Visits Per Calendar Year Paid By Plan After Deductible

• •

100% (Deductible Waived)

50%

Speech Outpatient Hospital And Office Therapy: • Co-pay Per Visit

$25

Not Applicable

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. Vision Care Benefits:

Eye Exam: •

$25

Not Applicable

Co-pay Per Visit

1 Exam

• Maximum Exams Every 2 Calendar Years

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Refraction: •

$25

Not Applicable

Co-pay Per Visit

1 Exam

• Maximum Exams Every 2 Calendar Years

100% (Deductible Waived)

50%

Paid By Plan After Deductible

•

Note: One Co-pay Will Apply If An Eye Exam And Refraction Are Done At The Same Time.

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