2026 CODAC Benefit Summaries and Carrier Flyers

PROVIDER NETWORK

Refer to the Protection from Balance Billing section of this SPD for Covered health care services subject to the No Surprises Act protections. Covered health care services subject to the No Surprises Act requirements shall be reimbursed according to the Protection from Balance Billing section. This Plan is structured to provide the Covered Person with access to high quality care at an affordable cost. As such, the Plan calculates benefits differently depending on the type of Provider, the service or supply provided, and the location where a Covered Person receives services or supplies.

SERVICES PROVIDED BY HEALTHCARE FACILITIES

For Covered Expenses performed by a facility or Hospital, the Plan provides open access to any facility or Hospital of the Covered Person’s choosing. This means the Plan does not provide access to a Preferred Provider Organization (“PPO”) Network for facilities or Hospitals.

FACILITIES AND PROVIDERS BILLING AS FACILITIES

The Plan provides the Covered Person with open access to any facility or Hospital of the Covered Person ’s choosing. The following are examples of facilities:

Hospitals (Inpatient and Outpatient treatment);

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• Inpatient facilities (such as skilled nursing facilities or hospice facilities); • Outpatient facilities (such as rehabilitation Hospitals, infusion therapy centers, or hospice facilities) • Inpatient and Outpatient facilities for treatment of Mental Health Disorders, or substance abuse disorders; • Air/ground ambulance; • Ambulatory Surgery Centers; or • Dialysis clinics. Payment for Covered Expenses at facilities, or for Providers billing as a facility, will be the Reasonable and Allowable Amount and claims will normally be processed in accordance with benefit levels that are listed on the Schedule of Benefits. Please see the Schedule of Benefits for additional information on benefits and limitations. Please note that if a facility or Provider billing as a facility does not agree to the reimbursement set by the Plan, then Y ou may be balance billed for the difference between the Plan’s Reasonable and Allowable Amount and the amount billed by the Provider. Please see Patient Advocacy Center section for information about assistance with a balance bill.

SERVICES PROVIDED BY HEALTHCARE PROFESSIONALS AND ANCILLARY PROVIDERS

For Covered Expenses performed by a Professional Services Provider, which includes but is not limited to a Physician, a licensed speech or occupational therapist, physical therapist, the Plan provides access to a Provider Network. The plan also provides you with open access to non-Network providers. The Provider Network also includes access for Covered Expenses performed by an ancillary Provider. Ancillary Providers include but are not limited to independent labs, Durable Medical Equipment Providers, or Home Health Care. The Plan also provides You with open access to non-Network Providers.

The Plan offers access to a contracted PPO Network. A list of the PPO Network Providers can be accessed at healthscopebenefits.com.

Please note that the PPO Network does not includes services and supplies provided by Hospitals, Ambulatory Surgery Centers, dialysis clinics, or facilities. For these services and supplies, the Plan will calculate payment based on the Reasonable and Allowable Amount

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