2026 CODAC Benefit Summaries and Carrier Flyers

If your Provider is in the PPO Network, payment for Covered Expenses will be the Negotiated Rate. If Your Provider is not in the PPO Network, then Your Provider is considered to be open access. Payment for Covered Expenses by open access Providers will be the Reasonable and Allowable Amount. 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 non-Network Provider 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.

PROVIDER-PATIENT RELATIONSHIP

Each Covered Person has a free choice of any Provider, and the Provider-patient relationship shall be maintained. The Covered Person, and their Physician, are ultimately responsible for determining the appropriate course of medical treatment, regardless of whether the Plan will pay for all or a portion of the cost of such care. In addition, each Covered Person has a free choice to select a Hospital or to make a free choice of the attending Physician or professional Provider. However, benefits will be paid in accordance with the provisions of this Plan.

CLAIMS AUDIT

In addition to the Plan’s Medical Record Review process, the Plan Administrator may use its discretionary authority to utilize an independent bill review and/or claim audit program or service for a complete claim. While every claim may not be subject to a bill review or audit, the Plan Administrator has the sole discretionary authority for selection of claims subject to review or audit. The analysis will be employed to identify charges billed in error and/or charges that are in excess of the Reasonable and Allowable Amount and/or Medically Necessary, if any, and may include a patient medical billing records review and/or audit of the patient’s medical charts and records. Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the charges deemed in excess of the Reasonable and Allowable Amount or other applicable provisions, as outlined in this Plan. In addition to services required to be covered as specified under the Protection from Balance Billing section of this SPD, some benefits may be processed at Network benefit levels on the Schedule of Benefits when provided by non-Network Providers. When non-Network charges are covered in accordance with Network benefits, the charges may be subject to Plan limitations. The following exceptions may apply: • Non-air Ambulance Transportation services will be payable at the Network level of benefits when provided by a non-Network Provider. • Covered services (including Preventive Services) provided by a radiologist, anesthesiologist, certified registered nurse anesthetist, or pathologist will be payable at the Network level of benefits when services are provided at a Network facility or referred by a Network Physician, even if the Provider is a non-Network Provider. • Covered services provided by a Physician (excluding surgeons) during an Inpatient stay will be payable at the Network level of benefits when provided at a Network Hospital. • If there is no Network Provider, or no Network Provider is willing or able to provide the necessary service(s) to the Covered Person within a 50- mile radius of the Covered Person’s residence, the Covered Person may be eligible to receive Network benefits from a non-Network Provider. In this situation, Your Network Physician will notify the Claims Administrator, who will work with You and Your Network Physician to coordinate care through a non-Network Provider. • Wigs, toupees, and hairpieces will be payable at the Network level of benefits when provided by a non-Network Provider. EXCEPTIONS TO THE PROVIDER NETWORK

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