2026 CODAC Benefit Summaries and Carrier Flyers

• If the equipment is purchased, benefits may be payable for subsequent repairs excluding batteries or replacement only if required: ➢ due to the growth or development of a Dependent Child; ➢ because of a change in the Covered Person’s physical condition; or ➢ because of deterioration caused from normal wear and tear. The repair or replacement must also be recommended by the attending Physician. In all cases, repairs or replacement due to abuse, misuse, loss, or theft, as determined by the Plan, are not covered, and replacement is subject to prior approval by the Plan. • This Plan covers taxes and shipping and handling charges for Durable Medical Equipment. 26. Emergency Room Hospital and Physician Services including Emergency room services for stabilization or initiation of treatment of a medical Emergency condition provided on an Outpatient basis at a Hospital, as shown in the Schedule of Benefits. 27. Emergency Services Provided in a Foreign Country, including Emergency room services for stabilization or initiation of treatment of a medical Emergency condition provided on an Inpatient or Outpatient basis at a Hospital or Physician services in a P rovider’s office .

28. Extended Care Facility Services for both mental and physical health diagnoses. Charges will be paid under the applicable diagnostic code. The following services are covered:

Room and board.

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• Miscellaneous services, supplies, and treatments provided by an Extended Care Facility, including Inpatient rehabilitation.

29. Eye Refractions if related to a covered medical condition.

30. Foot Care (Podiatry) that is recommended by a Physician as a result of infection. The following charges for foot care will also be covered:

• Treatment of any condition resulting from weak, strained, flat, unstable, or unbalanced feet when surgery is performed. • Treatment of corns, calluses, and toenails, when at least part of the nail root is removed or when needed to treat a metabolic or peripheral vascular disease. • Physician office visit for diagnosis of bunions. The Plan also covers treatment of bunions when an open cutting operation or arthroscopy is performed. 31. Gender Dysphoria: Benefits for the Medically Necessary treatment of Gender Dysphoria provided by or under the direction of a Physician. For the purpose of this benefit Gender Dysphoria is a disorder characterized by the specific diagnostic criteria classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Surgeries that alter physical appearance only and are not for the treatment of Gender Dysphoria are not covered by the Plan. This Plan provides an allowance for reasonable travel and lodging expenses, up to the maximum listed on the Medical Schedule of Benefits, if any, for a Covered Person and travel companion when the Covered Person must travel at least 50 miles from their address, as reflected in our records, to receive the covered health services from an available Network Provider. Lodging expenses are further limited to $50 per night for the Covered Person, or $100 per night for the Covered Person with a travel companion. Please remember to save travel and lodging receipts to submit for reimbursement. Travel and lodging reimbursements that exceed IRS limits may be subject to IRS codes for taxable income. If You would like additional information regarding travel and lodging, You may contact us at the telephone number on Your ID card.

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