2026 CODAC Benefit Summaries and Carrier Flyers

COST MANAGEMENT Administered by MedWatch

Note: HealthSCOPE Benefits (the Claims Administrator) does not administer the benefits or services described within this provision.

UTILIZATION MANAGEMENT PROGRAM

The Plan includes a Utilization Management as described below. Utilization Management Programs assist Covered Persons to obtain maximum benefit coverage under this Plan while receiving care in a cost-effective manner through prior authorization. • The Utilization Management Programs are designed to assist this Plan in: • Evaluating a Covered Person’s health care services for Medical Necessity and appropriateness, • Evaluating alternative level-of-care opportunities, • Coordinating care needs, • Identifying high risk Covered Persons for proactive Case Management programs when applicable. • This Plan uses the methods described in this document to coordinate and review care and identify covered services under the Plan. The Plan Sponsor has contracted with an independent organization, MedWatch, to provide prior authorization. The name and phone number of the organization is shown on the back of the Plan identification card. Utilization review and prior authorization are part of a Utilization Management Program designed to help Covered Persons receive necessary and appropriate health care while avoiding unnecessary expenses. Prior authorization is one type of utilization review, reviewing the Medical Necessity and appropriateness of a proposed treatment plan against nationally accepted clinical criteria. The granting of prior authorization for a specific covered service will not under any circumstances obligate the Plan to pay any invalid charges or any amounts in excess of the maximum allowable charge for such covered service. Payment of charges will be withheld if prior authorization for treatment is based on a diagnosis for which treatment is covered, but the treatment is actually undertaken for a condition that is not covered by the Plan. Payment of charges will be withheld if prior authorization for treatment is based on a diagnosis for which treatment is covered, but the treatment is actually undertaken for a condition that is not covered by the Plan. This Plan complies with the Newborns’ and Mothers’ Health Protection Act. Prior authorization is not required for a Hospital or Birthing Center stay of 48 hours or less following a normal vaginal delivery or 96 hours or less following a Cesarean section. Prior authorization may be required for a stay beyond 48 hours following a vaginal delivery or 96 hours following a Cesarean section. PRIOR AUTHORIZATION

This Utilization Management Program consists of the following:

• Prior authorization of whether medical non-Emergency services delivered in a medical care facility are Medically Necessary;

If a particular course of treatment or medical service is not Medically Necessary as defined by this Plan, the Plan will not pay for charges and the charges will not be counted for any cost-sharing purposes. The charges will be outside the Plan and will be th e Covered Person’s financial responsibility.

• Retrospective review of the Medical Necessity of services provided on a medical Emergency basis in a medical care facility;

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