2026 CODAC Benefit Summaries and Carrier Flyers

Any Drug above $1,500 a dose.

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Biologic Drugs.

Dialysis.

DME over $2,500 (excluding CPAP’s) .

• Behavioral Health: Intensive Outpatient Program, Residential Treatment Centers, Partial Hospitalization Program. • Radiation Treatments. • Skilled Nursing Facility. • Extended Nursing Facility. • Long Term Acute Care (LTAC). • Home Health Care. • Hospice Care. • Inpatient Rehabilitation. • Panniculectomy/Abdominoplasty. • Cosmetic Surgery Potentials: • Mammoplasty. • Varicose Veins stripping and ligation. • Ongoing Wound Care. • Any procedure that has the potential to be experimental or investigational. • Clinical trials. Note that if a Covered Person receives prior authorization for one facility, but then is transferred to another facility, prior authorization is also needed before going to the new facility, except in the case of an Emergency.

PENALTIES FOR NOT OBTAINING PRIOR AUTHORIZATION

A non-Prior Authorization penalty is the amount a Covered Person may be required to pay if an authorization has not been completed prior to receiving certain services or prior to admissions as defined in this section. A penalty of $250 may be applied to applicable claims if a Covered Person receives services but does not obtain the required prior authorization.

The phone number to call for prior authorization is listed on the back of the Plan identification card.

The fact that a Covered Person receives prior authorization from the Utilization Review Organization does not guarantee that this Plan will pay for the medical care. The Covered Person must be eligible for coverage on the date services are provided. Coverage is also subject to all provisions described in this SPD, including additional information obtained that was not available at the time of the prior authorization. The Prior Authorization / Notification requirements detailed within this section may be deemed satisfied for certain services, Providers, and/or facilities meeting specific conditions or in a situation of a confirmed cyberattack that could result in a waiver only for a specified period of time. If a Covered Person’s condition is, or is expected to become, serious and complex in nature, the Plan Administrator may arrange for review and/or Case Management services from a professional qualified organization. Case Management is a program whereby a case manager monitors patients with complex conditions and explores, discusses, educates, and recommends coordinated and/or alternate types of appropriate Medically Necessary care. Each plan of care is individually tailored to a specific Covered Person. The case manager consults with the patient, the family, and the attending Physician in order to develop and implement a mutually agreeable and cost-effective plan of care. This plan of care may include some or all of the following: CASE MANAGEMENT

Personal support to the patient.

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Contacting the family to offer assistance and support.

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7670-00-417233