2026 CODAC Benefit Summaries and Carrier Flyers

Reasonable and Allowed Amount: “Reasonable and Allowed Amount” or “Reasonable and Allowable Amount” means the maximum amount payable by the Plan for a service, supply and/or treatment that is considered a Covered Expense. The Reasonable and Allowable Amount is the lesser of: 1) the charge made by the Provider that furnished the care, service, or supply; 2) the negotiated amount established by a discounting or negotiated arrangement (see Negotiated Rate), 3) the reasonable and customary charge for the same treatment, service, or supply furnished in the same geographic area by a Provider of like service of similar training and experience as further described below; or 4) an amount equivalent to the following:

1. For Inpatient or Outpatient facility claims, an amount equivalent to 140% of the Medicare equivalent allowable amount;

2. For Physician and ancillary claims, an amount equivalent to <120%> of the Medicare equivalent allowable amount;

3. For specialty drugs, the lesser of the average wholesale price (AWP) minus 14% or the amount set by the Plan’s prescription drug service vendor.

The term “Reasonable and Customary Charge” shall mean an amount equivalent to the lesser of a commercially available database or such other cost or quality-based reimbursement methodologies as may be available and utilized by the Plan from time to time. If there is insufficient information submitted for a given procedure, the Plan will determine the Reasonable and Allowed Amount based upon charges made for similar services. Determination of the Reasonable and Customary Charge will take into consideration the nature and severity of the condition being treated, medical complications or unusual circumstances that require more time, skill or experience, and any cost and quality data for that Provider. The term “Geographic Area” shall be defined as a metropolitan area, county, zip code, state or such greater area as is necessary to obtain a representative cross-section of Providers, persons, or organizations rendering such treatment, service, or supply for which a specific charge is made. For Covered Expenses rendered by a Provider in a Geographic Area where applicable law may dictate the maximum amount that can be billed by the rendering Provider, the Reasonable and Allowed Amount shall mean the lesser of amount established by applicable law for that Covered Expense or the amount determined as set forth above. The Plan Administrator or its designee has the ultimate discretionary authority to determine the Reasonable and Allowable Amount, including establishing the negotiated terms of a Provider arrangement as the Reasonable and Allowable Amount even if such negotiated terms do not satisfy the “lesser of” test described above. Negotiated Rate : On occasion, HealthSCOPE Benefits will negotiate a payment rate with a Provider for a particular covered service, such as transplant services, Durable Medical Equipment, Extended Care Facility treatment, or other services. The Negotiated Rate is what the Plan will pay to the Provider, minus any Co-pay, Deductible, Plan Participation rate, or penalties that the Covered Person is responsible for paying. If a Network contract is in place, the N etwork contract determines the Plan’s Negotiate d Rate. Modifiers or Reducing Modifiers, if Medically Necessary. These terms apply to services and procedures performed on the same day and may be applied to surgical, radiological, and other diagnostic procedures. For a Provider participating with a primary or secondary Network, claims will be paid according to the Network contract. For a Provider who is not participating with a Network, where no discount is applied, the industry guidelines are to allow the Reasonable and Allowed Amount for the primary procedure and a percentage of the Reasonable and Allowed Amount for all secondary procedures. These allowances are then processed according to Plan provisions. A global package includes the services that are a necessary part of the procedure. For individual services that are part of a global package, it is customary for the individual services not to be billed separately. A separate charge will not be allowed under the Plan.

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