2026 CODAC Benefit Summaries and Carrier Flyers

IN-NETWORK

OUT-OF-NETWORK

Contraceptive Methods Approved By The FDA And Contraceptive Counseling:

For Men: •

80%

50%

Paid By Plan After Deductible

For Women: •

100% (Deductible Waived)

50%

Paid By Plan After Deductible

Counseling Services: •

80%

50%

Paid By Plan After Deductible

Nutritional Counseling If Medically Necessary, Outpatient Hospital Only:

No Benefit

80%

Paid By Plan After Deductible

•

Nutritional Counseling If Medically Necessary, Office Only: • Paid By Plan After Deductible Dental Services - Refer To The Covered Benefits Section For Details: • Paid By Plan After Deductible

80%

50%

80%

80%

Durable Medical Equipment: • Emergency Services / Treatment: Paid By Plan After Deductible

80%

50%

Urgent Care: •

80%

50%

Paid By Plan After Deductible

Walk-in Retail Health Clinics: • Paid By Plan After Deductible

80%

50%

Emergency Room / Emergency Physicians: • Paid By Plan After In-Network Deductible Extended Care Facility Benefits, Such As Skilled Nursing, Convalescent, Or Subacute Facility: • Maximum Days Per Calendar Year

80%

50%

60 Days

80%

50%

Paid By Plan After Deductible

•

Gender Dysphoria: •

80%

50%

Paid By Plan After Deductible

Travel And Lodging:

No Benefit

$10,000

Maximum Benefit Per Calendar Year

• •

100%

Paid By Plan After Deductible

Habilitative Services: •

20 Visits

Maximum Visits Per Calendar Year

Habilitative Services, Outpatient Hospital Only:

No Benefit

80%

Paid By Plan After Deductible

•

Habilitative Services, Office Only: • Paid By Plan After Deductible

80%

50%

Note: Medical Necessity Will Be Reviewed After 20 Visits.

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7670-00-412271