2026 CODAC Benefit Summaries and Carrier Flyers

IN-NETWORK

OUT-OF-NETWORK

Physical Outpatient Hospital And Office Therapy: • Maximum Visits Per Calendar Year

20 Visits

No Benefit

Physical Outpatient Hospital Only:

80%

Paid By Plan After Deductible

•

Physical Outpatient Office Therapy Only: • Paid By Plan After Deductible

80%

50%

Speech Outpatient Hospital And Office Therapy: • Maximum Visits Per Calendar Year

20 Visits

Speech Outpatient Hospital Therapy Only:

No Benefit

80%

Paid By Plan After Deductible

•

Speech Office Therapy Only: • Paid By Plan After Deductible

80%

50%

Note: Medical Necessity Will Be Reviewed After 20 Visits. Vision Care Benefits:

Eye Exam: •

1 Exam

Maximum Exams Every 2 Years Paid By Plan After Deductible

80%

50%

•

Refraction: •

1 Exam

Maximum Exams Every 2 Years Paid By Plan After Deductible

80%

50%

•

Wigs (Cranial Prostheses), Toupees, Or Hairpieces Related To Cancer Treatment And Alopecia Areata: • Paid By Plan After In-Network Deductible

80%

80%

All Other Covered Expenses: • Paid By Plan After Deductible

80%

50%

-11-

7670-00-412271