2026 CODAC Benefit Summaries and Carrier Flyers

28. Extended Care Facility Services for both mental and physical health diagnoses. Charges will be paid under the applicable diagnostic code. The following services are covered:

Room and board.

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• Miscellaneous services, supplies, and treatments provided by an Extended Care Facility, including Inpatient rehabilitation.

29. Eye Refractions if related to a covered medical condition.

30. Foot Care (Podiatry) that is recommended by a Physician as a result of infection. The following charges for foot care will also be covered:

• Treatment of any condition resulting from weak, strained, flat, unstable, or unbalanced feet when surgery is performed. • Treatment of corns, calluses, and toenails when at least part of the nail root is removed or when needed to treat a metabolic or peripheral vascular disease. • Physician office visit for diagnosis of bunions. The Plan also covers treatment of bunions when an open cutting operation or arthroscopy is performed. 31. Gender Dysphoria: Benefits for the Medically Necessary treatment of Gender Dysphoria provided by or under the direction of a Physician. For the purpose of this benefit Gender Dysphoria is a disorder characterized by the specific diagnostic criteria classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Surgeries that alter physical appearance only and are not for the treatment of Gender Dysphoria are not covered by the Plan. This Plan provides an allowance for reasonable travel and lodging expenses, up to the maximum listed on the Medical Schedule of Benefits, if any, for a Covered Person and travel companion when the Covered Person must travel at least 50 miles from their address, as reflected in our records, to receive the covered health services from an available Network provider. Lodging expenses are further limited to $50 per night for the Covered Person, or $100 per night for the Covered Person with a travel companion. Please remember to save travel and lodging receipts to submit for reimbursement. Travel and lodging reimbursements that exceed IRS limits may be subject to IRS codes for taxable income. If You would like additional information regarding travel and lodging, You may contact us at the telephone number on Your ID card.

32. Genetic Testing or Genetic Counseling in relation to Genetic Testing based on Medical Necessity.

Genetic testing MUST meet the following requirements:

The test must not be considered Experimental, investigational, or Unproven. The test must be performed by a CLIA-certified laboratory. The test result must directly impact or influence the disease treatment of the Covered Person.

Genetic testing must also meet at least one of the following:

• The patient has current signs and/or symptoms (i.e., the test is being used for diagnostic purposes). • Conventional diagnostic procedures are inconclusive. • The patient has risk factors or a particular family history that indicates a genetic cause. • The patient meets defined criteria that place him or her at high genetic risk for the condition.

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