2026 CODAC Benefit Summaries and Carrier Flyers

➢ For non-network charges, any charge over a semi-private room charge will be a Covered Expense only if determined by the Plan to be Medically Necessary. If the Hospital has no semi-private rooms, the Plan will allow the private room rate, subject to the Protection from Balance Billing allowed amount, Usual and Customary charges, or Negotiated Rate, whichever is applicable. • Intensive care unit room and board. • Miscellaneous and Ancillary Services. • Blood, blood plasma, and plasma expanders, when not available without charge. Observation in a Hospital room will be considered Inpatient treatment if the duration of the observation status exceeds 72 hours. Observation means the use of appropriate monitoring, diagnostic testing, treatment, and assessment of patient symptoms, signs, laboratory tests, and response to therapy for the purpose of determining whether a patient will require further treatment as an Inpatient or can be discharged from the Hospital setting. Observation in a Hospital room will be considered Outpatient treatment if the duration of the observation status is 72 hours or less. Observation means the use of appropriate monitoring, diagnostic testing, treatment, and assessment of patient symptoms, signs, laboratory tests, and response to therapy for the purpose of determining whether a patient will require further treatment as an Inpatient or can be discharged from the Hospital setting. 39. Infertility Treatment t o the extent required to treat or correct underlying causes of infertility, when such treatment is Medically Necessary and cures the condition of, alleviates the symptoms of, slows the harm to, or maintains the current health status of the Covered Person. Once the patient is receiving fertility treatment to achieve pregnancy, diagnostic tests and treatments are then considered part of the infertility benefit. 38. Hospital Services (Outpatient).

Infertility Treatment does not include Genetic Testing. (See General Exclusions for details).

40. Laboratory or Pathology Tests and Interpretation Charges for covered benefits. Charges by a pathologist for interpretation of computer-generated automated laboratory test reports are not covered by the Plan.

41. Manipulations: Treatments for musculoskeletal conditions when Medically Necessary. Also refer to Maintenance Therapy under the General Exclusions section of this SPD.

42. Marriage Counseling that is part of a behavioral health treatment plan.

43.

Maternity Benefits for Covered Persons include:

• Hospital or Birthing Center room and board. • Vaginal delivery or Cesarean section. • Non-routine prenatal care. • Postnatal care. • Diagnostic testing. • Medically Necessary diagnostic testing. • Abdominal operation for intrauterine pregnancy or miscarriage. • Outpatient Birthing Centers. • Midwives.

44. Mental Health Treatment. (Refer to the Behavioral Health section of this SPD).

45. Nursery And Newborn Expenses, Including Circumcision, are covered for the following Children of the covered Employee or covered spouse: natural (biological) Children and newborn Children who are adopted or Placed for Adoption at the time of birth.

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