2026 CODAC Benefit Summaries and Carrier Flyers

72.

Surgery and Assistant Surgeon Services.

• If an assistant surgeon is required, the assistant surgeon’s covered charge will not exceed 20% of the allowance for the primary procedure performed. For in-network providers, the assistant surgeon’s allowable amount will be determined per the network contract. • If bilateral or multiple surgical procedures are performed by one surgeon, benefits will be determined based on the Usual and Customary charge that is allowed for the primary procedure; 50% of the Usual and Customary charge will be allowed for each additional procedure performed through the same incision; and 70% of Usual and Customary charge will be allowed for each additional procedure performed through a separate incision. • If multiple unrelated surgical procedures are performed by two more surgeons on separate operative fields, benefits will be based on the Usual and Customary charge for each surgeon’s primary procedure. If two or more surgeons perform a procedure that is normally performed by one surgeon, benefits for all surgeons will not exceed the Usual and Customary percentage allowed for that procedure.

73. Telehealth: Consultations made by a Physician to a Covered Person.

74. Telemedicine. (Refer to the Teladoc Health Services section of this SPD for more details.)

75. Therapy Services: Therapy must be ordered by a Physician and provided as part of the Covered Person’s treatment plan. Services include:

• Occupational therapy by a Qualified occupational therapist (OT) or other Qualified Provider, if applicable. • Physical therapy by a Qualified physical therapist (PT) or other Qualified Provider, if applicable. • Respiratory therapy by a Qualified respiratory therapist (RT) or other Qualified Provider, if applicable. • Aquatic therapy by a Qualified physical therapist (PT), Qualified aquatic therapist (AT), or other Qualified Provider, if applicable. • Speech therapy necessary for the diagnosis and treatment of speech and language disorders that result in communication disabilities when performed by a Qualified speech therapist (ST) or other Qualified Provider, if applicable, including therapy for the treatment of disorders of speech, language, voice, communication, and auditory processing when such a disorder results from Injury, stroke, cancer, a Congenital Anomaly, or other types of communication disorders such as categorized language disorder, speech sound disorder, child-onset fluency disorder, and pragmatic communication disorder. The Plan allows coverage for medical charges and occupational and/or physical therapy for Developmental Delays due to Accidents or Illnesses such as Bell's palsy, CVA (stroke), apraxia, cleft palate/lip, recurrent/chronic otitis media, vocal cord nodules, Down's syndrome and cerebral palsy when performed by a Qualified Provider. The Plan allows coverage for the treatment of disorders such as speech, language, voice, communication, and auditory processing when such a disorder results from Injury, stroke, cancer, or a Congenital Anomaly. The Plan will pay benefits for cognitive rehabilitation therapy only when Medically Necessary following a post-traumatic brain Injury or cerebral vascular Accident.

76. Tobacco Addiction: Preventive / Routine Care as required by applicable law.

77. Transplant Services. (Refer to the Transplant Benefits section of this SPD.)

78. Urgent Care Facility as shown in the Schedule of Benefits of this SPD.

79. Vision Care Services. (Refer to the Vision Care Benefits section of this SPD.)

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