CODAC 2024 Benefit Summaries and Carrier Materials

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 1 Facility+ PHCS Professional & Ancillary

Tier 2 All Other Providers

Primary care visit to treat an injury or illness

$25 Copay per visit; Deductible Waived

50% Coinsurance

None

If you visit a health care provider’s office or clinic

$50 Copay per visit; Deductible Waived

Specialist visit

50% Coinsurance

None

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Preventive care/screening/ immunization

No charge; Deductible Waived

50% Coinsurance

Labs - office or outpatient setting no charge; Deductible Waived X-ray - office no charge; Deductible Waived $75 copay outpatient setting; Deductible Waived

Diagnostic test (x-ray, blood work)

50% Coinsurance

None

If you have a test

Preauthorization is required for MRI/MRA/PET scans. If you don’t get preauthorization, a penalty of $250 may be applied.

Imaging (CT/PET scans, MRIs)

30% Coinsurance

50% Coinsurance

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