CODAC 2024 Benefit Summaries and Carrier Materials

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

Retail: Up to a 31 day supply Mail-Order: Up to a 90 day supply 90 day supply at CVS retail pharmacy subject to Mail-Order copay. Specialty drugs 31 day supply regardless of retail or mail order. You may need to obtain certain drugs, including certain specialty drugs, from a pharmacy designated by CVS/Caremark. For eligible specialty medications, $0 copay if filled through the PrudentRx program. If you opt out you will pay 30% of the cost. Certain drugs may have a prior authorization requirement. Not all drugs are covered. If you use a non-network pharmacy, you are responsible for any amount over the allowed amount. Certain preventive medications are covered at No Charge. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Retail: $15 copay Mail-Order: $37.50 copay

Retail: $15 copay + amount over allowed amount

Generic drugs (Tier 1)

If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.caremark. com & www.prudentrx. com.

Retail: $45 copay Mail-Order: $112.50 copay

Retail: $45 copay + amount over allowed amount

Preferred brand drugs (Tier 2)

Retail: $85 copay Mail-Order: $212.50 copay

Retail: $85 copay + amount over allowed amount

Non-preferred brand drugs (Tier 3)

Specialty drugs (Tier 4)

Retail: $170 copay Mail-Order: $170 copay

Retail: $170 copay + amount over allowed amount

Facility fee (e.g., ambulatory surgery center)

If you have outpatient surgery If you need immediate medical attention

30% Coinsurance

50% Coinsurance

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

$350 Copay per visit; Deductible Waived

$350 Copay per visit; Deductible Waived

Emergency room care

Copay may be waived if admitted

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