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

Tier 1 deductible applies to Tier 2 benefits; Preauthorization is required for Non-emergent transports. If you don’t get preauthorization, a penalty of $250 may be applied.

Emergency medical transportation

30% Coinsurance

30% Coinsurance

$75 Copay per visit; Deductible Waived

Urgent care

50% Coinsurance

None

Facility fee (e.g., hospital room)

30% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required for Partial hospitalization & Intensive treatment. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Cost sharing does not apply for preventive services. Depending on the type of services, deductible, copayment or coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

If you have a hospital stay

Physician/surgeon fees

30% Coinsurance

50% Coinsurance

$25 Copay per visit; Deductible Waived Office visits; 30% Coinsurance other outpatient services

If you have mental health, behavioral

Outpatient services

50% Coinsurance

health, or substance abuse services

Inpatient services

30% Coinsurance

50% Coinsurance

No charge; Deductible Waived

Office visits

50% Coinsurance

If you are pregnant

Childbirth/delivery professional services

30% Coinsurance

50% Coinsurance

Childbirth/delivery facility services

30% Coinsurance

50% Coinsurance

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