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

60 Maximum visits per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

Home health care

30% Coinsurance

50% Coinsurance

50% Coinsurance office therapy; Not covered outpatient hospital

20 Maximum visits per calendar year OT; 20 Maximum visits per calendar year PT; 20 Maximum visits per calendar year ST;

$25 Copay per visit; Deductible Waived

Rehabilitation services

50% Coinsurance office therapy; Not covered outpatient hospital

20 Maximum visits per calendar year Habilitation services for Learning Disabilities are not covered. 60 Maximum days per calendar year; Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. Preauthorization is required for DME in excess of $1,500 for purchases & all rentals. 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.

If you need help recovering or have other special health needs

$25 Copay per visit; Deductible Waived

Habilitation services

Skilled nursing care

30% Coinsurance

50% Coinsurance

Durable medical equipment

30% Coinsurance

50% Coinsurance

Hospice service

30% Coinsurance

50% Coinsurance

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