CODAC 2024 Benefit Summaries and Carrier Materials

Do you need a referral to see a specialist?

No.

You can see the specialist you choose without a referral.

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

In-network (You will pay the least)

Out-of-network (You will pay the most)

Primary care visit to treat an injury or illness

20% Coinsurance

50% Coinsurance

None

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

Specialist visit

20% Coinsurance

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

50% Coinsurance Office setting; Not covered Outpatient setting

Diagnostic test (x-ray, blood work)

20% Coinsurance

None

If you have a test

50% Coinsurance Office setting; Not covered Outpatient setting

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)

20% Coinsurance

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