CODAC 2024 Benefit Summaries and Carrier Materials

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)

In-network deductible applies to Out-of-network benefits; Preauthorization is required for

Emergency medical transportation

20% Coinsurance

20% Coinsurance

Non-emergent transports. If you don’t get preauthorization, a penalty of $250 may be applied.

Urgent care

20% Coinsurance

50% Coinsurance

None

Facility fee (e.g., hospital room)

20% Coinsurance

50% Coinsurance

Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied.

If you have a hospital stay

Physician/surgeon fees

20% Coinsurance

50% Coinsurance

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 mental health, behavioral

50% Coinsurance Office visits; Not covered other outpatient services

Outpatient services

20% Coinsurance

health, or substance abuse services

Inpatient services

20% Coinsurance

50% Coinsurance

No charge; Deductible Waived

Office visits

50% Coinsurance

If you are pregnant

Childbirth/delivery professional services

20% Coinsurance

50% Coinsurance

Childbirth/delivery facility services

20% Coinsurance

50% Coinsurance

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