CODAC 2024 Guide To Your Benefits

VBP – MultiPlan’s PHCS Network

UMR HDHP - UHC Choice Plus Network

Value - Based Payments (VBP)

UMR $3,200 HDHP

PHCS Network Professional Providers

Non - Network Professional Providers

Plan Provisions

In - Network

Out - of - Network

and all Facility & Hospital Benefits

Company Contribution to HSA

Not Applicable

$46.15 per pay period

Annual Deductible (Individual/Family) Embedded

$2,500 / $8,000

$5,000 / $10,000

$3,200 / $6,400

$8,000 / $16,000

Out - of - Pocket Maximum (Includes Deductible, Coinsurance & Copays)

$5,000 / $10,000

$10,000 / $20,000

$5,000 / $10,000

Unlimited

Lifetime Maximum

Unlimited

Unlimited

Preventive Care

Covered 100%

50% after deductible

Covered 100%

50% after deductible

Physician Office/Telehealth Visit

$25 copay

50% after deductible

20% after deductible

50% after deductible

Specialist Office/Telehealth Visit

$50 copay

50% after deductible

20% after deductible

50% after deductible

X - Ray

$75 copay

50% after deductible

20% after deductible

50% after deductible

Labs

Covered 100%

50% after deductible

20% after deductible

50% after deductible

Advanced Imaging (CT, PET, MRI)

30% after deductible

50% after deductible

20% after deductible

50% after deductible

Inpatient

30% after deductible

50% after deductible

20% after deductible

50% after deductible

Outpatient

30% after deductible

50% after deductible

20% after deductible

Excluded

Urgent Care

$75 copay

50% after deductible

20% after deductible

50% after deductible

Emergency Room Care

$350 copay

20% after deductible

20% after deductible

Teladoc - Virtual Visits (General Medicine/Dermatology)

$20 copay

20%, deductible waived

Medical plan deductible applies. Waived for certain preventative drugs.

Prescription Drug Deductible

None

Retail Prescription Drugs (30 day) Generic Preferred Brand Non - preferred Brand Specialty

$10 copay $30 copay $50 copay After deductible $0 with Prudent Rx enrollment 30% without Prudent Rx enrollment

$15 copay $45 copay $85 copay $0 with Prudent Rx enrollment 30% without Prudent Rx enrollment

Responsible for any amount over allowed amount

Responsible for any amount over allowed amount

Mail Order Prescription Drugs (90 day) Generic Preferred Brand Non - preferred Brand

After deductible is met $25 copay $75 copay $125 copay

$37.50 copay $112.50 copay $212.50 copay

N/A

N/A

Dependents are eligible to age 26.

DEDUCTIBLE DEFINITIONS EMBEDDED deductible means one person in a family meeting their individual deductible at which point the health plan will begin paying. The remainder of the family can make up the remaining portion of the family deductible.

4 CODAC Health, Recovery & Wellness | 2024 Employee Benefits Guide