CODAC 2025 Benefit Plan Summaries

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

Important Information

$350 Copay per visit; Deductible Waived

$350 Copay per visit; Deductible Waived

Emergency room care

Copay may be waived if admitted

If you need immediate medical attention

Tier 1 deductible applies to Tier 2 benefits; Preauthorization is required for non-emergent air 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.

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,

50% Coinsurance

Subject to Medical Necessity Review.

Outpatient services

behavioral health, or substance abuse services

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

Inpatient services

30% Coinsurance

50% Coinsurance

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