CODAC 2025 Benefit Plan Summaries

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

Tier 2 All Other Providers

Tier 1 Facility+ PHCS Professional & Ancillary

No charge; Deductible Waived

50% Coinsurance

Office visits

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 are pregnant

Childbirth/delivery professional services

50% Coinsurance

30% Coinsurance

Childbirth/delivery facility services

50% Coinsurance

30% Coinsurance

60 Maximum visits per calendar year. Subject to Medical Necessity Review. 20 Maximum visits per calendar year OT; 20 Maximum visits per calendar year PT; 20 Maximum visits per calendar year ST. Preauthorization is required. If you don’t get preauthorization, a penalty of $250 may be applied. 20 Maximum visits per calendar year. Habilitation services for Learning Disabilities are not covered

50% Coinsurance

Home health care

30% Coinsurance

50% Coinsurance office therapy; Not covered outpatient hospital

$25 Copay per visit; Deductible Waived

If you need help recovering or have other special health needs

Rehabilitation services

50% Coinsurance office therapy; Not covered outpatient hospital

$25 Copay per visit; Deductible Waived

Habilitation services

60 Maximum days per calendar year. Subject to Medical Necessity Review.

50% Coinsurance

Skilled nursing care

30% Coinsurance

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