CODAC 2025 Benefit Plan Summaries

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information

Services You May Need

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

In-network (You will pay the least)

In-network deductible applies to Out-of-network benefits

Emergency room care

20% Coinsurance

20% Coinsurance

In-network deductible applies to Out-of-network benefits; Preauthorization is required for Non-emergent transports. If you don’t get preauthorization, a penalty of $250 may be applied.

If you need immediate medical attention

Emergency medical transportation

20% Coinsurance

20% Coinsurance

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

20% Coinsurance

Physician/surgeon fees

50% Coinsurance

Preauthorization is required for Partial hospitalization. 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.

50% Coinsurance Office visits; Not covered other outpatient services

If you have mental health,

Outpatient services

20% Coinsurance

behavioral health, or substance abuse services

Inpatient services

20% Coinsurance

50% Coinsurance

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