2026 CODAC Benefit Summaries and Carrier Flyers

TABLE OF CONTENTS

SECTION 1: RX PLAN INTRODUCTION SECTION 2: BASIC INFORMATION

1 1 2 2 2 3 3 3 3 3 8 8

SECTION 3: ADMINISTRATION AND RELATED INFORMATION

3.1 Plan Funding and Constituent Benefit Programs

3.2 Plan Administrator, Claims Administrator and Discretionary Authority

3.3 Plan Amendment and Termination SECTION 4: PROGRAM OF BENEFITS 4.1 Pharmacy Benefit Manager ("PBM") 4.2 Schedule(s) of Benefits – Exhibit A 4.3 Rx Plan Benefit Information 4.4 Accessing Your Benefits 4.5 Exclusions and Limitations 4.6 Definitions – Rx Plan Benefits

10 19 19 20

SECTION 5: ELIGIBILITY AND EFFECTIVE DATE

5.1 Who Is Eligible for Coverage 5.2 Effective Date of Coverage

SECTION 6: WHEN YOUR COVERAGE WILL END 21 SECTION 7: CLAIMS FOR BENEFITS, BENEFIT DETERMINATION AND CLAIM APPEALS 21 7.1 Claims for Benefits and Benefit Determinations 21 7.2 Important Terms 22 7.3 Claim and Appeal Procedures 22 a) Initial Claim for Benefits 22 b) Notice of Denial 23 c) Appeal of Decision 24 d) Final Determination 24 7.4 External Review (Only Applies to Non-Grandfathered Health Plans) 25 7.5 Time Limit to Appeal Denial of a Claim Will Be Strictly Enforced 27 7.6 Exhaustion, Process and Correction of De Minimis Process Matters 28 7.7 One Year Limit to File a Legal Action, Assignment 28 SECTION 8: RIGHTS OF REIMBURSEMENT AND SUBROGATION 28 SECTION 9: ACCESS TO RECORDS 29 SECTION 10: RECOVERY OF BENEFITS 30

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CIDN:199534