2026 CODAC Benefit Summaries and Carrier Flyers

5. the Prescription Medicine is not subject to an Exclusion or limit under this Rx Plan or Exhibits A or C; 6. the Prescription Medicine is in the Formulary specified by the PBM; 7. you pay the required Deductible, Co-Payment and/or Co-Insurance amount; and 8. you have otherwise complied with the terms of the Rx Plan. What the Rx Plan Covers - The Rx Plan provides benefits to Covered Persons for Prescription Medicines (or Drugs): 1. prescribed by a Prescriber; 2. listed as a Medication on the then applicable Formulary and otherwise payable under this Rx Plan, subject to the rules and requirements of this Rx Plan and the PBM; 3. in an amount not to exceed the day's supply stated in the applicable Schedule of Benefits (if any); 4. Medically Necessary for the care and treatment of an Illness or Injury; 5. subject to the payment of any required Deductible, Co-Payment, and/or Co-Insurance amount; 6. not excluded in the Exclusions and Limitations Section, or otherwise; 7. not Experimental, Investigative, or Unproven; 8. with certain limited exceptions, may only be obtained by Prescription and are dispensed in a container labeled "Rx only;" 9. dispensed by a Pharmacy or a Participating Pharmacy that is both legally permitted to dispense the Medication and is a permitted dispensing Pharmacy, either Network, or Non-Network permitted under this Rx Plan and by the PBM; and 10. certain non-prescription products prescribed by a duly licensed medical professional as provided in the Formulary of the PBM. See below. Deductibles, Co-Payments, Co-Insurance and Out-of-Pocket Maximums Coverage is subject to the payment of any required Deductible, Co-Payment, or Co-Insurance, subject to any Out-of Pocket Maximums and the provisions of this Rx Plan, and the Schedule(s) of Benefits at Exhibit A. Deductible . A Deductible, if any, is the amount you must pay each year before the Rx Plan pays for benefits under the Rx Plan. The applicable "year" that applies is defined in the Schedule(s) of Benefits at Exhibit A. This is a payment that is required in order for you to receive benefits under the Rx Plan. Deductible amounts are subject to and count toward the Out-of-Pocket Maximum, as stated in Exhibit A. The Deductible will be waived for certain preventive Drugs. Co-Payments . A Co-Payment (or Copay) is the amount you pay each time you receive Drugs or Supplies under the Rx Plan, and if applicable, it is stated in the Schedule(s) of Benefits at Exhibit A. The Co-Payment is usually a fixed dollar amount and is paid at the time of service when receiving a Drug or supply. If the cost of the Drug or supply is less than the Co-Payment, you are only responsible for paying the cost of the Covered Drug or supply. Network Prescription Drug Co-Payments are subject to and count toward the Out-of-Pocket Maximum, as stated in Exhibit A. Co-Insurance . A Co-Insurance is the amount you pay each time you receive Drugs or Supplies under the Rx Plan, and if applicable, it is stated in the Schedule(s) of Benefits at Exhibit A. The Co-Insurance is usually a percentage of the cost of the Drug payable by the Rx Plan or as otherwise negotiated between the PBM and the Pharmacy and is paid at the time of service when receiving a Drug or supply. Drug Co-Insurance amounts are subject to and count toward the Out-of-Pocket Maximum, as stated in Exhibit A. Out-of-Pocket Maximum . The Out-of-Pocket Maximum is your overall limit for the out-of-pocket amounts you will pay during the applicable year for Drugs or Supplies, and this amount is stated in the Schedule(s) of Benefits at Exhibit A. The Out-of-Pocket Maximum that applies to Network Pharmacies may be different than that applicable to Non Network Pharmacies, as stated in Exhibit A. Also, the Out-of-Pocket Maximum amount may coordinate with another group health plan or other plan or program of the Employer, as stated in Exhibit A. Once the Covered Person reaches the applicable Out-of-Pocket Maximum, the Covered Person will not be required to pay additional out-of-pocket expenses for benefits under the Rx Plan for the remainder of the Plan Year. Special rules regarding the applicability of Out-of-Pocket Maximums are stated in the Schedule(s) of Benefits at Exhibit A, or under the Special Rules at Exhibit C.

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CIDN:199534