2026 CODAC Benefit Summaries and Carrier Flyers

About the Formulary - The Drug List The PBM will establish a "Formulary" or "Formulary Medication" list or "Drug List" of the Medications covered by the Rx Plan. Formulary Lists may be compiled by Drug categories, such as "Generic" or "Preferred," or even by Tiers, or otherwise, and the Formulary list or lists are available to Covered Persons as stated in this Rx Plan. The establishment of the Formulary or Drug List is the responsibility of the PBM and its determinations of what is on any Formulary is subject to its full and complete discretion. The Formulary or Drug List is also subject to the terms of the Plan and any specific parameters developed by the Plan Sponsor in the design of the Rx Plan. The Formulary list or lists are subject to change at any time. Covered Persons will be reasonably notified of any changes or updates, including any additions or deletions to the Formulary, consistent with the terms of the Rx Plan and applicable law. The Formulary lists serve also as a guide for Covered Persons and their Prescribers and Physicians. See Section 4.2 and the Schedule(s) of Benefits at Exhibit A for additional information regarding the Formulary or Drug List. Certain Restrictions and Limitations. Some Medications may be subject to quantity limits. These limits help your doctor and pharmacist check to ensure that the Medication that you are taking is being used correctly and safely for an appropriate duration. The PBM may employ various tools to assist it in determining quantity limits, which may include medical guidelines, FDA-approved recommendations, and recommendations from Drug manufacturers. The quantity limits determined by the PBM are done so at its discretion and all Covered Persons are bound by such determinations. Medications lost as a direct result of a natural disaster, or other circumstance may be replaced under rules and guidelines established by the PBM in its sole discretion. Covered Persons will be given the opportunity to prove that the Medications were lost due to a legitimate reason, including a natural disaster. Acceptable proof could include, but not necessarily be limited to, proof of other filed claim of loss or other writing. Information About Generic Medications . Generic Medications contain the same active ingredients in the same amount as Brand Medications, but may not otherwise resemble the Brand Medication in name or packaging. Generic Medications are widely seen as one of the best ways to save money on Prescriptions and are as safe and effective as Brand Medications, but on average Generic Medications can cost about 30 percent to 80 percent less. All Generic Medications that have been approved for substitution have been reviewed by the FDA and found to be as safe and effective as the equivalent Brand Medication. The companies that manufacture Generic Medications must meet the same FDA manufacturing and quality standards as those that make Brand Medications. Only your Physician can decide what's best for you, but be sure to ask about your generic options. Ask your Physician or other Prescriber to approve Generic substitution whenever appropriate. You can use these FDA-approved products with confidence and the knowledge that you are saving money. Some Plans have requirements regarding the use of Generics when one is available. See the Schedule(s) of Benefits at Exhibit A and the Section "Generic Drug Limitation" below. Information About Preferred or Brand Medications . "Preferred" or "Brand" Medications are safe and effective choices that the PBM identifies in the Formulary or Drug List. They are often more expensive than Generic Medications, when a Generic is available, and Covered Persons should always consider whether a Generic version of the Medication is available. Coverage of Preventive Care Medications . Certain preventive care Medications, specifically, evidence-based items that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force are normally covered under the Rx Plan without any cost sharing. That means the Covered Person will not be required to pay a Deductible, Co-Payment or Co-Insurance when obtaining such preventive care medications from a Network Pharmacy. The PBM will determine what Medications are to be treated as preventive care Medications subject to this provision of the Rx Plan consistent with the terms of this Rx Plan and applicable law.

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CIDN:199534