2026 CODAC Benefit Summaries and Carrier Flyers

Unless covered under the applicable formularies, the Prescription Drug Plan does not pay costs or expenses for the following Medications, services, supplies, charges, or other items, or for Medications prescribed for the following, even if deemed to be Medically Necessary, unless otherwise expressly stated below: 1. International Claims for Drugs covered under the Plan will generally be reimbursed; however, all claims are subject to review, and reimbursement is not guaranteed. 2. Durable Medical Equipment: These excluded devices include, but are not limited to, therapeutic devices, artificial appliances, braces, support garments, or any similar device. 3. Except as provided under the Clinical Trial coverage, Experimental, Investigational, or Unproven Medicines, or any charges related to them, even though a charge is made to a Covered Person, and whether or not incurred prior to, in connection with, or subsequent to an Experimental, Investigational, or Unproven service or supply, all as determined by the PBM; Medications or other substances used for other than FDA-approved indications; or Medications labeled: "Caution – limited by Federal law to investigational use." 4. Any Medication not approved by the FDA, or any that is approved for purposes other than for which the Medication is prescribed. 5. Except as provided under the Clinical Trial coverage, new FDA-approved drug product or technology (including but not limited to Medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to pharmacies, for the first six months after the date the product or technology received FDA new drug approval or other applicable FDA approval. The Rx Plan may, in its sole discretion, waive this exclusion in whole in part for a specific new FDA approved drug product or technology. 6. Medications that are prescribed for, and related to, procedures, treatments, and/or services that are otherwise excluded or not covered under the Rx Plan, or are excluded under the group health plan. 7. Any Prescription Medications that may be properly received without charge under local, state, or federal Plans. 8. Any Medications, treatments, supplies, charges, or items for which the Covered Person has no legal obligation to pay in the absence of coverage under the Rx Plan or other such prescription drug coverage. 9. Except as described elsewhere within this document, over-the-counter Medications and Medications that can legally be bought without a written Prescription or a pharmaceutical alternative to an over-the-counter Medication other than insulin. 10. Cosmetic surgery and care primarily intended to improve the Covered Person's appearance. However, benefits are provided under the Rx Plan if necessary to improve a deformity arising from or directly related to a congenital abnormality, a personal injury resulting from accident or trauma, or a disfiguring disease. 11. Chemical face peels or abrasion of the skin. 12. Cosmetic products (other than certain acne Medications such as retinoids). 13. Comfort, luxury, personal hygiene, or convenience items that are not Medically Necessary. 14. Completion of Claim forms or charges for medical records or reports, unless otherwise required by law. 15. Conditions resulting from a riot, war (declared or undeclared), civil disobedience, nuclear explosion, nuclear accident, or terrorist act. 16. Court-ordered testing or care unless Medically Necessary. 17. Custodial care, domiciliary care, or convalescent care. 18. Medical supplies stocked in the home for general use, like adhesive bandages, thermometers, and petroleum jelly, or any delivery charges associated with any Medication. 19. Medications, services, supplies, charges, or items that are not Medically Necessary.

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CIDN:199534