2026 CODAC Benefit Summaries and Carrier Flyers

20. Medications consumed at the time and place where dispensed or where the Prescription is issued, including but not limited to samples provided by a Physician or Prescriber. 21. Medications dispensed prior to the effective date of the Rx Plan. 22. Medications received from other than a licensed pharmacy. 23. Vitamins and other nutritional diet supplements, unless prescribed and Medically Necessary. 24. Drugs used for cosmetic purposes. 25. Drugs used to treat erectile dysfunction. 26. Abortifacients. 27. Off-label use and any use prohibited by law. 28. Quantities that exceed limits established by the Rx Plan, or replacement Medications due to being lost, stolen. 29. Quantities that exceed the quantity prescribed, or for any refill dispensed later than one year after the date of the original Prescription order. 30. Specialty Drugs, including but not limited to gene and cellular therapies, if excluded under Exhibit A or C. If not excluded, Specialty Drugs obtained from pharmacies that are not approved by the PBM. 31. Orphan Drugs, if excluded under Exhibit A or C. If not excluded, Orphan Drugs obtained from pharmacies or other providers that are not approved by the PBM. 32. Any Medication or category of Medication that the PBM publishes as excluded or that is not contained in the PBM's Formulary. 33. Any Medications which are prescribed, dispensed, or intended for use while the Covered Person is an inpatient in a hospital or other facility. 34. Any other Medication, product, service or supply not specifically authorized and payable under the Rx Plan or otherwise payable under any separate program of benefits of the Employer. 35. Any other Medication, product, service or supply that is specifically excluded under Exhibit C to the Rx Plan. 36. Drugs used for weight loss. 4.6 Definitions – Rx Plan Benefits The following are definitions and related terms regarding the Rx Plan benefits. ALLOWED CHARGE OR AMOUNT The maximum amount the Rx Plan determines is payable for a covered expense for pharmacy benefits. The Allowable Charge under the Rx Plan is generally the lower of following amounts: A. The Customary and Reasonable charge; B. Any price specified on a PBM maximum allowable cost list plus Dispensing Fee; or C. The Average Wholesale Price less a contractually determined discount amount plus Dispensing Fee. When this Rx Plan is secondary to other coverage, the Allowed Charge will be the amount allowed but not covered by the other plan subject to the coverage provisions of this Rx Plan. APPROVED CLINICAL TRIAL The term "Approved Clinical Trial" means a phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other Life Threatening Condition and is one of the following:

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CIDN:199534