2026 CODAC Benefit Summaries and Carrier Flyers

A. A federally funded trial that is approved or funded, including in-kind contributions, by one or more of the following entities: 1. the Centers for Disease Control and Prevention; 2. the Agency for Health Care Research and Quality; 3. the Centers for Medicare & Medicaid Services; 4. the National Institutes of Health; 5. the United States Department of Defense; 6. the United States Department of Veterans Affairs; 7. cooperative group or center of any of the above entities; 8. the United States Department of Energy; or 9. a qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants; B. A clinical trial conducted under an FDA investigational new drug application; or C. A drug trial that is exempt from the requirement of an FDA investigational new drug application. AVERAGE WHOLESALE PRICE Average Wholesale Price ("AWP") is a nationally tracked pricing index provided to the PBM by Medi-Span, or such other nationally available reporting service of pharmaceutical prices as recommended by the PBM. AWP is the list price charged by wholesalers in the United States for the drug products they sell to a Pharmacy. BRAND (BRAND-NAME) MEDICATION The term "Brand Medication" or "Brand-name Medication" means a Prescription Medicine identified by the PBM based on criteria provided by nationally recognized source(s) of prescription drug pricing information, as appropriate as a non-generic product, that is also not a Specialty or Orphan Drug. Designations by a manufacturer are not binding on the PBM as to its determination of whether a medication is a Brand Medication. CLEAN CLAIM The term "Clean Claim" means a billing for a service and/or supply that is submitted to the Rx Plan by a Covered Person or a Provider that has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. It must clearly identify the Covered Person receiving the services or supplies and the Rx Plan to which it is being submitted and be submitted on an appropriate form that has been properly and entirely completed, including all data elements required by the applicable form. If a claim that has been submitted to this Rx Plan is determined by the Claims Administrator or Plan Administrator to not constitute a Clean Claim, the Covered Person and/or the Provider will be notified of the defects, and it will not be considered to have been received by the Rx Plan until all required information is received. COMPOUND MEDICATION Compound Medication is a medication mixed for a specific patient and not available commercially. To be eligible for reimbursement, claims for compounds must meet the PBM's requirements, including without limitation, they must list the 11-digit National Drug Code for each ingredient used in the compound. CO-INSURANCE The term "Co-Insurance" means a percentage of the Covered Expenses that the Covered Person must pay before the Prescription Drug Plan pays benefits for a particular service or supply. CO-PAYMENT The term "Co-Payment" (or "Copay") means a specific dollar amount, of the Covered Expenses that the Covered Person must pay before the Prescription Drug Plan pays benefits for a particular service or supply.

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CIDN:199534