2026 CODAC Benefit Summaries and Carrier Flyers

QUANTITY LIMIT The PBM and/or Provider may apply limits to the number of units of Prescription Drugs dispensed under their discretion or in accordance with nationally recognized guidelines. If a Prescription Medicine may be dispensed above the Quantity Limit, the Covered Person may be responsible for the entire cost of the Prescription Medication that exceeds the Quantity Limit. REASONABLE See Usual, Customary and Reasonable below. ROUTINE PATIENT COSTS The term "Routine Patient Costs" means all items and services consistent with the coverage provided under the Plan that is typically covered for a Qualified Individual for treatment of cancer or another Life Threatening Condition or disease who is not enrolled in a clinical trial. However, costs associated with the following are excluded from that definition, and the Plan is not required under federal law to pay for the following: a) the cost of the investigational item, device or service; b) the cost of items and services provided solely to satisfy data collection and analysis needs and that are not used in direct clinical management; or c) the cost for a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis. ROUTINE VACCINES Routine Vaccines refers to certain scheduled immunizations, and payment for such Vaccines may be subject to guidelines based on age, risk factors, dosage, and frequency determined by the PBM. In general, these include Hepatitis A and Hepatitis B, Herpes Zoster, Human Papilloma Virus (HPV), Influenza (Flu), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis (Tdap), Tetanus, Diphtheria, Varicella. Certain of these Routine Vaccines may be preventive care and if they are, they are covered under the Rx Plan without cost sharing. SPECIALTY DRUG The term "Specialty Drug" means certain pharmaceuticals and/or biotech or biological drugs that are high-cost/high technology and are used in the management of chronic or genetic disease, including, but not limited to, injectable, infused or oral Medications, or that otherwise require special handling, dispensing conditions or monitoring, delivered by any means including by purchase at a pharmacy and processed for payment by the pharmacy benefit manager or an Outpatient basis from a provider or facility or purchased directly by the Covered Person. For this purpose, the term "Specialty Drug" means any injectable or non-injectable drug that is on the PBM's list of Specialty Drugs as it determines such list from time to time. Specialty drugs may be found by selecting the appropriate formulary at the PBM's website. See Section 4.1 and Exhibit A. THERAPEUTICALLY EQUIVALENT "Therapeutically Equivalent" describes a circumstance in which two or more Prescription Medicines have essentially the same clinical effectiveness and safety characteristics. TIER If a Tier structure applies to this Rx Plan, it will be so indicated in Exhibit A. A Tier refers to a level of Co-Payment or Co-Insurance that applies for certain categories of Prescription Medicines or supplies. The Tiers (in some cases there

may only be one) are stated in Exhibit A. UNPROVEN DRUG OR SERVICE

A Drug or other therapy, medication or device that has not been determined to be effective for treatment of a particular Sickness, Injury or other medical condition and/or that has not been shown to have a beneficial effect on health outcomes due to insufficient and/or inadequate clinical evidence, including those from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

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CIDN:199534