2026 CODAC Benefit Summaries and Carrier Flyers

7.2 Important Terms Adverse Benefit Determination . An "Adverse Benefit Determination" is a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigative or not Medically Necessary or appropriate; and in the case of a plan providing disability benefits, the term "Adverse Benefit Determination" also means any rescission of disability coverage with respect to a Participant or beneficiary (whether or not, in connection with the rescission, there is an adverse effect on any particular benefit at that time). For this purpose, the term "rescission" means a cancellation or a denial, reduction, or termination of, or a failure to provide or make payment for (in whole or in part), a benefit. Claim . A "Claim" under the Plan is a request for benefits under the Rx Plan made by a Claimant in accordance with the procedure for filing benefit claims. All Claims must be filed as specified in this Rx Plan. Claim appeals on Adverse Benefit Determinations must be in writing. Claimant . A "Claimant" is the Rx Plan Covered Person who files a Claim or an Appeal. A personal representative may be authorized to act on behalf of a Claimant. This authorization must be in writing and signed by the Claimant. Claim File . A "Claim File" means the file or other compilation of "Relevant" information, which includes information that: 1) was relied upon in making the benefit determination; 2) was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; 3) demonstrates compliance with the administrative processes and safeguards as provided in this procedure, or 4) constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the Claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination. Claims Administrator . The "Claims Administrator" for the Rx Plan is the PBM, unless the Plan Administrator has determined that it will handle the claim and/or appeal. Plan Administrator . The "Plan Administrator" for the Plan is the Employer. 7.3 Claim and Appeal Procedures In the event that this Claims Procedure applies to a Claim or Appeal, as stated in Section 7.1 above, the following claim and appeal process is to be followed. a) Initial Claim for Benefits Filing of Claim . A Claim for benefits under the Rx Plan will be filed, in writing, with the PBM with a copy to the Plan Administrator. Notice of Denial . If a Claim is for post service, or certain concurrent non-urgent service claims for benefits under the Rx Plan is wholly or partially denied, except as otherwise provided herein, the Plan Administrator or the PBM will, within 30 days after receipt of the Claim, notify the Claimant of the denial of the Claim. Such 30-day period may be extended for no more than an additional 15 days if the Plan Administrator or the PBM determines that an extension of time for processing the Claim is necessary due to matters beyond the control of the Rx Plan, in which case the Plan Administrator or PBM will notify the Claimant of the extension in writing within the initial 30-day period, and such notice of extension will indicate the circumstances requiring the extension and the date by which the Plan Administrator or PBM expects to render its decision.

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CIDN:199534