2026 CODAC Benefit Summaries and Carrier Flyers

state the Claimant may have a right to bring a civil action under Section 502(a) of ERISA; include any internal rule, guideline, protocol, or other similar criterion that was relied upon in an Adverse Benefit Determination, or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the Claimant upon request; include either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the Claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request when an Adverse Benefit Determination is based on a medical necessity or experimental treatment or similar exclusion or limit; and include the following statement: "You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your State insurance regulatory agency." Authorized Representative . The Plan Administrator or PBM will permit an authorized representative of the Claimant to act on behalf of the Claimant under this claim and appeal procedure. The Plan Administrator or PBM may establish reasonable procedures for determining whether an individual who purports to be an authorized representative of a Claimant has in fact been authorized to act on behalf of such Claimant. Culturally and Linguistically Appropriate Notices . Whenever the phrase: "culturally and linguistically appropriate" appears in this claims procedure, the following requirements apply: The plan will provide oral language services (such as a telephone customer assistance hotline) that include answering questions in any applicable non-English language and providing assistance with filing claims and appeals in any applicable non-English language. The plan will provide, upon request, a notice in any applicable non-English language. The plan will include in the English versions of all notices, a statement prominently displayed in any applicable non-English language clearly indicating how to access the language services provided by the plan. For purposes of these rules, with respect to an address in any United States county to which a notice is sent, a non-English language is an applicable non-English language if ten percent or more of the population residing in the county is literate only in the same non-English language, as determined in guidance published by the Secretary. Administrative Processes and Safeguards . The Plan Administrator will develop such administrative processes and safeguards as it deems necessary to ensure and verify that claim determinations are made in accordance with the Rx Plan and other governing documents, if any, and that where appropriate, the provisions of the Rx Plan have been applied consistently with respect to similarly situated Claimants. 7.4 External Review (Only Applies to Non-Grandfathered Health Plans) Voluntary External Review . This is a special default language for a procedure that applies only if the Rx Plan has "non-grandfathered" status, or if it loses grandfathered status. In such a case, a voluntary external review process applies if the Claimant has exhausted the two levels of appeal (when required), and the Claimant is still not satisfied with the final determination. Voluntary external review only applies to the denial of medical, mental health/substance abuse, prescription drug, certain dental, or vision claim denials if the denial is based on one of the following: 1. Clinical reasons based upon medical judgment, including medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit; or if a treatment is experimental or investigational; or 2. Rescission (retroactive termination) of care.

25

CIDN:199534