2026 CODAC Benefit Summaries and Carrier Flyers

1. Your medical records; 2. Your attending health care professional's recommendation, reports from appropriate health care professionals and other documents submitted by the Claims Administrator, you or your treating provider; 3. Plan terms, unless the terms are inconsistent with applicable law; 4. Appropriate practice guidelines, which include applicable evidence-based standards; 5. Any applicable clinical review criteria developed and used by the Administrator involved, unless the criteria are inconsistent with Rx Plan terms or applicable law; and 6. The opinion of the IRO's clinical reviewer(s) after considering the information described above to the extent the information or documents are available and the clinical reviewer(s) consider appropriate. The IRO will provide written notice of the decision to you and the Plan Administrator or PBM involved within 45 days after the IRO receives your request. This notice may contain, if relevant: 1. A general description of the reason for the request and information that identifies the claim such as the date(s) of service, health care provider, and claim amount (if applicable); 2. A statement describing the availability, upon request, of the diagnosis code and/or treatment code (and their corresponding meanings); 3. The reason for the prior denial; 4. The date the IRO received the request and the date of the decision; 5. References to the evidence or documents (including the specific coverage provisions and evidence-based standards) considered in reaching the decision; 6. A discussion of the principal reason(s) for the decision, including the rationale for the decision and any evidence-based standards that were relied on in making the decision; 7. A statement that the IRO's determination is binding, unless other remedies are available under state or federal law; 8. A statement that judicial review may be available to you; and 9. The phone number and other current contact information for any applicable office of health insurance consumer assistance or ombudsmen. If the Plan Administrator or PBM receives notice from the IRO that reverses a denial, the Plan Administrator or PBM, as applicable, will immediately provide or authorize coverage for or payment of the claim. The IRO will maintain records of all claims and notices associated with the outside review process for six years and make these records available for examination by you, the Plan Administrator or PBM, or a state or federal oversight agency upon request (except where disclosure would violate state or federal privacy laws). Expedited External Review . An urgent care claim or urgent health appeal is determined as such by the attending provider. In such case, for notification of the Rx Plan's benefit determination (whether adverse or not) must be completed as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the receipt of the claim. 7.5 Time Limit to Appeal Denial of a Claim Will Be Strictly Enforced The time limits for a Claimant to file an appeal after an initial denial of a Claim for benefits and to file a final appeal will be strictly enforced. If a Claim is initially denied and the Claimant does not request a review within the time limit after receipt of that determination, the Claimant will forever forfeit their right to request a review of this determination.

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CIDN:199534