2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit A - Schedule of Benefits HDHP $3,400 Plan

Employees of CODAC Health, Recovery & Wellness, Inc. who are covered under the HDHP $3,400 Plan option under the CODAC Health, Recovery & Wellness, Inc. Group Medical Plan Employee Enters as of the Date the Employee of CODAC Health, Recovery & Wellness, Inc. enters the HDHP $3,400 Plan under the CODAC Health, Recovery & Wellness, Inc. Group Medical Plan Combination of Employer and Employee contributions Only Spouses who are covered under the HDHP $3,400 Plan option under the Group Medical Plan

Eligible Employees:

Eligible Entry Date:

Who Pays for the Coverage Any Restrictions on Spouse Participation? Is Spousal Coverage Subject to a Limitation Secondary Coverage Only?

See Medical Plan Document

Individual: $3,400 Family: $6, 8 00

Deductible:

Out of Network - Individual: $8,000 Out of Network - Family: $16,000

Is the Deductible for Individual Embed in the Family Deductible? Does the Deductible Accumulate with the Group Medical Plan of the Employer?

Yes

Yes

Individual: $5,000 Family: $10,000

Maximum Out-of-Pocket "MOOP"

Out of Network - Individual: No Maximum Out of Network - Family: No Maximum

Is MOOP for Individual Embed in the Family MOOP? Does the MOOP Accumulate with the Group Medical Plan of the Employer?

Yes

Yes

Exclusive Specialty Network Mandatory - Plan participants must use the Exclusive Specialty Network for Specialty Medications. Specialty Medications filled through other pharmacies will not be covered by the Plan. Please contact the PBM for more information. PrudentRx including HDHP Plans - The Plan has teamed up with PrudentRx to help with certain specialty medications. PrudentRx helps individuals find and sign up for manufacturer copay assistance programs. If you enroll with PrudentRx, you'll pay $0 for specialty medications covered by the PrudentRx Program and the Plan. Without PrudentRx enrollment, a 30% coinsurance will apply. For more details, see Exhibit C. Dispense As Written Penalty (DAW 1&2) - When a generic is available, but the pharmacy dispenses the brand name medication for any reason, then the Plan participant will pay the difference between the brand cost and the generic cost, and the member will be charged the brand cost share.

Special Rules?

Supply Method :

Retail

Mail Order

Exclusive Specialty Network

Supply Limits

31 Day

90 Day

30 Day

Generic

$10 Copay after deductible $30 Copay after deductible $50 Copay after deductible

$25 Copay after deductible $75 Copay after deductible $125 Copay after deductible

N/A N/A N/A

Preferred Brand

Non-Preferred Brand

Specialty

N/A N/A

N/A N/A

$50 Copay after deductible

Other Rules

N/A

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CIDN:199534