2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit A - Schedule of Benefits Value Based Plan (VBP)

Employees of CODAC Health, Recovery & Wellness, Inc. who are covered under the Value Based Plan (VBP) 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 Value Based Plan (VBP) under the CODAC Health, Recovery & Wellness, Inc. Group Medical Plan

Eligible Employees:

Eligible Entry Date:

Who Pays for the Coverage

Combination of Employer and Employee contributions

Only Spouses who are covered under the Value Based Plan (VBP) option under the Group Medical Plan

Any Restrictions on Spouse Participation?

Is Spousal Coverage Subject to a Limitation Secondary Coverage Only?

See Medical Plan Document

Individual: $2,500 Family: $5,000

Deductible:

Out of Network - Individual: $5,000 Out of Network - Family: $10,000

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: $10,000 Out of Network - Family: $20,000

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 - 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 Pharmacy

Supply Limits

31 Day

90 Day

30 Day

Generic

$15 Copay $45 Copay $85 Copay

$37.50 Copay

N/A N/A N/A

Preferred Brand

$112.50 Copay $212.50 Copay

Non-Preferred Brand

Specialty

N/A N/A

N/A N/A

$170 Copay

Other Rules

N/A

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CIDN:199534