2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit C - Addendums / Amendments

Addendum or Amendment Name: Effective Date:

Expensive Dosage Formulas

January 1, 2025 Please note that medications can often come in a variety of dosage forms, such as tablets, capsules, sprays, suspensions, and solutions, and despite being generic, certain dosage forms of these medications are marketed at an excessive cost even though clinically similar alternatives exist. The Plan will exclude coverage of specific high cost dosage forms when there is a therapeutically equivalent alternate formulation. When you present a prescription for one of these excluded forms, you’ll be prompted to receive the preferred, lower-cost alternative that delivers the same active ingredient and therapeutic effect. Please contact the PBM for more information.

45

CIDN:199534