2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit C - Addendums / Amendments

Addendum or Amendment Name: Effective Date:

Formulary Modifications

January 1, 2025 Please note that our pharmacy formulary is subject to periodic review and modification; as a result, a drug that appears on the current formulary may subsequently be excluded from the formulary and thus, excluded from coverage under the plan. Coverage of any medication is always determined at the time of dispensing, based on the most up-to-date formulary, utilization-management edits, and benefit design in effect.

47

CIDN:199534