2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit C - Addendums / Amendments

Addendum or Amendment Name: Effective Date:

Acthar | Cortrophin Gel

May 1, 2025 Acthar coverage is excluded in all formulations, except for Acthar Gel, when used as monotherapy for the treatment of infantile spasms in infants and children under 2 years of age, provided that established clinical criteria are met, as determined by the PBM and the Plan Administrator in their sole and absolute discretion. Coverage is also excluded for Purified Cortrophin Gel in all formulations.

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CIDN:199534