2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit C - Addendums / Amendments

Addendum or Amendment Name: Effective Date:

Exclusion – GLP-1 Receptor Agonists for Non-Diabetes Indications

January 1, 2026 Coverage for Glucagon-Like Peptide-1 (GLP-1) receptor agonist medications is limited to FDA-approved indications for the treatment of type 2 diabetes mellitus only. This includes, but is not limited to, medications such as semaglutide, tirzepatide, liraglutide, dulaglutide, exenatide, and any biosimilars or future FDA-approved GLP-1 agents. Use of GLP-1 receptor agonists for weight management, obesity, overweight, or other non-diabetic indications, or other products approved primarily for weight loss, cardiovascular disease, liver disease, or obstructive sleep apnea. is excluded from coverage under this Plan. Coverage of GLP-1 receptor agonists for type 2 diabetes will be subject to the Plan’s medical necessity review, utilization management, and prior authorization requirements.

49

CIDN:199534