2026 CODAC Benefit Summaries and Carrier Flyers

Exhibit C - Addendums / Amendments

Addendum or Amendment Name: Effective Date:

CVS Caremark Smart Logic Program

January 1, 2026 The Plan uses the CVS Caremark Smart Logic prior authorization program (the “Smart Logic Program”) to manage coverage for certain glucagon-like peptide-1 (GLP-1) receptor agonists and related agents, including combination GLP-1/GIP products (collectively, “GLP-1 medications”). The Smart Logic Program is intended to promote safe, clinically appropriate and cost-effective use of these medications and to help ensure that they are

used in accordance with the terms of the Plan. Medications subject to the Smart Logic Program

GLP-1 medications subject to the Smart Logic Program generally include, but are not limited to, certain brand name and generic products used for the treatment of type 2 diabetes. Examples of drugs in this class may include: • GLP-1 receptor agonists (e.g., semaglutide, liraglutide, dulaglutide, exenatide, lixisenatide) • GLP-1/GIP combination products (e.g., tirzepatide) The specific list of GLP-1 medications and strengths subject to the Smart Logic Program may change from time to time. For current information, contact CVS Caremark or visit the pharmacy benefits website listed on your ID card. Prior authorization and smart logic review All prescriptions and refills for GLP-1 medications that are subject to this Program require prior authorization under the Plan. CVS Caremark administers prior authorization on behalf of the Plan using clinical rules. Clinical criteria (overview) To be considered for coverage under the Smart Logic Program, members must meet clinical criteria established by CVS Caremark and the Plan. These criteria are based on FDA-approved indications and other evidence-based standards and may include, for example: • Documentation of a diagnosis of type 2 diabetes mellitus; and • Evidence of inadequate glycemic control or intolerance with other preferred agents, consistent with current clinical guidelines; and • Use consistent with FDA-approved dosing and frequency. The specific clinical criteria, including any requirements for step therapy, trial of preferred medications, BMI thresholds, comorbid conditions, maximum dose limits or maximum duration of therapy, may change over time. CVS Caremark will apply the criteria in effect at the time a prior authorization request is reviewed. Coverage for GLP-1 medications under the Smart Logic Program is typically approved for a limited period (for example, up to 6 or 12 months at a time). Continued coverage beyond the initial approval period may require reauthorization, including evidence of continued clinical need and, if applicable, appropriate response to therapy as determined under the Plan’s criteria. If a member does not continue to meet the applicable criteria upon reauthorization review, coverage for the GLP-1 medication may be reduced, modified or discontinued.

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