Prescription Summary Plan Description

Prescription Program Effective Date: January 1, 2025

INTRODUCTION Huntington County Community School Corporation (the “Employer”) sponsors the Huntington County Community Schools Employee Health Plan (the "Plan"). The Plan has two components: (1) this document which describes the prescription benefits available through the Plan (“Rx Program”); and (2) the medical component administered by Anthem (“Medical Component Plan”). Prescription benefits provided under the Rx Program are described in this document and are exclusively provided under and subject to the terms of this document, except as specifically provided herein. Non-prescription medical benefits are available under the Medical Component Plan. Under no circumstance shall benefits be covered under both the Rx Program and the Medical Component Plan. This document and the Medical Component Plan are deemed to be the plan document and summary plan description. For purposes of simplicity, this document incorporates by reference the following provisions from the Medical Component Plan: Eligibility; enrollment and termination of coverage; coordination of benefit provisions; HIPAA Privacy and Security Rules; the appeal procedures (except as modified herein); COBRA continuation of coverage; subrogation and reimbursement rights; exclusions and limitations and ERISA information and rights; all of which shall be deemed to be fully set forth herein. RETAIL PHARMACY As a Participant in the Medical Component Plan, you are eligible for prescription benefits under the Rx Program. Your eligibility for benefits under the Rx Program ends on the date your coverage ends under the Medical Component Plan. The Rx Program uses a network of preferred pharmacies (“Participating Providers”) that have contracted with the Rx Program to charge Participants reduced fees for covered prescription drugs. In addition, certain drugs must be purchased at designated pharmacies. TrueScripts Managements Services, LLC (“TrueScripts”) provides claims processing and ministerial services for the Rx Program (but is not an insurer). Any reimbursement by the Rx Program is determined per prescription (“Script”) by the reimbursement levels described herein, which is applied to each covered drug charge and is shown on the Schedule of Benefits. Scripts that exceed the identified per script annual limit will be excluded and not considered eligible expenses under the Plan or this Rx Program. If a drug is purchased from a nonparticipating pharmacy or a Participating Pharmacy when the covered Participant’s ID card is not used, the Participant must pay the entire cost of the prescription, including copay, and then submit the receipt for direct reimbursement to TrueScripts at 513 E. South St., Washington, IN 47501 or www.truescripts.com, subject to the terms of the Rx Program. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 2 of 15

PARTICIPATING PHARMACY The Rx Program has a network of participating retail pharmacies. You can find a local retail pharmacy by visiting www.TrueScripts.com and navigating to the Pharmacy Locator section or by calling TrueScripts at (844) 257-1955. Participating Providers will change, so you should check the above website or contact TrueScripts at the above phone number prior to obtaining pharmacy services or products. DESIGNATED PHARMACY If you require certain prescription drugs, TrueScripts may direct you to a designated pharmacy with which it has an arrangement to provide those prescription drugs. These drugs are listed on the formulary that can be found at www.truescripts.com or by calling TrueScripts at (844) 257-1955. REIMBURSEMENT LEVELS Benefits for eligible drugs are available for prescription drugs that are considered a covered expense as set forth in this document. The Rx Program pays benefits at different levels based upon prescription drug tiers as described below, subject to other exclusions described later in this summary. All prescription drugs covered by the Rx Program are categorized into these tiers on the Preferred Drug Formulary. The tier status of a prescription drug can change periodically, as frequently as monthly, based on TrueScripts’ P & T Management Committee’s periodic tier decisions. When that occurs, you may pay more or less for a prescription drug, depending on its tier assignment. Since the Preferred Drug Formulary may change periodically, for the most current information, call TrueScripts at (844)-257-1955. See the separate section below for Specialty Drugs. Each tier is assigned a reimbursement level which is the amount the Rx Program pays. You will also pay a copay/coinsurance when you visit the Pharmacy. As an example, here is how the tier system works with 3 tiers: Tier 1 • Description: This tier includes many commonly prescribed generic drugs and may include other lower-cost drugs. • Helpful Tips: Use Tier 1 drugs for the lowest out-of-pocket amount. Tier 2 • Description: This tier includes preferred brand-name drugs as well as some generic drugs. • Helpful Tips: Tier 2 drugs will generally have a lower out-of-pocket than Tier 3 drugs. Tier 3 • Description: This tier includes non-preferred brand-name drugs as well as some generic drugs. • Helpful Tips: Tier 3 drugs generally have the highest out-of-pocket cost. Ask your doctor if switching to an alternative drug from Tier 1 or Tier 2 may be right for you. You are responsible for your deductible, if any, or paying the lowest of: Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 3 of 15

1. Any applicable copay or coinsurance that is lower than the deductible; or 2. The network pharmacy's Usual and Customary Charge for the prescription drug; or 3. The price for the prescription drug using an applicable pre-negotiated discount card program; or 4. The prescription drug charge that TrueScripts agreed to pay the network pharmacy. Pharmacy benefits apply only if your prescription is for an eligible expense. For excluded charges, you are responsible for paying 100% of the cost, and those charges do not count towards deductibles or maximum out of pocket. Amounts more than the Rx Program’s specialty drug per script maximum are excluded. TrueScripts will assist Participants seeking reimbursement from third party resources but makes no guarantees. Other programs or services, which may reduce a Participant’s copay as outlined below or Plan expenses, may be implemented by the Plan Administrator or procedurally changed by TrueScripts, by exercising the settlor authority of the Employer, if the program or service will benefit the Plan and participant and there is a likelihood that Plan and/or Participant expenses will be reduced over the longer term. Please see the Exclusion Section regarding the treatment of drugs for which manufacturers provide rebates, discounts, or other payment methods. The Plan Sponsor may offer multiple levels of formularies (referred to as “Level 1,” “Level 2,” etc.). If a Plan Sponsor adopts a multiple level formulary, Participants will be automatically enrolled for benefits under the Level I Formulary, the terms of which are described herein. Upon request or if TrueScripts believes it is beneficial, a Participant will be provided information regarding the other Level(s), including enrollment opportunities, the amount of the premium equivalent a Participant will pay for enrolling in the enhanced Level(s), and other terms of such Level(s). If Level 6 is offered, a Participant may only be enrolled in such level for up to 12 continuous months, or such shorter period as set forth in the summary for Level 6. Upon the expiration of the durational limit, a Participant will have the opportunity to enroll in any other offered level. This information is also available by calling TrueScripts at (844)-257-1955. In addition to the traditional pharmacy benefit plan, the Prescription Drug benefit plan may provide coverage for prescription drugs imported into the United States from a pharmacy facilitated and approved through a plan approved international importation program. Drugs sourced and covered utilizing the international importation program may have associated member cost sharing waived. Drugs excluded by the Prescription Drug benefit plans are not eligible for coverage under the international importation program. Members should contact their international importation program to confirm if a drug is available through the international importation program. SCHEDULE OF BENEFITS PER PERSON Plan Name Drug Type Day Supply CoPay Structure PPO Option 1 Tier 1 1 - 30 $10 Tier 1 31 - 90 $25 Tier 2 1 - 30 $75 Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 4 of 15

Tier 2 31 - 90 $187.50 Tier 3 1 - 30 $150 Tier 3 31 - 90 $375 Specialty Tier 1 1 - 30 $400 Specialty Tier 2 1 - 30 20% to $550 maximum Specialty Tier 3 1 - 30 20% to $2000 maximum Specialty Tier 4 1 - 30 20% Specialty Tier 5 1 - 30 50% Deductible N/A Max Out of Pocket RX & Medical Combined / Individual $7,000.00 / Family $14,000.00 • Family Max OOP is Embedded. If the Plan is intended to be a high deductible health Plan (HDHP), benefits will be processed to maintain HSA eligibility. Plan Name Drug Type Day Supply CoPay Structure PPO Option 2 Tier 1 1 - 30 $10 Tier 1 31 - 90 $25 Tier 2 1 - 30 $75 Tier 2 31 - 90 $187.50 Tier 3 1 - 30 $150 Tier 3 31 - 90 $375 Specialty Tier 1 1 - 30 $400 Specialty Tier 2 1 - 30 20% to $550 maximum Specialty Tier 3 1 - 30 20% to $2000 maximum Specialty Tier 4 1 - 30 20% Specialty Tier 5 1 - 30 50% Deductible N/A Max Out of Pocket RX & Medical Combined / Individual $7,350.00 / Family $14,700.00 • Family Max OOP is Embedded. If the Plan is intended to be a high deductible health Plan (HDHP), benefits will be processed to maintain HSA eligibility. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 5 of 15

The portion of a covered expense that is actually paid by the Participant will apply towards deductibles and coinsurance under Medical Component Plan only if you enroll in the Integrated Medical Component Plan. Deductibles, coinsurance, and co-pays apply towards applicable out of pocket limits. SPECIALTY PHARMACY SCHEDULE OF BENEFITS PER PERSON “Specialty Drug” means a drug, biologic, or biosimilar that typically has more than one of the following key characteristics. 1. A drug, biologic, or biosimilar that treats a medical condition with complex biology which is often difficult to diagnose, requires frequent dosing adjustments, and intensive clinical monitoring to decrease drug toxicity and increase the probability for beneficial treatment outcomes. 2. A drug, biologic, or biosimilar that treats a medical condition that if left untreated would be progressive, enduring, debilitating, and potentially life threatening. 3. A drug, biologic, or biosimilar with an FDA designated orphan drug status. 4. A drug, biologic, or biosimilar approved by the FDA and has been determined that a Risk Evaluation and Mitigation Strategies (REMS) program is necessary for monitoring of medications with a high potential for serious adverse effects and assure safe and effective use. 5. A drug, biologic, or biosimilar approved for use by the FDA through the Emergency Use Authorization (EUA) process. 6. A drug, biologic, or biosimilar administered by a healthcare professional or healthcare setting such as an inpatient or infusion centers. 7. A drug, biologic, or biosimilar that has unique shipment, storage, or other special handling requirements. 8. A drug, biologic, or biosimilar supplied by a limited distribution drug pharmacy network dispensed directly to the patient or healthcare setting and not available through a retail pharmacy. 9. A drug, biologic, or biosimilar requiring individualized care, regardless of dosage form or route of administration, to assist, educate, monitor, and provide appropriate compliance behavior (e.g., persistence and adherence) to facilitate therapeutic goals. 10. A drug, biologic, or biosimilar with a high-cost level of care, defined as a claim greater than $1,500 per fill. Note: If a drug, biologic, or biosimilar therapeutic equivalent or biosimilar product becomes available for a brand specialty drug, then the equivalent drug, biologic, or biosimilar will be included in the Specialty Drug list. If the Plan covers Specialty Drugs, a prior authorization is required for all Specialty Drugs, a list of which can be obtained by calling TrueScripts at (844) 257-1955. First time dispensing of a Specialty Drug may be limited to less than a 30-day supply when not prepackaged for a larger quantity. Additionally, a maximum unit of measure quantity limit per person/plan year may apply to some Specialty Drugs. Covered prescription injectable(s) and certain other specialty drugs such as chemotherapies may only be available through a designated specialty pharmacy. Specialty Drugs are categorized into the above Copay Tiers under Schedule of Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 6 of 15

Benefits or as determined by TrueScripts’ P & T Management Committee exercising the settlor authority of the Employer as it relates to the formulary. For specialty drug maximum unit of measure quantity limit coverage per person/calendar year and Specialty Drugs available through the Specialty Pharmacy contact TrueScripts Member Care Team at (844)-257-1955. Further, some Specialty Drugs may be excluded from a formulary Level. A Participant who is prescribed a Specialty Drug should contact TrueScripts Member Care at the above phone number to determine if the Specialty Drug is excluded from the Participant’s Formulary Level and to determine if other Formulary Levels are available to the Participant that cover the Specialty Drug. DIRECT PARTICIPANT REIMBURSEMENT In order for a request for reimbursement to be processed, a Participant must complete a prescription drug claim form, obtained from the Employer or at www.truescripts.com, attach the receipt, and submit it to TrueScripts at the following address: TrueScripts Management Services 513 E. South St. Washington, IN 47501 Attn: Claims Department A Participant will be reimbursed the amount he/she paid to the pharmacy subject to the terms set forth in the Plan and this Rx Program. CLINICAL TRIAL COVERAGE Benefits for clinical trial coverage under this Rx Program will be administered consistently with the requirements of the Affordable Care Act. Please see the Medical Component Plan document for terms related to clinical trials. LIMITATION OF PHARMACY SELECTION If TrueScripts determines that you may be using prescription drugs in a harmful or abusive manner, or with harmful frequency, your selection of network pharmacies may be limited. If this happens, you may be required to select a single network pharmacy that will provide and coordinate all future pharmacy services. Benefits will be paid only if you use the designated single network pharmacy, subject to the terms of this Rx Program. SUPPLY LIMITS Some prescription drugs are subject to supply limits that may restrict the amount dispensed per prescription order or refill. Additionally, a maximum unit of measure quantity limit per person/plan year may apply to Specialty Drugs. To determine if a prescription drug has been assigned a supply limit or maximum unit of measure quantity limit per person/plan year for dispensing call TrueScripts at (844)-257-1955. Whether or not Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 7 of 15

a prescription drug has a supply limit or maximum unit of measure quantity limit coverage per person/plan year is subject to TrueScripts’ periodic review and modification. Any one retail non-specialty prescription is limited to a ninety (90) day supply and any authorized refills, per Script. “DISPENSED AS WRITTEN” DRUG PROVISION The Rx Program requires that retail pharmacies dispense generic when available unless the prescriber specifically prescribes a brand name drug and marks the prescription “dispense as written.” “Dispense as Written” prescriptions may require a Prior Authorization. Should a Participant choose a Brand name drug, rather than the generic equivalent when the prescriber does not indicate Dispense as Written, the Participant may be responsible for the applicable Brand name drug copay plus the cost difference between the Brand and generic drugs. Additionally, only the applicable generic copay the Participant would have paid may apply toward the Participant’s deductible and / or out-of-pocket maximum. PRESCRIPTION DRUGS LOST AS A DIRECT RESULT OF A NATURAL DISASTER Participants will be given the opportunity to prove that prescription drugs otherwise considered covered expenses under this plan were lost due to a natural disaster. Acceptable proof could include, but not necessarily be limited to, proof of other filed claims of loss (homeowner’s, property, etc.). COVERED EXPENSES The following are prescription products considered covered expenses under the Rx Program: 1. Medications that are necessary for the care and treatment of an illness or injury and are prescribed by a duly licensed medical professional; 2. Medications which can be obtained only by prescription and dispensed in a container labeled “Rx Only”; 3. The following non-prescription (OTC) drugs prescribed by a duly licensed medical professional: a. Medications or vitamins as required by the Affordable Care Act; b. In an amount not to exceed the day’s supply outlined in the prescription schedule of benefits; and c. All other non-prescription OTC drugs that are included in the Medical Component Plan document. 4. Medications for medical treatment or prescription coverage not otherwise excluded by the Medical Component Plan or this Rx Program; and 5. Covered medications prescribed and filled while the Participant is a Participant in this Rx Program. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 8 of 15

Covered expenses under the Rx Program include fees under the TrueScripts' Pharmacy Services Agreement. LIMITS AND EXCLUSIONS The Rx Program’s prescription drug benefits apply only when a Participant incurs a covered prescription drug charge. The covered drug charge for any one prescription will be limited to: 1. Refills only up to the number of times specified by a prescriber. 2. Refills up to one year from the date of order by a prescriber. In addition to exclusions in the Medical Component Plan document, the following exclusions apply. One or more exclusions may apply to any prescription. When exclusions apply to only certain prescription drugs, you can call TrueScripts at (844) 257-1955 for information about which prescription drugs are excluded. Excluded medications include: 1. Medications for any condition, injury, sickness, or mental health disorder arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received under any workers' compensation law or other similar laws. 2. Any prescription drug for which payment or benefits are covered or available as primary from the local, state, or federal government (for example Medicare), whether or not payment or benefits are received, except as otherwise provided by law. 3. Medications available over the counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the plan has designated over-the-counter medication as eligible for coverage as if it were a prescription drug and it is obtained with a prescription order or refill from a prescriber. 4. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a prescription order or refill. 5. Compounded drugs that are available as a similar commercially available prescription drug. 6. Medications dispensed outside of the United States, except in an emergency and except for International Importation Medications as approved for by the Plan. 7. Durable medical equipment (prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered in the Schedule of Benefits). 8. The amount dispensed (days’ supply or quantity limit) which exceeds the applicable supply limit. 9. The amount dispensed (days’ supply or quantity limit) which is less than the minimum supply limit. 10. Certain new drugs and/or new dosages, until they are reviewed and assigned to a tier by the TrueScripts P & T Management Committee, a list of which may be obtained by calling TrueScripts at (844) 257-1955. 11. Medications prescribed, dispensed, or intended for use during an inpatient stay. 12. Prescription drugs, including new prescription drugs or new dosage forms, that do not meet the definition of a covered expense. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 9 of 15

13. Medications used for conditions and/or at dosages determined to be experimental or investigational, or unproven, unless TrueScripts or the Plan have agreed to cover an experimental or investigational or unproven treatment. 14. Except for the assistance provided in 14(a) below, if a drug manufacturer or third party provides for rebates, discounts, and/or reimbursement of all or a portion of the medication supply, that supply portion may be excluded under the terms of the Rx Program. Manufacturer and third-party payment programs do change, and information about this exclusion may be obtained by calling TrueScripts. If a Participant is eligible for a rebate, discount, or reimbursement from a manufacturer or third party, and does not apply for this rebate, discount, or reimbursement, the number of Scripts associated with that rebate, discount, and/or reimbursement will be excluded unless/until the Participant completes and submits an Affidavit establishing that the Participant did not apply and stating the reason(s) for the failure to apply or provides evidence that any application for such rebate, discount, and/or reimbursement was denied. (a) Notwithstanding the foregoing, the Rx Program may establish, by written procedure, a maximum benefit for copay card assistance for each Participant in certain circumstances. The maximum Plan benefit shall be $30,000 and, thereafter, the Plan shall remit to the Participant, as payment assistance within 90 days from month end of benefit determination an amount equal to 10% of the excluded amount paid with a copay card up to $50 per month. Any assistance under this provision shall be deemed to be used by the Participant for medical expenses, and, therefore, tax exempt. 15. All exclusions and limitations under the Medical Component Plan. 16. Medications that are illegal under applicable law. 17. In accordance with the preferred formulary and procedures implemented by TrueScripts, as modified from time to time, certain prescriptions will be deemed processed under the Major- Medical portion of the Medical Component Plan, and therefore excluded under the prescription program. All other prescriptions covered by the Rx Program are excluded by the Major-Medical provisions of the Medical Component Plan DEDUCTIBLES AND OUT-OF-POCKET MAXIMUMS The following amounts do not accrue towards the total covered expenses that are the responsibility of the Participant and do not accumulate toward the applicable Deductible and/or Out-of-Pocket Maximum: 1. Premiums; 2. Expenses that are excluded under the Rx Program; 3. Expenses in excess of the reasonable and customary charges for services or supplies; 4. Expenses in excess of any maximum quantity list in the Rx Program; 5. Penalties; 6. Expenses reimbursed, waived, or covered through manufacturer or third-party assistance programs or discount programs; 7. Expenses for brand-name drugs above the applicable generic copay the Participant would have paid as outlined in the “Dispensed as Written Drug Provision”; and/or 8. Any cost related to a drug that is partially or wholly excluded. PRIOR AUTHORIZATION REQUIREMENT Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 10 of 15

TrueScripts has been retained by the Plan Administrator to provide Prior Authorization services for a particular set of drugs. The Plan has approved a predetermined set of criteria to be applied to this Prior Authorization process. For a drug which is subject to Prior Authorization to be covered by this Rx Program; the pharmacist, Participant, or prescriber must call the TrueScripts Customer Care Department to obtain Prior Authorization before the drug is purchased. TrueScripts will fax the prescriber the necessary forms to obtain the information necessary to determine whether the drug will be a covered expense, based upon the predetermined set of criteria and the information supplied by the prescriber. TrueScripts will notify the pharmacy/Participant or prescriber who submitted the request for Prior Authorization within 72 hours (once the letter of medical necessity is received from the prescriber) that the drug is or is not covered by the Plan. The request for Prior Authorization is considered to be a pre-service claim as described in the U.S. Department of Labor Regulations 2560.503-1 (issued November 21, 2000). TrueScripts authorization is not a guarantee that the drug is eligible for payment under the Rx Program or Plan. The Rx Program may include a Step Therapy program which promotes the utilization of certain Preferred Drugs in specific drug categories such as cholesterol lowering statins and proton pump inhibitors (gastro- intestinal agents); however, others may be identified. Certain drugs have been identified which will not be covered under the Rx Program if the Step Therapy program has not been followed and a Prior Authorization obtained. The Step Therapy program requires documentation from a prescriber that the Participant has tried a minimum number of alternative drug treatments and that they did not successfully treat the Participant’s condition. If a medication the Participant is taking is identified as a Step Therapy drug, the Participant is not required to change medications, but it will not be covered under the Rx Program unless approved through TrueScripts. For more Information on this Step Therapy program, please contact TrueScripts at (844) 257-1955 or visit www.truescripts.com. For a list of drugs that require prior authorization, please visit www.truescripts.com or by calling (844) 257- 1955. APPEALING A DENIED CLAIM OR PRIOR AUTHORIZATION Procedures to appeal denial of claims, services or pre-authorization requests are set forth in the Medical Component Plan and are deemed incorporated herein. However, all appeals for Rx Program shall be sent to and administered by: TrueScripts Management Services, LLC, C/O Appeals Dept. 513 E. South St. Washington, IN 47501. TrueScripts has the discretionary authority to determine the right to benefits and any appeals under the Rx Program. EMERGENCY SUPPLY For covered medications under this Rx Program and in instances in which a Prior Authorization cannot be immediately obtained, Participants may receive and be reimbursed for up to a 72-hour supply of a covered Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 11 of 15

outpatient drug as an “emergency supply.” Such emergency supply must be obtained in accordance with the Rx Program. PREVENTIVE CARE SCHEDULE OF BENEFITS PER PERSON PER CALENDAR YEAR The Plan routinely covers exams and screenings that prevent and identify early certain medical conditions. In accordance with the Affordable Care Act, the Rx Program covers services for preventive care at 100%. Contraceptive Preventive Care The Rx Program will cover certain contraceptive preventive care prescriptions or devices for women without cost sharing. Coverage without cost sharing means women can receive the prescriptions or devices without having to pay a deductible, coinsurance, or copayment. There are some contraceptive prescriptions for which Participants will have to pay a deductible, copayment, or coinsurance. To minimize your out-of-pocket pharmacy costs, follow the below guidelines for prescriptions that will be covered with no cost sharing. The Rx Program benefits cover female contraceptive prescriptions with no cost sharing for Participants receiving these drugs or devices for the prevention of pregnancy that are: 1. Prescribed by a prescriber; 2. Generic; 3. Brand-name drugs without a generic or therapeutic equivalent; and 4. Obtained from an in-network pharmacy. The Rx Program will also cover brand name drugs where a generic is available with no cost sharing if approved thru the TrueScripts Prior Authorization process. Contraceptives not included in the above will be covered at the applicable Participant’s cost share. Additional Preventive Care Additional preventive prescription drug benefits covered according to the Affordable Care Act include the following if: 1. Prescribed by a licensed prescriber; 2. Are generic; 3. Are brand-name drugs without a generic equivalent; and 4. Are obtained from an in-network pharmacy. Aspirin Quantity Limit: 1/day Aspirin products up to 325mg All prescription products, Age limit 45-75 years of including OTCs if processed Clenpiq, Gavilyte-C, Gialax Bowel prep medications age as a prescription. Brand Kit, PEG 3350, Peg-Prep, name will be covered only Plenvu, Suflave, Sutab. if it doesn't have a generic. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 12 of 15

∙ Sodium fluoride tab Fluoride - Sodium fluoride products 0.5mg – 1mg Chemoprevention of Age limit ≤ 6 years of age only, not in combination. ∙ Sodium fluoride chew tab dental cavities 0.25mg – 0.5mg ∙ Sodium fluoride solution Folic Acid - Women planning or Folic acid products only, ∙ Folic Acid tab 0.4mg and Supplementation with capable of pregnancy not in combination. 0.8mg. folic acid Quantity limit: 1/day Vitamin D for fall prevention Age limit ≥ 65 years of Vitamin D age All generic statin products Atorvastatin 10mg, in low to moderate doses, 20mg. Fluvastatin 20mg, Statins Age limit 40-75 years plus additional doses of 40mg. Lovastatin 10mg, generic statin products to 20mg. Rosuvastatin 5mg, the extent determined 10mg. Pravastatin 10mg, preventive by the Plan 20mg. Simvastatin 5mg, Administrator. 10mg, 20mg. Prescribed Anastrozole 1mg, Females only, ages > 35 chemoprevention Exemestane 25mg, Breast Cancer years of age medications for women at Raloxifene 60mg, and increased risk of breast Tamoxifen 10mg, 20mg. cancer. Iron supplements Age limit 6 to 12 months All dosage forms covered. at risk for anemia Emtricitabine and Tenofovir PrEP PrEP diagnosis only disoproxil fumarate Generic Truvada 200mg/300mg Any prescribed Age limit > 50 years of age Immunizations vaccination administered for Shingrix. at a pharmacy. Up to a 90-day supply of The prescriber must prescribed tobacco prescribe all smoking Nicotine patches, gum, Tobacco Cessation cessation drugs two cessation products for use lozenges, and Varenicline. times in 365 calendar within the 90-day days. treatment time frame. Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 13 of 15

Other Terms The Plan Administrator may approve certain charges or expenses that are otherwise excluded if it determines, in its sole discretion, that the Plan and participant will benefit, and there is a likelihood that Plan expenses will be reduced over the longer term. If third party funding, discount, or rebate is available, TrueScripts may allocate up to the total amount available proportionately over the remaining calendar months in the Plan Year and treat such proportionate amount as an excluded expense in each respective month, or, in the event the co-pay card or third party assistance is de minimis, TrueScripts may credit towards deductible and out of pocket maximum in accordance with its procedures. If selected by the Employer, prescriptions provided under a 340B program at an insignificant cost may be fully covered by the Plan, including for those covered by a qualified high deductible health plan. When Participation Begins Upon enrollment in the Medical Component Plan, you will be able to access prescription benefits under the Rx Program. When Your Participation Ends Your participation in the Rx Program ends on the date you are no longer covered under the Medical Component Plan. MISCELLANEOUS General 1. The Employer reserves the right to amend, modify, or terminate the Rx Program. The Employer delegates its settlor authority to TrueScripts as expressly provided herein. 2. Neither the Employer nor the service providers guarantee the tax consequences of any reimbursements under this Rx Program. 3. Expenses which you claim as deductions or credits on your Federal Income Tax Return cannot be reimbursed under the Rx Program. Oral Statements No oral statement of any person shall: 1. Modify or otherwise affect the benefits, limitations, or exclusions of the Rx Program; 2. Convey or void any coverage; 3. Increase or reduce any benefits of the Rx Program; or 4. Be used in the prosecution or defense of a claim under the Rx Program. Plan is not Worker’s Compensation Insurance The coverage provided under the Rx Program does not replace, supplement, or provide a substitute for benefits to which you are entitled under worker’s compensation; occupational disease; and similar laws. The Rx Program does not cover health services or expenses, directly or indirectly, related to such services that are provided or payable under worker’s compensation, occupational disease, and similar laws: 1. Even if you or the Employer are/is not properly insured or self-insured under such laws; Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 14 of 15

2. When you refuse to use your or the Employer’s designated prescriber; or 3. When you have not abided by the Employer’s policy for treatment or reporting of a work- related illness/injury. Anti-Assignment No Participant, beneficiary, or any other person such as a guardian, shall have the right to assign, transfer, alienate, mortgage, pledge, or otherwise encumber any benefit or right provided under the Rx Program, or any benefit or right provided by ERISA related to the Rx Program. This includes, but is not limited to, the right to file claims or appeals, request information, and the right to bring a lawsuit seeking benefits, penalties, damages, or equitable relief. Any such attempted disposition thereof shall be void. Benefits will not be subject to attachment, garnishment, execution, or levy of any kind. Notwithstanding the foregoing, this provision will not prevent direct payments to third party medical providers for the convenience of the Rx Program, the member, or claims administrator. The Plan Administrator reserves the discretionary authority to determine the validity of any arrangement to direct the payment of benefits to a third party and does not guarantee that any arrangement will be valid under the Rx Program. Any payment to a third party shall not be construed to give such party any rights under the Rx Program, including any right to receive future payments or ERISA rights. __________________________________________________ Plan Sponsor 12 2024 16 ____ / _____ / ______ V13 10212024 Huntington County Community Schools Prescription Benefits Program SPD January 1, 2025 Page 15 of 15