Common use of Dependent Benefits Clause in Contracts

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife • When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “higher cost share hospitals.” See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, you’re still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provider you are referred to is affiliatedwith one of the doctor’s genderhigher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refersyou.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife • When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; Blue Care Elect Deductible SM MIIA PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “higher cost share hospitals.” See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferredprovider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, you’re still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provideryou are referred to is affiliatedwith one of the higher cost share hospitals listed below. Your cost will be greater when you the doctor’s genderreceive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refersyou.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot services not coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) • General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife • When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; EXHIBIT B Blue Care Elect Deductible SM MIIA PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. You will pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “yrvice cost share hospitals.p See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, youvid still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provider you are referred to is affiliated with one of the doctor’s genderhigher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refers you.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) • General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot services not coveredare: cosmeticsurgerycosmetic surgery; custodialcarecustodial care; most dentalcaredental care; and anyservicescoveredbyworkersany services covered by workers’ compensation. For acompletelist a complete list of limitations and exclusions, refer to your benefit description and riders. EXHIBIT C 7/1/2022 – 6/30/2024 When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife • When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. You will pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “yrvice cost share hospitals.p See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, youvid still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provider you are referred to is affiliated with one of the doctor’s genderhigher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refers you.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. • North Shore Medical Center – Salem Campus When you enroll in Network Blue New England, you must choose a primary care provider. Be sure provider (PCP) who is available to choose a PCP who can accept you and your family members and who participates in the our network of providers in throughout the New EnglandEngland states. For children, you may choose designate a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, GYNs: visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the our Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They We can give tell you the doctor’s genderwhether a doctor is male or female, the medical school school(s) he or she or he attended, and whether there are if any languages other than English are spoken in the office. Your PCP is the first person you call when you need routine or sick care(seeEmergencyCare–WhereverYouAre for emergency care services). If you and your PCP decide that you need to see a specialist for covered services, your PCP will refer you to an appropriatenetwork specialist, who is probably someone affiliated with your PCPeonhospital or medical group. You will not need prior authorization or referral to see a HMO Blue New England network provider who specializes in OB/GYN services. Your providers may also work with Blue Cross Blue Shield concerning referrals, and the Utilization Review Requirements, which are Pre- Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services, and Individual Case Management. Information concerning Utilization Review and services requiring referral from your PCP is detailed in your benefit description.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office When performed by your PCP or OB/GYN When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) In other general hospitals (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “higher cost share hospitals.” See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferredprovider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, you’re still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provideryou are referred to is affiliatedwith one of the higher cost share hospitals listed below. Your cost will be greater when you the doctor’s genderreceive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refersyou.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife • When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; EXHIBIT B Blue Care Elect Deductible SM MIIA PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “higher cost share hospitals.” See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, you’re still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provider you are referred to is affiliatedwith one of the doctor’s genderhigher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refersyou.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) • General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot services not coveredare: cosmeticsurgerycosmetic surgery; custodialcarecustodial care; most dentalcaredental care; and anyservicescoveredbyworkersany services covered by workers’ compensation. For acompletelist a complete list of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 member $5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) Mental health and substance abuse treatment $100 20 per visit after in-network visit, no deductible (copayment waived if admitted or for an observation stay) Office visits When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioneryour PCP, OB/GYN, network nurse practitioner, or pediatrician nurse midwife When performed by other covered network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office When performed by your PCP or OB/GYN When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays, lab tests, rays and other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance Prosthetic devices Nothing after deductible Home health care and hospice services Nothing after deductible Surgery and related anesthesia Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers Ambulatory in an ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance Inpatient Care (including maternity care) In other general hospitals (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care (as many days as medically necessary) In higher cost *** Cost share hospitals (as many days as medically necessary) $275 waived for one breast pump per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up birth. † This copayment applies to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible mental health admissions in a general hospital. Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most dentalcare; and anyservicescoveredbyworkers’ compensationbenefits under this plan. For acompletelist of limitations and exclusionsIf you are not sure when your plan year begins, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the contact Blue Cross Blue Shield Shield. Your deductibles are $300 per member (or $900 per family) for in-network services and $400 per member (or $800 per family) for out-of-network services. The plan has two levels of Massachusetts website hospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at xxx.xxxxxxxxxxx.xxx; consult or by “higher cost share hospitals.” See the Provider Directory; or call chart on the Physician Selection Service back page for your cost share amounts. Please note: If a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at 0the in-000-000-0000network level. If the provider you have trouble choosing are referred to is not a doctorpreferred provider, you’re still covered, but your benefits, in most situations, will be covered at the Physician Selection Service can helpout-of-network level, even if the preferred provider refers you. They can give It is also important to check whether the provider you are referred to is affiliatedwith one of the doctor’s genderhigher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, the medical school she or he attended, and whether there are languages other than English spoken in the officeeven if your preferred provider refersyou.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: 10 visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) • General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 for Tier 2 $65 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 for Tier 1*** $75 for Tier 2 $165 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot services not coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and whether there are languages other than English spoken in the office.

Dependent Benefits. This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. Please see your benefit description (and riders, if any) for exact coverage details. Plan-year deductible $300 250 per member $900 750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-out- of-network services combined Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: • 10 visits during the first year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year from age 3 through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after deductible Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits • When performed by a family or general practitioner, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician • When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $20 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Surgery and related anesthesia • Office setting – When performed by a family or general practitioner, geriatric specialist, internist, nurse midwife, nurse practitioner, OB/GYN, or pediatrician – When performed by other covered providers • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 35 per visit,*** no deductible $250 150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. ** In-network cost share waived for one breast pump per birth. *** Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate. Inpatient care (including maternity care) General hospital care s In other general hospitals (as many days as medically necessary) s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 for Tier 1*** $30 25 for Tier 2 $65 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 20 for Tier 1*** $75 50 for Tier 2 $165 110 for Tier 3 Not covered * This cost share applies to mental health admissions in a general hospital. ** Cost share waived for certain orally-administered anticancer drugs. *** Cost share waived for birth control. Visit us at xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) No additional charge For questions about Blue Cross Blue Shield of Massachusetts, visit the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. servicesnot coveredare: cosmeticsurgery; custodialcare; most dentalcare; and anyservicescoveredbyworkers’ compensation. For acompletelist of limitations and exclusions, refer to your benefit description and riders. 7/1/2020 – 6/30/2022 • North Shore Medical Center – Salem Campus When you enroll in Network Blue New England, you must choose a primary care provider. Be sure provider (PCP) who is available to choose a PCP who can accept you and your family members and who participates in the our network of providers in throughout the New EnglandEngland states. For children, you may choose designate a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, GYNs: visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the our Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They We can give tell you the doctor’s genderwhether a doctor is male or female, the medical school school(s) he or she or he attended, and whether there are if any languages other than English are spoken in the office. Your PCP is the first person you call when you need routine or sick care(seeEmergencyCare–WhereverYouAre for emergency care services). If you and your PCP decide that you need to see a specialist for covered services, your PCP will refer you to an appropriatenetwork specialist, who is probablysomeone affiliated with your PCPeonhospital or medical group. You will not need prior authorization or referral to see a HMO Blue New England network provider who specializes in OB/GYN services. Your providers may also work with Blue Cross Blue Shield concerning referrals, and the Utilization Review Requirements, which are Pre- Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services, and Individual Case Management. Information concerning Utilization Review and services requiring referral from your PCP is detailed in your benefit description.