Common use of SUBSTANCE USE DISORDER TREATMENT BENEFITS Clause in Contracts

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Tier 2 Preferred Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 40 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐nam e Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 70 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 80 per Prescription — Tier 3 Non‐Preferred Brand‐Name Drugs $140 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 1,000 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 2,000 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstancescircumstances, the references refer­ ences in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 5 per Prescription — Formulary Tier 2 Preferred Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 30 per Prescription — Non‐Formulary Tier 3 Non‐Preferred Brand‐name Drugs for which there is no generic available $45 Prescription — If your Physician indicates dispense as written on the prescription, you will not be charged any amount other than the Copayment amount specified above and Non‐Formulary the following provision will not apply. — Tier 3 Non‐Preferred Brand‐name Diabetic Supplies Drugs for which there is a generic available $35 45, plus the difference between the generic and brand name drugs costs per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 60 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐Name Drugs for which there is no generic available $90 per Prescription — If your Physician indicates dispense as written on the prescription, you will not be charged any amount other than the Copayment amount specified above and Non‐Formulary Brand‐name Diabetic Supplies the following provision will not apply. — Tier 3 Non‐Preferred Brand‐Name Drugs for which there is a generic available $35 90, plus the difference between the generic and brand name drugs costs per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 Day Supply Prescrip­ tion Prescription Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Prescription Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 20 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 40 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 70 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 25 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 25 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Prescription Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 15 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 30 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Tier 3 Non‐Preferred Brand Name Drugs $50 per Prescription — Tier 4 Specialty Drugs $100 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Prescription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Prescription Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 30 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 60 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 100 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Prescription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed described in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer service at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er customer service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased purchased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age coverage under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly family member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der under the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers providers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icateCertificate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age coverage for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on Union and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired required information (“Application(sapplication(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(sapplication(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners Union or dependents. In those cir­ cumstancescircumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ toryhistory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits benefits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your You and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 5,350 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 10,700 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Tier 3 Non‐Preferred Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 40 per Prescription — Tier 3 Non‐Preferred Brand‐Name Drugs $70 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 5,350 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 10,700 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners Union or dependents. In those cir­ cumstancescircumstances, the references refer­ ences in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 15 per Prescription — Formulary Tier 2 Preferred Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 30 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐ name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 50 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 30 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 60 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐ Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 100 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 1,500 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners Union or dependents. In those cir­ cumstancescircumstances, the references refer­ ences in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 30 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 30 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 30-Day Supply Prescrip­ tion Prescription Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 8 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 35 per Prescription GB‐16 HCSC 2 — Formulary Brand‐name Specialty Drugs and Non‐Formulary Brand‐name Drugs and Non‐ Formulary Brand‐name Diabetic Supplies for which there is no generic available $75 per Prescription — Formulary Brand‐name Specialty Drugs and Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies for which there is a generic available $35 75, plus the difference between the generic and brand name drugs costs per Prescription — Non‐Formulary Brand‐name Specialty Drugs $150 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 30-Day Supply Pre­ scription Drug Program: — For drugs or diabetic supplies purchased within Illinois: No benefits will be provided for drugs or diabetic supplies purchased from a Non‐Participating Prescription Drug Provider. — For drugs or diabetic supplies purchased outside Illinois: The appropriate Copayment(s) or Coinsurance indicated above plus any difference between the Participating Provider's Charge and the Non‐Participating Provider's Charge for drugs prescribed for emergency emer­ gency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Prescription Drug Program: — Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 16 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 70 per Prescription GB‐16 HCSC 3 — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies for which there is no generic available $150 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies for which there is a generic available $35 150, plus the difference between the generic and brand name drugs costs per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. GB‐16 HCSC 4 Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. GB‐16 HCSC 5 You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 20 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 20 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 50 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 100 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 1,000 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 2,000 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable law, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 per Visit Refer None Please refer to the OTHER THINGS YOU SHOULD KNOW section Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding Covered Services Expense Limitation how payment is determined. Benefits are available for up to a 12 month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 30-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Tier 2 Preferred Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 15 per Prescription — Non‐Formulary Tier 3 Non‐Preferred Brand‐name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 25 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 30-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic SuppliesDrugs, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Formulary Brand‐name Diabetic Supplies $20 15 per Prescription — Non‐Formulary Brand‐name Tier 3 Non‐Preferred Brand‐Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies $35 25 per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Diabetic Supplies None — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 3,000 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 6,000 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners Union or dependents. In those cir­ cumstancescircumstances, the references refer­ ences in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.

SUBSTANCE USE DISORDER TREATMENT BENEFITS. Your Cost for Inpatient Substance Use Disorder Treatment None — Your Cost for Outpatient Office Visits for Substance Use Disorder Treatment $10 25 per Visit — Your Cost for Outpatient Specialist Physician Office Visits for Substance Use Disorder Treatment $10 25 per Visit Refer to the OTHER THINGS YOU SHOULD KNOW section of your Certificate for information regarding Covered Services Expense Limitation Please refer to the Outpatient Prescription Drug Program Benefit Section of your Certificate for additional information regarding how payment is determined. Benefits are available for up to a 12month supply for dispensed contraceptives. Benefits are available for contraceptive drugs and products shown on the Contraceptive Coverage List and will not be subject to any deductible, Coinsurance and/or Copayment when received from a Participating Pharmacy Provider. Your share of the cost for all other contraceptive drugs and products will be provided as shown below. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 34 34-Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Tier 2 Preferred Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies preferred brand‐name diabetic supplies $20 30 per Prescription — Non‐Formulary Tier 3 Non‐Preferred Brand‐name Drugs and Non‐Formulary non‐preferred brand‐name diabetic supplies for which there is no generic available $45 Prescription — If your Physician indicates dispense as written on the prescription, you will not be charged any amount other than the Copayment amount specified above and the following provision will not apply. — Tier 3 Non‐Preferred Brand‐name Diabetic Supplies Drugs and non‐preferred brand‐name diabetic supplies for which there is a generic available $35 45, plus the difference between the generic and brand name drugs costs per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 34 34-Day Supply Pre­ scription Drug Program: The appropriate Copayment(s) indicated above for drugs prescribed for emergency conditions. — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Participating in the 90‐Day Supply Prescrip­ tion Drug Program: — Tier 1 Generic Drugs and Generic Diabetic Supplies, insulin and insulin syringes $10 per Prescription — Formulary Brand‐name Drugs and Formulary Brand‐name Diabetic Supplies $20 per Prescription — Non‐Formulary Brand‐name Tier 2 Preferred Brand‐Name Drugs and Non‐Formulary Brand‐name Diabetic Supplies preferred brand‐name diabetic supplies $35 60 per Prescription — Tier 3 Non‐Preferred Brand‐Name Drugs and non‐preferred brand‐name diabetic supplies for which there is no generic available $90 per Prescription — If your Physician indicates dispense as written on the prescription, you will not be charged any amount other than the Copayment amount specified above and the following provision will not apply. — Tier 3 Non‐Preferre Brand‐Name Drugs and non‐preferred brand‐name diabetic supplies for which there is a generic available $90, plus the difference between the generic and brand name drugs costs per Prescription — Self‐Injectable Drugs other than Insulin and Infertility Drugs $50 per Prescription — Individual Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $5,100 2,000 per Calendar Year* — Family Out‐of‐Pocket Expense Limit for prescription drugs and diabetic supplies $10,200 4,000 per Calendar Year* * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) — Your Cost for Prescription Drugs and Diabetic Supplies Purchased from a Prescription Drug Provider Not Participating in the 90‐Day Supply Pre­ scription Drug Program: — No benefits will be provided for drugs or diabetic supplies purchased from a Participating Prescription Drug Provider not participating in the 90‐day supply program. * Applies towards the Covered Services Expense Limitation (see the OTHER THINGS YOU SHOULD KNOW section of this Certificate.) Changes in state or federal law or regulations or interpretations thereof may change the terms and conditions of coverage. Subject to the other terms and conditions of the Group Policy, the benefits de­ scribed in this Certificate will be provided to persons who: — Meet the definition of an Eligible Person as specified in the Group Policy; — Have applied for this coverage; — Have received a Blue Cross and Blue Shield identification card; — Live within the Plan's service area. (Contact your Group or Member Ser­ vices customer ser­ vice at 1‐800‐892‐2803 for information regarding service area.); — Reside, live or work in the geographic network service area served by Blue Cross and Blue Shield for this Certificate of coverage. You may call custom­ er service at the number shown on the back of your identification card to determine if you are in the network service area or log on to the Web site website at xxx.xxxxxx.xxx and; — If Medicare eligible, have both Part A and B coverage. When your Group initially purchases this coverage and such coverage is pur­ chased as replacement of coverage under another carrier's group policy, those persons who are Totally Disabled on the effective date of this coverage and who were covered under the prior group policy will be considered eligible for cover­ age under this Certificate. Your Totally Disabled dependents will be considered eligible dependents under this Certificate provided such dependents meet the description of an eligible fami­ ly member as specified below under the heading Family Coverage. Your dependent children who have reached the limiting age of this Certificate will be considered eligible dependents under this Certificate if they were covered un­ der the prior group policy and, because of a handicapped condition, are incapable of self sustaining employment and are dependent upon you or other care provid­ ers for lifetime care and supervision. If you are Totally Disabled, you will be entitled to all of the benefits of this Certif­ icate. The benefits of this Certificate will be coordinated with benefits under your prior group policy. Your prior group policy will be considered the primary cover­ age for all services rendered in connection with your disabling condition when no coverage is available under this Certificate due to the absence of coverage in this Certificate. The provisions of this Certificate regarding Primary Care Physician referral remain in effect for such Totally Disabled persons. You may apply for coverage for yourself and/or your spouse, party to a Civil Uni­ on on, Domestic Partner and/or dependents (see below) by submitting the application(s) for medical insurance form, along with any exhibits, appendices, addenda and/or other re­ quired required information (“Application(s)”) to the Plan. You can get the application form from your Group Administrator. An application to add a newborn to Family Coverage is not necessary if an additional premium is not required. However, you must notify your Group Administrator within 31 days of the birth of a newborn child for coverage to continue beyond the 31 day period or you will have to wait until your Group's open enrollment period to enroll the child. The Application(s) for coverage may or may not be accepted. Please note, some Employers only offer coverage to their employees, not to their employees' spouses, parties to a Civil Union, Domestic Partners or dependents. In those cir­ cumstances, the references in this Certificate to an employee's family members are not applicable. No eligibility rules or variations in premium will be imposed based on your health status, medical condition, Claims experience, receipt of health care, medical his­ tory, genetic information, evidence of insurability, disability or any other health status related factor. You will not be discriminated against for coverage under this Certificate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual orientation. Variations in the administration, processes or bene­ fits of this Certificate that are based on clinically indicated, reasonable medical management practices, or are part of permitted wellness incentives, disincentives and/or other programs do not constitute discrimination. You may enroll in or change coverage for yourself and/or your eligible spouse and/or dependents during one of the following enrollment periods. Your and/or your eligible spouse and/or dependents' effective date will be determined by the Plan depending upon the date your application is received and other determining factors. The Plan may require acceptable proof (such as copies of legal adoption or legal guardianship papers, or court orders) that an individual qualifies as an Eligible Person under this Certificate. Your Group will designate annual open enrollment periods during which you may apply for or change coverage for yourself and/or your eligible spouse, party to a Civil Union Union, Domestic Partner and/or dependents. This section “Annual Open Enrollment Periods/Effective Date of Coverage” is subject to change by the Plan, and/or applicable lawlaw or regulatory guidance, as appropriate.