attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate HMO-PPO (1-1-2022) Page 1 hppodedIISoB-0125 Schedule of Benefits Preferred Blue® PPO Deductible II This is the Schedule of Benefits that is a part of your Subscriber Certificate. This chart describes the cost share amounts that you will have to pay for covered services. It also shows the benefit limits that apply for covered services. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Certificate to understand the requirements you must follow to receive all of your coverage. You should also read the descriptions of covered services and the limitations and exclusions that apply for this coverage. All words that show in italics are explained in Part 2. To receive the highest level of coverage, you must obtain your health care services and supplies from covered providers who participate in your health plan’s provider network. Also, for some health care services, you may have to have an approved referral from your primary care provider or approval from your health plan in order for you to receive coverage from your health plan. These requirements are fully outlined in Part 4. If a referral or an approval is required, you should make sure that you have it before you receive your health care service. Otherwise, you may have to pay all costs for the health care service. Your health plan’s provider network is the PPO provider network. See Part 1 for information about how to find a provider in your health care network. The following definitions will help you understand your cost share amounts and how they are calculated.  A deductible is the cost you may have to pay for certain covered services you receive during your annual coverage period before benefits are paid by the health plan. This chart shows the dollar amount of your deductible and the covered services for which you must first pay the deductible.  A copayment is the fixed dollar amount you may have to pay for a covered service, usually when you receive the covered service. This chart shows the times when you will have to pay a copayment.  A coinsurance is the percentage (for example, 20%) you may have to pay for a covered service. This chart shows the times, if there are any, when you will have to pay coinsurance. Your cost share will be calculated based on the allowed charge or the provider’s actual charge if it is less than the allowed charge. You will not have to pay charges that are more than the allowed charge when you use a covered provider who participates in your health care network to furnish covered services. But, when you use an out-of-network provider, you may also have to pay all charges that are in excess of the allowed charge for covered services. This is called “balance billing.” These balance billed charges are in addition to the cost share you have to pay for covered services. (Exceptions to this paragraph are explained in Part 2.) IMPORTANT NOTE: The provisions described in this Schedule of Benefits may change. If this happens, the change is described in a rider. Be sure to read each rider (if there are any) that applies to your coverage in this health plan to see if it changes this Schedule of Benefits. The explanation of any special provisions as noted by an asterisk can be found after this chart.