attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate R13-7040 (2022) to be attached to HMO-PPO Page 1 hppo13-7040 Rider Cost Share Assistance Pharmacy Program This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate for easy reference. The outpatient benefits described in your Subscriber Certificate for covered drugs and supplies have been changed. Your health plan includes a cost share assistance program for certain specialty drugs and/or supplies. Cost share assistance is a process in which the health plan facilitates your enrollment in a program where drug manufacturers provide financial support to members by reducing or removing cost share applied to a drug and/or supply. For covered drugs and supplies that are eligible under this cost share assistance program, the initial cost share amount that is provided will be equal to 30% of the total cost of the drug or supply. When you enroll for cost share assistance with a drug manufacturer for an eligible covered drug or supply, the initial cost share amount will be either reduced or removed. In these cases, cost share assistance is provided by a drug manufacturer on the initial cost share. This means that your final cost share amount will be calculated based off of the initial cost share amount minus the drug manufacturer’s cost share assistance. The final cost share amount that you will pay is described in the cost share assistance drug list. If you choose not to enroll for cost share assistance with a drug manufacturer for an eligible covered drug or supply, the initial cost share amount will not be reduced or removed and your cost share amount will be higher. This means that the final cost share amount that you will pay is equal to 30% of the total cost of the drug or supply. There may be times when you cannot enroll for cost share assistance with a drug manufacturer for a certain covered drug or supply that may otherwise be eligible under this cost share assistance program. Some examples of when this will occur include (but are not limited to): when the drug or supply is not approved by the Food and Drug Administration to treat your condition; or, when the drug or supply has specific age restrictions that you do not meet. In these cases, the provisions of this cost share assistance program will not apply, and you will pay the cost share amount that applies for all other covered drugs and supplies as described in your Schedule of Benefits and/or riders. The cost share amounts that you pay for these drugs and supplies as described above will count toward your out-of-pocket maximum. To obtain the cost share assistance drug list that describes the drugs and/or supplies eligible for cost share assistance and their applicable cost share, you can call the Blue Cross Blue Shield HMO Blue customer service office. The toll-free phone number is shown on your ID card. Or, you may log on to the Blue Cross Blue Shield HMO Blue internet Web site at www.bluecrossma.org. The list of these specialty drugs and supplies may change from time to time. This rider does not change the cost share amount that you will pay for all other covered drugs and supplies. Refer to your Schedule of Benefits and/or riders for your cost share amount for other covered drugs and supplies. All other provisions remain as described in your Subscriber Certificate.