Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 12 Blue Cross Blue Shield HMO Blue Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. is the not-for-profit managed care subsidiary of Blue Cross and Blue Shield of Massachusetts, Inc. Blue Cross Blue Shield HMO Blue is licensed by the Commonwealth of Massachusetts as a health maintenance organization (HMO) to arrange for the coordinated delivery of health care services to its members. The term “Plan” is often used to refer to Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. “Blue Cross Blue Shield HMO Blue” and “Plan” also means an employee or designee of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. (including Blue Cross and Blue Shield of Massachusetts, Inc. or another Blue Cross and/or Blue Shield Plan) who is authorized to make decisions or take action called for by this health plan. This also means, for example, that Blue Cross Blue Shield HMO Blue policies, programs, documents, tools, and administrative areas may mean the policies, programs, documents, tools, and administrative areas of Blue Cross and Blue Shield of Massachusetts, Inc. or another designee. Blue Cross Blue Shield HMO Blue has full discretionary authority to interpret this Subscriber Certificate. This includes determining the amount, form, and timing of benefits, conducting medical necessity reviews, and resolving any other matters regarding your right to benefits for covered services as described in this Subscriber Certificate. All determinations by Blue Cross Blue Shield HMO Blue with respect to benefits under this health plan will be conclusive and binding unless it can be shown that the interpretation or determination was arbitrary and capricious. Blue Cross and Blue Shield of Massachusetts, Inc. is the parent company of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. (Blue Cross Blue Shield HMO Blue). Blue Cross and Blue Shield of Massachusetts, Inc. has entered into a management contract with Blue Cross Blue Shield HMO Blue to provide administrative services. Blue Cross and Blue Shield of Massachusetts, Inc. will not be responsible for or have any contractual obligations with respect to this health plan. “Blue Cross and Blue Shield of Massachusetts, Inc.” also means an employee or designee of Blue Cross and Blue Shield of Massachusetts, Inc. who is authorized to make decisions or take action called for by this health plan. Coinsurance For some covered services, you may have to pay a coinsurance. This means the cost that you pay for these covered services (your “cost share amount”) will be calculated as a percentage. When a coinsurance does apply to a specific covered service, Blue Cross Blue Shield HMO Blue will calculate your cost share amount based on the health care provider’s actual charge or the Blue Cross Blue Shield HMO Blue allowed charge, whichever is less (unless otherwise required by law). The Schedule of Benefits for your plan option shows the covered services for which you must pay a coinsurance (if there are any). If a coinsurance does apply, your Schedule of Benefits also shows the percentage that Blue Cross Blue Shield HMO Blue will use to calculate your cost share amount. (Also refer to riders—if there are any—that apply to your coverage in this health plan.) Copayment For some covered services, you may have to pay a copayment. This means the cost that you pay for these covered services (your “cost share amount”) is a fixed dollar amount. In most cases, a covered provider will collect the copayment from you at the time they furnish the covered service. However, when the health care provider’s actual charge at the time of providing the covered service is less than your copayment, you pay only that health care provider’s actual charge or the Blue Cross Blue Shield HMO Blue allowed charge, whichever is less (unless otherwise required by law). Any later charge adjustment— up or down—will not affect your copayment (or the cost you were charged at the time of the service if it was less than the copayment). The Schedule of Benefits for your plan option shows the amount of your