Owl Labs Inc. Welcome Guide

MASSACHUSETTS CONTENTS PLAN OPTIONS Get the most out of your plan INTRODUCING THE NEW MYBLUE APP The simplest way to tap into your health plan . Sign in to the MyBlue app.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 202 4 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. WELCOME Owl Labs Inc. https://planinfo.bluecrossma. com/customblue/2025/owllabsinc MEDICAL: Preferred Blue Ded 4000 SBC - Summary MEDICAL: Preferred Blue Saver 2900 SBC - Summary HELPFUL RESOURCES Telehealth Brochure 24/7 Nurse Line Pregnancy and Baby ahealthyme rewards Stopping the Flu Starts with You Fitness Reimbursement Maven Maternity Weight-Loss Reimbursement Blue Card Program Brochure Commitment To Confidentiality SBC Glossary Medical Terms Summary of Health Plan Payments Guide Enrollment Form MyBlue Fact Sheet Coordination of Benefits How to Find PCP ID Number Virtual Primary Care Mail Service Pharmacy Member Fact Sheet and Order Form Cost Share Assistance Member Fact Sheet Health Savings Account Medication List

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SUMMARY OF BENEFITS This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. Download the app, or create an account at bluecrossma.org . Sign in UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan: COVERAGE AND BENEFITS CLAIMS AND BALANCES DIGITAL ID CARD An Association of Independent Blue Cross and Blue Shield Plans Preferred Blue PPO $4,000 Deductible II Plan-Year Deductible: $4,000/$8,000 Owl Labs Inc.

Your Choice Your Deductible Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for certain benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield of Massachusetts. Your deductible is $4,000 per member (or $8,000 per family) for in-network and out-of-network services combined. When You Choose Preferred Providers You receive the highest level of benefits under your health care plan when you obtain covered services from preferred providers. These are called your in-network benefits. See the charts for your cost share. Note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you are referred to is not a preferred provider, you are still covered, but your benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. How to Find a Preferred Provider To find a preferred provider: Look up a provider on Find a Doctor at bluecrossma.com/findadoctor . If you need a copy of your directory or help choosing a provider, call the Member Service number on your ID card. Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org When You Choose Non-Preferred Providers You can also obtain covered services from non-preferred providers, but your out-of-pocket costs are higher. These are called your out-of-network benefits. See the charts for your cost share. Payments for out-of-network benefits are based on the Blue Cross Blue Shield allowed charge as defined in your subscriber certificate. You may be responsible for any difference between the allowed charge and the providers actual billed charge (this is in addition to your deductible and coinsurance). Your Out-of-Pocket Maximum Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical benefits is $7,000 per member (or $14,000 per family) for in-network and out-of-network services combined. Your out-of-pocket maximum for prescription drug benefits is $1,000 per member (or $2,000 per family) for in-network and out-of-network combined. Emergency Room Services In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). After meeting your deductible, you pay nothing for in-network or out-of-network emergency room services. Telehealth Services Telehealth services are covered when the same in-person service would be covered by the health plan and the use of telehealth is appropriate. Your health care provider will work with you to determine if a telehealth visit is medically appropriate for your health care needs or if an in-person visit is required. For a list of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org , consult Find a Doctor, or call the Member Service number on your ID card. Your Virtual Care Team Your health plan includes an option for a tech-enabled primary care delivery model where virtual care team covered providers furnish certain covered services. See your subscriber certificate (and riders, if any) for exact coverage details. Utilization Review Requirements Certain services require pre-approval/prior authorization through Blue Cross Blue Shield of Massachusetts for you to have benefit coverage; this includes non-emergency and non-maternity hospitalization and may include certain outpatient services, therapies, procedures, and drugs. You should work with your health care provider to determine if pre-approval is required for any service your provider is suggesting. If your provider, or you, dont get pre-approval when its required, your benefits will be denied, and you may be fully responsible for payment to the provider of the service. Refer to your subscriber certificate for requirements and the process you should follow for Utilization Review, including Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge Planning, and Individual Case Management. Dependent Benefits This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your subscriber certificate (and riders, if any) for exact coverage details. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.

Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: Ten visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year for age 3 and older Nothing , no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests (one per calendar year) Nothing , no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing , no deductible 20% coinsurance after deductible Mental health wellness exams (at least one per calendar year) Nothing , no deductible Nothing , no deductible Routine hearing exams, including routine tests Nothing , no deductible 20% coinsurance after deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the maximum , no deductible 20% coinsurance after deductible and all charges beyond the maximum Routine vision exams (one every 24 months) Nothing , no deductible 20% coinsurance after deductible Family planning servicesoffice visits Nothing , no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits Nothing after deductible Nothing after deductible Office or health center visits, when performed by: A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, limited services clinic, multi-specialty provider group, or by a physician assistant or nurse practitioner designated as primary care $25 per visit after deductible 20% coinsurance after deductible Other covered providers, including a physician assistant or nurse practitioner designated as specialty care $40 per visit after deductible 20% coinsurance after deductible Mental health or substance use treatment $25 per visit after deductible 20% coinsurance after deductible Outpatient telehealth services With a covered provider Same as in-person visit Same as in-person visit With the in-network designated telehealth vendor $25 per visit after deductible Only applicable in-network Diabetic management services (first two visits per calendar year*) Nothing , no deductible 20% coinsurance after deductible Chiropractors office visits $40 per visit after deductible 20% coinsurance after deductible Acupuncture visits (up to 12 visits per calendar year) $40 per visit after deductible 20% coinsurance after deductible Short-term rehabilitation therapyphysical and occupational (up to 60 visits per calendar year**) $40 per visit after deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatmentspeech therapy $40 per visit after deductible 20% coinsurance after deductible Diagnostic x-rays and lab tests, including CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Durable medical equipmentsuch as wheelchairs, crutches, hospital beds 20% coinsurance after deductible*** 40% coinsurance after deductible*** Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia in an office or health center, when performed by: A family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, multi-specialty provider group, or by a physician assistant or nurse practitioner designated as primary care $25 per visit after deductible 20% coinsurance after deductible Other covered providers, including a physician assistant or nurse practitioner designated as specialty care $40 per visit after deductible 20% coinsurance after deductible Surgery and related anesthesia in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit Nothing after deductible 20% coinsurance after deductible Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible * These diabetic services are for diabetes evaluation and management services, diabetic eye exams, or diabetic foot care. ** No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. *** In-network cost share waived for one breast pump per birth, including supplies (20% coinsurance after deductible out-of-network). Copayment waived for restorative dental services and orthodontic treatment or prosthetic management therapy for members under age 18 to treat conditions of cleft lip and cleft palate.

Covered Services Your Cost In-Network Your Cost Out-of-Network Prescription Drug Benefits* At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill)** No deductible $15 for Tier 1 $30 for Tier 2 $50 for Tier 3 No deductible $30 for Tier 1 $60 for Tier 2 $100 for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill)** No deductible $30 for Tier 1 $60 for Tier 2 $150 for Tier 3 Not covered * Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs. ** Cost share may be waived, reduced, or increased for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders. Registered Marks of the Blue Cross and Blue Shield Association. 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 003409150 (3/24) MR Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org . Get the Most from Your Plan: Visit us at bluecrossma.org or call 1-800-782-3675 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Fitness Reimbursement: a program that rewards participation in qualified fitness programs or equipment (See your subscriber certificate for details.) $150 per calendar year per policy Weight Loss Reimbursement: a program that rewards participation in a qualified weight loss program (See your subscriber certificate for details.) $150 per calendar year per policy 24/7 Nurse Line: Speak to a registered nurse, day or night, to get immediate guidance and advice. Call 1-888-247-BLUE (2583). No additional charge.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 04/01/2025 Preferred Blue PPO $4000 Deductible II: Owl Labs Inc. Coverage for: Individual and Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see bluecrossma.org/coverage-info . For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at bluecrossma.org/sbcglossary or call 1-800-782-3675 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $4,000 member / $8,000 family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. In-network preventive and prenatal care; prescription drugs. This plan covers some items and services even if you havent yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . Are there other deductibles for specific services? No. You dont have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? For medical benefits, $7,000 member / $14,000 family; and for prescription drug benefits, $1,000 member / $2,000 family. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums , balance - billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See bluecrossma.com/findadoctor or call the Member Service number on your ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plans network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the providers charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies . Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you visit a health care providers office or clinic Primary care visit to treat an injury or illness $25 / visit 20% coinsurance Deductible applies first; family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, limited services clinic, multi-specialty provider group, or by a physician assistant or nurse practitioner designated as primary care; in-network cost share waived for the first two diabetic PCP and / or specialist visits per calendar year; a telehealth cost share may be applicable Specialist visit $40 / visit; $40 / chiropractor visit; $40 / acupuncture visit 20% coinsurance; 20% coinsurance / chiropractor visit; 20% coinsurance / acupuncture visit Deductible applies first; includes physician assistant or nurse practitioner designated as specialty care; in-network cost share waived for the first two diabetic PCP and / or specialist visits per calendar year; limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Preventive care/screening/immunization No charge 20% coinsurance Deductible applies first for out-of- network; limited to age-based schedule and / or frequency; cost share waived for at least one mental health wellness exam per calendar year; a telehealth cost share may be applicable. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Deductible applies first; pre- authorization may be required If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bluecrossma.org/medicatio n Generic drugs $15 / retail supply or $30 / mail service supply $30 / retail supply and all charges for mail service Up to 30-day retail (90-day mail service) supply; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs Preferred brand drugs $30 / retail supply or $60 / mail service supply $60 / retail supply and all charges for mail service Non-preferred brand drugs $50 / retail supply or $150 / mail service supply $100 / retail supply and all charges for mail service Specialty drugs Applicable cost share (generic, preferred, non-preferred) Not covered When obtained from a designated specialty pharmacy; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If you need immediate medical attention Emergency room care No charge No charge Deductible applies first Emergency medical transportation No charge No charge Deductible applies first Urgent care $40 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable

Page 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you need mental health, behavioral health, or substance abuse services Outpatient services $25 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable; pre- authorization required for certain services Inpatient services No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you are pregnant Office visits No charge 20% coinsurance Deductible applies first except for in - network prenatal care; cost sharing does not apply for in-network preventive services; maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance

Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Rehabilitation services $40 / visit for outpatient services; No charge for inpatient services 20% coinsurance for outpatient services; 20% coinsurance for inpatient services Deductible applies first; limited to 60 outpatient visits per calendar year (other than for autism, home health care, and speech therapy); limited to 60 days per calendar year for inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Habilitation services $40 / visit 20% coinsurance Deductible applies first; outpatient rehabilitation therapy coverage limits apply; cost share and coverage limits waived for early intervention services for eligible children; a telehealth cost share may be applicable Skilled nursing care No charge 20% coinsurance Deductible applies first; limited to 100 days per calendar year; pre- authorization required Durable medical equipment 20% coinsurance 40% coinsurance Deductible applies first; in-network cost share waived for one breast pump per birth, including supplies (20% coinsurance for out-of-network) Hospice services No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services

Page 6 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If your child needs dental or eye care Childrens eye exam No charge 20% coinsurance Deductible applies first for out-of- network; limited to one exam every 24 months Childrens glasses Not covered Not covered None Childrens dental check-up No charge for members with a cleft palate / cleft lip condition 20% coinsurance for members with a cleft palate / cleft lip condition Deductible applies first for out-of- network; limited to members under age 18 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Children's glasses Cosmetic surgery Dental care (Adult) Long - term care Private - duty nursing Other Covered Services (Limitations may apply to these services. This isnt a complete list. Please see your plan document.) Acupuncture (12 visits per calendar year) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 or younger) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care - adult (one exam every 24 months) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy)

Page 7 of 8 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform and the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov . Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact the Massachusetts Division of Insurance at 1-877-563-4467 or www.mass.gov/doi . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. For more information about possibly buying individual coverage through a state exchange, you can contact your states marketplace, if applicable. If you are a Massachusetts resident, contact the Massachusetts Health Connector by visiting www.mahealthconnector.org . For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually the members employer or organization that provides group health coverage to the member.) Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, call 1-800-472-2689 or contact your plan sponsor. (A plan sponsor is usually the members employer or organization that provides group health coverage to the member.) You may also contact The Office of Patient Protection at 1-800-436-7757 or www.mass.gov/hpc/opp . Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesnt meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern. To see examples of how this plan might cover costs for a sample medical situation, see the next section.

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in - network prenatal care and a hospital delivery) The plans overall deductible $4,000 Delivery fee copay $0 Facility fee copay $0 Diagnostic tests copay $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost sharing Deductibles $4,000 Copayments $10 Coinsurance $0 What isnt covered Limits or exclusions $60 The total Peg would pay is $4,070 Managing Joe's Type 2 Diabetes (a year of routine in - network care of a well - controlled condition) The plans overall deductible $4,000 Specialist visit copay $40 Primary care visit copay $25 Diagnostic tests copay $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost sharing Deductibles $900 Copayments $1,000 Coinsurance $0 What isnt covered Limits or exclusions $20 The total Joe would pay is $1,920 Mias Simple Fracture (in - network emergency room visit and follow - up care) The plans overall deductible $4,000 Specialist visit copay $40 Emergency room copay $0 Ambulance services copay $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost sharing Deductibles $2,800 Copayments $10 Coinsurance $0 What isnt covered Limits or exclusions $0 The total Mia would pay is $2,810 The plan would be responsible for the other costs of these EXAMPLE covered services. 003409084 (3/25) JM Registered Marks of the Blue Cross and Blue Shield Association. 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 8 of 8

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001652563 55-0647 (6/23) This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. MCC COMPLIANCE

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SUMMARY OF BENEFITS This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. Download the app, or create an account at bluecrossma.org . Sign in UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan: COVERAGE AND BENEFITS CLAIMS AND BALANCES DIGITAL ID CARD An Association of Independent Blue Cross and Blue Shield Plans Preferred Blue PPO Saver Plan-Year Deductible: $2,900/$5,800 Owl Labs Inc.

Your Choice Your Deductible Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for certain benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield of Massachusetts. Your deductible is $2,900 per individual membership (or $5,800 per family membership) for in-network and out-of-network services combined. The entire family deductible must be satisfied before benefits are provided for any one member enrolled under a family membership. When You Choose Preferred Providers You receive the highest level of benefits under your health care plan when you obtain covered services from preferred providers. These are called your in-network benefits. See the charts for your cost share. Note: If a preferred provider refers you to another provider for covered services (such as a lab or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you are still covered, but your benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. How to Find a Preferred Provider To find a preferred provider: Look up a provider on Find a Doctor at bluecrossma.com/findadoctor . If you need a copy of your directory or help choosing a provider, call the Member Service number on your ID card. Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org When You Choose Non-Preferred Providers You can also obtain covered services from non-preferred providers, but your out-of-pocket costs are higher. These are called your out-of-network benefits. See the charts for your cost share. Payments for out-of-network benefits are based on the Blue Cross Blue Shield allowed charge as defined in your subscriber certificate. You may be responsible for any difference between the allowed charge and the providers actual billed charge (this is in addition to your deductible and/or your coinsurance). Your Out-of-Pocket Maximum Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical and prescription drug benefits is $6,450 per member (or $12,900 per family) for in-network and out-of-network services combined. Emergency Room Services In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). After meeting your deductible, you pay a copayment per visit for in-network or out-of-network emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your cost share. Telehealth Services Telehealth services are covered when the same in-person service would be covered by the health plan and the use of telehealth is appropriate. Your health care provider will work with you to determine if a telehealth visit is medically appropriate for your health care needs or if an in-person visit is required. For a list of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org , consult Find a Doctor, or call the Member Service number on your ID card. Your Virtual Care Team Your health plan includes an option for a tech-enabled primary care delivery model where virtual care team covered providers furnish certain covered services. See your subscriber certificate (and riders, if any) for exact coverage details. Utilization Review Requirements Certain services require pre-approval/prior authorization through Blue Cross Blue Shield of Massachusetts for you to have benefit coverage; this includes non-emergency and non-maternity hospitalization and may include certain outpatient services, therapies, procedures, and drugs. You should work with your health care provider to determine if pre-approval is required for any service your provider is suggesting. If your provider, or you, dont get pre-approval when its required, your benefits will be denied, and you may be fully responsible for payment to the provider of the service. Refer to your subscriber certificate for requirements and the process you should follow for Utilization Review, including Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge Planning, and Individual Case Management. Dependent Benefits This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your subscriber certificate (and riders, if any) for exact coverage details. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.

Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: Ten visits during the first year of life Three visits during the second year of life (age 1 to age 2) Two visits for age 2 One visit per calendar year for age 3 and older Nothing , no deductible 20% coinsurance , no deductible Routine adult physical exams, including related tests (one per calendar year) Nothing , no deductible 20% coinsurance , no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing , no deductible 20% coinsurance , no deductible Mental health wellness exams (at least one per calendar year) Nothing , no deductible Nothing , no deductible Routine hearing exams, including routine tests Nothing , no deductible 20% coinsurance , no deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the maximum after deductible 20% coinsurance after deductible and all charges beyond the maximum Routine vision exams (one every 24 months) Nothing , no deductible 20% coinsurance , no deductible Family planning servicesoffice visits Nothing , no deductible 20% coinsurance , no deductible Outpatient Care Emergency room visits $150 per visit after deductible (copayment waived if admitted or for observation stay) $150 per visit after deductible (copayment waived if admitted or for observation stay) Office or health center visits Nothing after deductible 20% coinsurance after deductible Mental health or substance use treatment Nothing after deductible 20% coinsurance after deductible Outpatient telehealth services With a covered provider Same as in-person visit Same as in-person visit With the in-network designated telehealth vendor Nothing after deductible Only applicable in-network Diabetic management services (first two visits per calendar year*) Nothing , no deductible 20% coinsurance after deductible Chiropractors office visits Nothing after deductible 20% coinsurance after deductible Acupuncture visits (up to 12 visits per calendar year) Nothing after deductible 20% coinsurance after deductible Short-term rehabilitation therapyphysical and occupational (up to 60 visits per calendar year**) Nothing after deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatmentspeech therapy Nothing after deductible 20% coinsurance after deductible Diagnostic x-rays and lab tests, including CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Durable medical equipmentsuch as wheelchairs, crutches, hospital beds 20% coinsurance after deductible*** 40% coinsurance after deductible*** Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia Nothing after deductible 20% coinsurance after deductible Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible * These diabetic services are for diabetes evaluation and management services, diabetic eye exams, or diabetic foot care. ** No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care or for the treatment of autism spectrum disorders. *** In-network cost share waived for one breast pump per birth, including supplies (20% coinsurance after deductible out-of-network).

Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders. Registered Marks of the Blue Cross and Blue Shield Association. 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 003409067 (03/25) LK Covered Services Your Cost In-Network Your Cost Out-of-Network Prescription Drug Benefits* At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill)** $10 after deductible for Tier 1 $25 after deductible for Tier 2 $45 after deductible for Tier 3 $20 after deductible for Tier 1 $50 after deductible for Tier 2 $90 after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill)** $20 after deductible for Tier 1 $50 after deductible for Tier 2 $135 after deductible for Tier 3 Not covered * Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs. ** Cost share may be waived, reduced, or increased for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org . Get the Most from Your Plan: Visit us at bluecrossma.org or call 1-800-782-3675 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Fitness Reimbursement: a program that rewards participation in qualified fitness programs or equipment (See your subscriber certificate for details.) $150 per calendar year per policy Weight Loss Reimbursement: a program that rewards participation in a qualified weight loss program (See your subscriber certificate for details.) $150 per calendar year per policy 24/7 Nurse Line: Speak to a registered nurse, day or night, to get immediate guidance and advice. Call 1-888-247-BLUE (2583). No additional charge.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 04/01/2025 Preferred Blue PPO Saver: Owl Labs Inc. Coverage for: Individual and Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see bluecrossma.org/coverage-info . For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at bluecrossma.org/sbcglossary or call 1-800-782-3675 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? $2,900 individual contract / $5,800 family contract. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. Are there services covered before you meet your deductible? Yes. In-network prenatal care; preventive care. This plan covers some items and services even if you havent yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . Are there other deductibles for specific services? No. You dont have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $6,450 member / $12,900 family. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of- pocket limit has been met. What is not included in the out-of-pocket limit? Premiums , balance - billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See bluecrossma.com/findadoctor or call the Member Service number on your ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plans network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the providers charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist ? No. You can see the specialist you choose without a referral.

Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies . Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you visit a health care providers office or clinic Primary care visit to treat an injury or illness No charge 20% coinsurance Deductible applies first; in-network cost share waived for the first two diabetic PCP and / or specialist visits per calendar year; a telehealth cost share may be applicable Specialist visit No charge; No charge / chiropractor visit; No charge / acupuncture visit 20% coinsurance; 20% coinsurance / chiropractor visit; 20% coinsurance / acupuncture visit Deductible applies first; in-network cost share waived for the first two diabetic PCP and / or specialist visits per calendar year; limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Preventive care/screening/immunization No charge 20% coinsurance Limited to age-based schedule and / or frequency; cost share waived for at least one mental health wellness exam per calendar year; a telehealth cost share may be applicable. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Deductible applies first; pre- authorization may be required

Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bluecrossma.org/medicatio n Generic drugs $10 / retail supply or $20 / mail service supply $20 / retail supply and all charges for mail service Deductible applies first; up to 30-day retail (90-day mail service) supply; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs Preferred brand drugs $25 / retail supply or $50 / mail service supply $50 / retail supply and all charges for mail service Non-preferred brand drugs $45 / retail supply or $135 / mail service supply $90 / retail supply and all charges for mail service Specialty drugs Applicable cost share (generic, preferred, non-preferred) Not covered Deductible applies first; when obtained from a designated specialty pharmacy; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre- authorization required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If you need immediate medical attention Emergency room care $150 / visit $150 / visit Deductible applies first; copayment waived if admitted or for observation stay Emergency medical transportation No charge No charge Deductible applies first Urgent care No charge 20% coinsurance Deductible applies first; a telehealth cost share may be applicable

Page 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you need mental health, behavioral health, or substance abuse services Outpatient services No charge 20% coinsurance Deductible applies first; a telehealth cost share may be applicable; pre- authorization required for certain services Inpatient services No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you are pregnant Office visits No charge 20% coinsurance Deductible applies first except for in - network prenatal care; cost sharing does not apply for in-network preventive services; maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services No charge 20% coinsurance

Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Rehabilitation services No charge for outpatient services; No charge for inpatient services 20% coinsurance for outpatient services; 20% coinsurance for inpatient services Deductible applies first; limited to 60 outpatient visits per calendar year (other than for autism, home health care, and speech therapy); limited to 60 days per calendar year for inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Habilitation services No charge 20% coinsurance Deductible applies first; outpatient rehabilitation therapy coverage limits apply; coverage limits waived for early intervention services for eligible children; a telehealth cost share may be applicable Skilled nursing care No charge 20% coinsurance Deductible applies first; limited to 100 days per calendar year; pre- authorization required Durable medical equipment 20% coinsurance 40% coinsurance Deductible applies first; in-network cost share waived for one breast pump per birth, including supplies (20% coinsurance for out-of-network) Hospice services No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If your child needs dental or eye care Childrens eye exam No charge 20% coinsurance Limited to one exam every 24 months Childrens glasses Not covered Not covered None Childrens dental check-up No charge for members with a cleft palate / cleft lip condition 20% coinsurance for members with a cleft palate / cleft lip condition Limited to members under age 18

Page 6 of 8 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Children's glasses Cosmetic surgery Dental care (Adult) Long - term care Private - duty nursing Other Covered Services (Limitations may apply to these services. This isnt a complete list. Please see your plan document.) Acupuncture (12 visits per calendar year) Bariatric surgery Chiropractic care Hearing aids ($2,000 per ear every 36 months for members age 21 or younger) Infertility treatment Non-emergency care when traveling outside the U.S. Routine eye care - adult (one exam every 24 months) Routine foot care (only for patients with systemic circulatory disease) Weight loss programs ($150 per calendar year per policy)

Page 7 of 8 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform and the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov . Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact the Massachusetts Division of Insurance at 1-877-563-4467 or www.mass.gov/doi . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. For more information about possibly buying individual coverage through a state exchange, you can contact your states marketplace, if applicable. If you are a Massachusetts resident, contact the Massachusetts Health Connector by visiting www.mahealthconnector.org . For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually the members employer or organization that provides group health coverage to the member.) Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, call 1-800-472-2689 or contact your plan sponsor. (A plan sponsor is usually the members employer or organization that provides group health coverage to the member.) You may also contact The Office of Patient Protection at 1-800-436-7757 or www.mass.gov/hpc/opp . Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesnt meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern. To see examples of how this plan might cover costs for a sample medical situation, see the next section.

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in - network prenatal care and a hospital delivery) The plan s overall deductible $2,900 Delivery fee copay $0 Facility fee copay $0 Diagnostic tests copay $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost sharing Deductibles $2,900 Copayments $10 Coinsurance $0 What isnt covered Limits or exclusions $60 The total Peg would pay is $2,970 Managing Joe's Type 2 Diabetes (a year of routine in - network care of a well - controlled condition) The plan s overall deductible $2,900 Specialist visit copay $0 Primary care visit copay $0 Diagnostic tests copay $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost sharing Deductibles $2,900 Copayments $400 Coinsurance $0 What isnt covered Limits or exclusions $20 The total Joe would pay is $3,320 Mias Simple Fracture (in - network emergency room visit and follow - up care) The plan s overall deductible $2,900 Specialist visit copay $0 Emergency room copay $150 Ambulance services copay $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test ( x-ray ) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isnt covered Limits or exclusions $0 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 003409050 (3/25) GSP Registered Marks of the Blue Cross and Blue Shield Association. 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 8 of 8

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001652563 55-0647 (6/23) This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. MCC COMPLIANCE

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DOCTORS ON CALL, ON YOUR DEVICE. Get convenient access to telehealth care by using Well Connection. Sign in to MyBlue, or create an account, then click Well Connection Video Visit under My Care. REAL DOCTORS. REAL EXPERIENCE. REALLY FAST. CLOCK GET MEDICAL CARE 24/7 Speak face to face with a doctor, in the privacy of your home. 1 comments THERAPY THAT COMES TO YOU Talk to a licensed therapist or psychiatriston your terms. Its convenient and confidential. AWARD HIGHLY EXPERIENCED, HIGHLY RATED Qualified providers. Rated 4.8/5 stars and averaging 15 years of experience. 2 Sign In Download the MyBlue App from the App Store or Google Play TM , or go to bluecrossma.org . Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. 1. Medical services are available 24/7. Mental health visits must be made by appointment. If your local doctor in the Blue Cross Blue Shield of Massachusetts network offers covered services using live video visits through a service other than Well Connection, youre still covered. This service is only available in the United States. 2. Source: American Well. Amwell Telehealth Report, February 2018. Patient Satisfaction Survey Data compiled December 2017-February 2018. Data, compiled December 2017-February 2018. Data reverified, August 2020.

000770131 55-1287 (5/21) Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). 3. Source: American Well. AmWell TeleHealth Report, February 2018. Patient Satisfaction Survey Data, compiled December 2017-February 2018. Data reverified, August 2020. 4. Prescription availability is defined by doctor judgment. IS A VIDEO DOCTOR VISIT RIGHT FOR ME? You can do a lot over your tablet, laptop, or smartphone. Heres how members are using this service. Im not feeling well. Get care for: Cold and flu symptoms Fever Runny nose, sinus pain Sore throat Pink eye Skin rash My loved one is under the weather. If theyre on your plan: Get quick, expert family care Save time in your busy family schedule AWARD Well Connection is highly rated: 4.8 out of 5 Doctor and Provider rating from our members 3 Licensed doctors and providers in the Well Connection network have an average of 15 years of experience. They can look up your medical history, diagnose and treat your symptoms, and prescribe medication, 4 if necessary. I need emotional support. Talk to a therapist about: Depression and anxiety Substance use disorder Loss of a loved one Relationship issues Emotional trauma Stress You can also schedule a visit with a psychiatrist for medication management services.

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SAVE MONEY ON YOUR MEDICATIONS WITH THE MAIL SERVICE PHARMACY Maintenance medications, also known as long-term medications, are used to treat chronic or ongoing conditions. Save 33% when you order them in 90-day supplies through the mail service pharmacy. 1 BENEFITS OF USING THE MAIL SERVICE PHARMACY Youll pay 33% less for 90-day supplies of most maintenance medications (thats one less copay). Theres no additional cost for standard delivery. Signing up for automatic refills makes it less likely to miss a dose. 1. In most cases for eligible maintenance medications. Check plan materials for more details. 2. For illustrative purposes only, using a 3-tier plan. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. (continued) EXAMPLE OF HOW YOULL SAVE 2 TYPE OF PRESCRIPTION MEDICATION COPAY Tier 1 Tier 2 Tier 3 30-day supply, retail pharmacy $15 $30 $50 90-day supply, mail service pharmacy $30 $60 $150

If you have any questions, call CVS Customer Care at 1-877-817-0477 (TTY: 711 ). Questions? Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). CaremarkPCS Health, LLC (CVS Caremark) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001542278 55-001542278 (10/22) Certain medications that require immediate administration or are used for short periods of time arent available through the mail service pharmacy. In addition, some specialty medications are only available through specialty pharmacies. WHY ISNT MY MEDICATION AVAILABLE THROUGH THE MAIL SERVICE PHARMACY? Certain prescribed medications may be subject to other dispensing limitations and to the professional judgment of the pharmacist. If you have any questions about your medication, call CVS Customer Care at 1-877-817-0477 (TTY: 711 ). Its the patients responsibility to report any changes in drug allergies, health conditions, chronic diseases, and drug sensitivities. Prescription information about members and dependents is used to administer your prescription program. That information is reported to Blue Cross Blue Shield of Massachusetts, and is used for reporting and analysis, without identifying individual patients in accordance with applicable laws. Please Note: You can also fill prescriptions by calling CVS Customer Care at 1-877-817-0477 (TTY: 711 ), or by using the included order form. HOW TO USE THE MAIL SERVICE PHARMACY TRANSFER PRESCRIPTIONS Click Start Rx Delivery by Mail ORDER REFILLS Click View/Refill All Prescriptions SET UP AUTOMATIC REFILLS Click Manage Automatic Refills Download the MyBlue app or create an account at bluecrossma.org . Once signed in, click Pharmacy Benefit Manager under My Medications, then go to the Prescriptions tab. To:

Mail this form to: Number of New prescriptions: Number of Refill prescriptions: New Prescriptions - Mail your new prescriptions with this form. Refills - Order by Web, phone, or write in Rx number(s) below. Refills. To order mail service refills, enter your prescription number(s) here. A B Apt./Suite # City State ZIP Code Daytime Phone #: Evening Phone #: Last Name First Name MI Suffix (JR, SR) 1) 2) 3) 4) 5) 6) 7) 8) Prescription Plan Sponsor or Company Name Member ID # (if not shown or if different from above) Street Address Please use blue or black ink and print in capital letters. Fill in both sides of this form. Instructions: Use shipping address for this order only. Shipping Address. To ship to an address different from the one printed above, enter the changes here. We may package all of these prescriptions together unless you tell us not to. All claims for prescriptions submitted to CVS Caremark Mail Service Pharmacy using this form ZLOOEHVXEPLWWHGWR\RXUSUHVFULSWLRQEHQHWSODQIRUSD\PHQW,I\RXGRQRWZDQWWKHPVXEPLWWHG to your plan, do not use this form. You may call Customer Care to make alternate arrangements for submission of your order and payment. 2020 CVS Caremark. All rights reserved. P13-N Mail Service Order Form CVS Caremark wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute equivalent generic medicines for brand name medicines whenever possible. If you do not want XVWRVXEVWLWXWHJHQHULFVSOHDVHSURYLGHVSHFLFLQVWUXFWLRQVLQFOXGLQJGUXJQDPHVLQWKH Special Instructions section of this form. CaremarkPCS Health, LLC (CVS Caremark) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. TO RECEIVE YOUR ORDER SOONER request refills or new prescriptions online at bluecrossma.org . Go to 90-Day Mail Service under My Medications . CVS Caremark PO BOX 659541 SAN ANTONIO, TX 78265-9541 USVUUVTTVVTUUUVUUVUUVTTUUUTSUUSTSUUSSVUUTTVUVSUVTVSVUVSUSTUSUSTUV

. Spanish forms and labels Allergies: Special instructions: Credit or debit card. (VISA , MasterCard , Discover , or American Express ) Check or money order. Amount: $ C D E Spanish forms and labels Erythromycin Cephalosporin Codeine Aspirin None Sulfa Other: Peanuts Arthritis Asthma Diabetes Acid reflux Glaucoma High blood pressure Other: High cholesterol Migraine Osteoporosis Prostate issues Penicillin Heart problem Thyroid Date new prescription written: Doctors last name Doctors first name Doctors phone # Allergies: Erythromycin Cephalosporin Codeine Aspirin None Sulfa Other: Peanuts Arthritis Asthma Diabetes Acid reflux Glaucoma High blood pressure Other: High cholesterol Migraine Osteoporosis Prostate issues Penicillin Heart problem Thyroid Date new prescription written: Doctors last name Doctors first name Doctors phone # Fill in this oval if you DO NOT want us to use this payment method for future orders. 2nd business day ($17) Next business day ($23) Credit card holder signature/Date Suffix (JR,SR) Suffix (JR,SR) Date of birth: Last Name Nickname Nickname First Name MI Last Name First Name MI Date of birth: MM-DD-YYYY MM-DD-YYYY MMYY Exp.Date Tell us about new health information for 1st person if never provided or if changed. Medical conditions: Tell us about new health information for 2nd person if never provided or if changed. Medical conditions: Electronic check. Pay from your bank account. (You must first register online or call Customer Care.) How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.) E-mail address: E-mail address: Tell us about the people ordering prescriptions. If there are more than two people, please complete another form. First person with a refill or new prescription. Use your card on file. Use a new card or update your cards expiration date. Second person with a refill or new prescription. Regular delivery is free and takes up to 5 days after your order is processed. If you want faster delivery, choose: Faster delivery can only be sent to a street address, not a PO Box Expected processing time from receipt of this form: Refills: 1-2 days New/renewed prescriptions: Within 5 days unless additional information is needed from your doctor (Charges subject to change) MOF WEB 0122 BCBSMA Make check or money order payable to CVS Caremark. :ULWH\RXUSUHVFULSWLRQEHQHW,'QXPEHURQ\RXU check or money order. If your check is returned, we will charge you up to $40. Payment for Balance Due and Future Orders: If you choose electronic check or a credit or debit card, we will use it to pay for any balance due and for future orders unless you provide another form of payment.

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SAVING SHOULD ALWAYS BE THIS EASY You shouldnt have to go out of your way to save money on medications. The Cost-Share Assistance Program provides financial assistance, using coupons from manufacturers of medication, to cover most or all of your out-of-pocket costs for eligible medications that you or your dependent may be taking. You dont have to change anything about your prescriptions to get these savings. You just need to be enrolled in the program. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Your medication costs will be higher if you or your dependent isnt enrolled. Enrollment in the Cost-Share Assistance Program is optional. However, if you dont enroll in the program or decide to opt out of it, youll be responsible for paying 30% of the full retail cost of eligible medications . Fill your prescription When you fill an eligible medication, a manufacturers coupon will be automatically applied at checkout. Enjoy instant savings Youll pay $0 to $35, depending on the medication. Get personalized, ongoing support PillarRx checks your claims every month to make sure youre receiving the correct savings, and provides additional support as needed. If you have any questions, call a PillarRx Care Team Coordinator at 1-636-614-3128 (TTY: 711 ), Monday through Friday, 8:00 a.m. to 7:00 p.m. ET. Questions? (Continued) How do I or my dependent become enrolled in the cost-share assistance program? There are two ways to be enrolled: How the program works If youre not using coupons for an eligible medication at the beginning of your plan year, or you or your dependent start taking an eligible medication during the plan year, PillarRx will call you to discuss the program and help you enroll. If you were already using coupons to help cover your costs for medications that you were taking before your plan year began, youve been automatically enrolled in the program . PillarRx Consulting, an independent company that administers the program, will call you to confirm your enrollment. 1. 2.

What is a manufacturers coupon? A manufacturers coupon (also known as a copay card, copay coupon, copay assistance card, or manufacturer financial assistance) is part of the copay savings programs offered by manufacturers of medication to members with commercial health insurance. How do I enroll myself or my dependent in the program? If you or your dependent is taking an eligible medication, and youre not using a coupon to cover your costs, a Care Team Coordinator from PillarRx will call to talk to you about the program and walk you through the enrollment process. Theyll also call you if you or your dependent start taking a new eligible medication. You can also call PillarRx directly at 1-636-614-3128 (TTY: 711 ). Do I need to enroll if Im already using a manufacturers coupon for an eligible medication? No. If youre already using a manufacturers coupon, youll be automatically enrolled in the program . A Care Team Coordinator from PillarRx will call you to confirm your participation. Theyll also ensure that youre paying the lowest possible cost for your medication. You can also call PillarRx directly at 1-636-614-3128 (TTY: 711 ). Am I required to be enrolled in the program? No, enrollment is optional. However, if you dont enroll yourself or your dependent in the program, or decide to opt out after being enrolled, your out-of-pocket costs for your medications will be higher because youll be responsible for paying 30% of the cost of the eligible medications. What if I filled my eligible medication before I enrolled in the program? If youve already filled an eligible medication and youre eligible for the program, call PillarRx at 1-636-614-3128 (TTY: 711 ) to learn more about retroactive enrollment. How does the program affect my out-of-pocket maximum? Once you or your dependent is enrolled in the Cost-Share Assistance Program, your plan will apply only your actual out-of-pocket costs to your annual out-of-pocket maximum. For example, if you pay $10 for an eligible medication, only $10 will be applied to your annual out-of-pocket maximum. How does the program affect my deductible? If you have a Health Savings Account (HSA)-qualified Saver plan, or a plan with a deductible that applies to your pharmacy benefits, your plan will apply your out-of-pocket costs to your annual deductible as well as to your out-of-pocket maximum. 1 For example, if you pay $10 for an eligible medication, only $10 will be applied to both your out-of-pocket maximum and your deductible. What happens if the manufacturer no longer offers financial assistance for my medication? PillarRx will notify you that your medication is no longer eligible for this program. Youll then pay the standard cost share for this medication according to your pharmacy benefit. Check your Summary of Benefits or Schedule of Benefits for details. Are there instances where I may not be able to sign up for the program? Although most members can enroll, there may be specific instances that make you ineligible for the program, such as: You have or are eligible for government health insurance, such as Medicare or Medicaid. Your medication isnt approved by the Food and Drug Administration (FDA) to treat your condition. Your medication has specific age restrictions you dont meet. You use a secondary insurer in addition to Blue Cross to cover your plans out-of-pocket costs. If a manufacturer of medication determines that youre ineligible for the program, PillarRxs Care Team will ensure that your medication is covered, based on the standard cost-share amount that applies for all other covered medications and supplies as described in your Summary of Benefits, Schedule of Benefits, and/or riders. In this instance, you wouldnt be eligible for cost savings for your medication through this program. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks are the property of their respective owners. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002745206 55-001544994 (5/24) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). 1. Exceptions may apply. Check your plan materials for details. See if your medication is eligible To see a list of eligible medications: 1 . Download the MyBlue app, or create an account at bluecrossma.org . 2 . Once signed in, click Cost-Share Assistance under My Medications . 3 . Select See Eligible Medications . You can also call PillarRx Care at 1-636-614-3128 (TTY: 711 ), Monday through Friday, 8:00 a.m. to 7:00 p.m. ET.

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Last updated: January 1, 2025 THE PHARMACY THAT COMES TO YOU AND SAVES YOU MONEY With the mail service pharmacy, most maintenance medications can be automatically refilled and shipped every 90 days at a lower cost.* To start, create an account at bluecrossma.org . Once signed in, click Pharmacy Benefit Manager under My Medications , then go to Start Rx Delivery by Mail under the Prescriptions tab. You can also call CVS Customer Care at 1-877-817-0477 (TTY: 711 ) . *Not all medications are available through the mail service pharmacy. Check your plan details to see if the mail service pharmacy is included with your plan. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Health Savings Account (HSA) Preventive Medication List For plans that use the: Blue Cross Blue Shield of Massachusetts Formulary

2 Preventive Medications Covered by HSA-Qualified Saver Plans 1 The medications on this list are commonly prescribed to help you stay healthy by preventing complications or secondary conditions. Depending on your plan, you may not be required to pay the deductible for some of the medications. In some cases, your employer may also exempt the copayment or co-insurance. Check your benefit materials for details. This isnt a complete list of covered medications, and inclusion on this list doesnt guarantee coverage. 2 You must have a valid prescription from a licensed health provider to receive coverage for these medications. Some medications may also be subject to pharmacy management programs, such as step therapy, prior authorization, or quality care dosing, or have other coverage requirements. NOTE: Some medications on this list may be considered non-covered, including new medications under review by Blue Cross. Your doctor may request an exception for a non-covered medication when medically necessary. 3 1. Blue Cross Blue Shield of Massachusetts plans that are HSA-qualified include the term Saver in the plan name. For example: Blue Care Elect Saver or HMO Blue New England Saver $2,000. 2. Not all medications listed are covered by all prescription plans. Check your benefit materials for details. 3. If approved, youd pay the highest-tier cost. For more information about coverage for these medications, sign in to MyBlue at bluecrossma.org then go to Medication Lookup Tool under My Medications . If you're not a member, you can get more information by visiting bluecrossma.org/medication . Learn more about your coverage

3 Medication class Medication name ACE inhibitors/angiotensin II receptor antagonists and combination agents ACCUPRIL ACCURETIC ALTACE AMLODIPINE/BENAZEPRIL ATACAND ATACAND HCT AVALIDE AVAPRO BENAZEPRIL BENAZEPRIL/HYDROCHLOROTHIAZIDE BENICAR BENICAR HCT CANDESARTAN CANDESARTAN/HYDROCHLOROTHIAZIDE CAPTOPRIL CAPTOPRIL/HYDROCHLOROTHIAZIDE COZAAR DIOVAN DIOVAN HCT EDARBI EDARBYCLOR ENALAPRIL ENALAPRIL/HYDROCHLOROTHIAZIDE EPANED FOSINOPRIL FOSINOPRIL/HYDROCHLOROTHIAZIDE HYZAAR IRBESARTAN IRBESARTAN/HYDROCHLOROTHIAZIDE LISINOPRIL LISINOPRIL/HYDROCHLOROTHIAZIDE

4 Medication class Medication name ACE inhibitors/angiotensin II receptor antagonists and combination agents (continued) LOSARTAN LOSARTAN/HYDROCHLOROTHIAZIDE LOTENSIN LOTENSIN HCT LOTREL MICARDIS MICARDIS HCT MOEXIPRIL OLMESARTAN OLMESARTAN/HYDROCHLOROTHIAZIDE PERINDOPRIL PRESTALIA QBRELIS QUINAPRIL QUINAPRIL/HYDROCHLOROTHIAZIDE RAMIPRIL TELMISARTAN TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL TRANDOLAPRIL/VERAPAMIL ER VALSARTAN VALSARTAN/HYDROCHLOROTHIAZIDE VASERETIC VASOTEC ZESTORETIC ZESTRIL Agents for chemical dependency ACAMPROSATE CALCIUM BRIXADI BUPRENORPHINE SUBLINGUAL BUPRENORPHINE/NALOXONE SUBLINGUAL DEPADE

5 Medication class Medication name Agents for chemical dependency (continued) DISULFIRAM NALTREXONE SUBLOCADE SUBOXONE FILM VIVITROL ZUBSOLV Allergenic extracts GRASTEK ODACTRA ORALAIR PALFORZIA RAGWITEK Anaphylaxis therapy agents ADRENALIN ADYPHREN AUVI-Q EPINEPHRINE EPINEPHRINE PRO EPIPEN EPIPEN-JR EPISNAP SYMJEPI Anti-arrhythmic agents AMIODARONE BETAPACE BETAPACE AF DISOPYRAMIDE DOFETILIDE FLECAINIDE MULTAQ NORPACE NORPACE CR PACERONE PROPAFENONE

6 Medication class Medication name Anti-arrhythmic agents (continued) PROPAFENONE ER SOTALOL SOTALOL AF SOTYLIZE TIKOSYN Anti-coagulants ARIXTRA DABIGATRAN ELIQUIS ENOXAPARIN FONDAPARINUX FRAGMIN JANTOVEN LOVENOX PRADAXA PRADAXA PAK SAVAYSA WARFARIN XARELTO Anti-convulsants APTIOM BANZEL BRIVIACT CARBAMAZEPINE CARBAMAZEPINE ER CARBATROL CELONTIN CLOBAZAM CLONAZEPAM DEPAKOTE DEPAKOTE ER DIACOMIT DILANTIN

7 Medication class Medication name Anti-convulsants (continued) DIVALPROEX SODIUM DR DIVALPROEX SODIUM ER ELEPSIA XR EPIDIOLEX EPITOL EPRONTIA ETHOSUXIMIDE FELBAMATE FELBATOL FINTEPLA FYCOMPA KEPPRA KEPPRA XR KLONOPIN LACOSAMIDE LAMICTAL LAMICTAL XR LAMOTRIGINE LAMOTRIGINE ER LEVETIRACETAM LEVETIRACETAM ER METHSUXIMIDE MOTPOLY XR MYSOLINE ONFI OXCARBAZEPINE OXCARBAZEPINE ER OXTELLAR XR PHENOBARBITAL PHENYTEK PHENYTOIN

8 Medication class Medication name Anti-convulsants (continued) PHENYTOIN SODIUM ER PRIMIDONE QUDEXY XR ROWEEPRA RUFINAMIDE SABRIL TEGRETOL TEGRETOL-XR TIAGABINE TOPAMAX TOPIRAMATE TOPIRAMATE ER TRILEPTAL TROKENDI XR VALPROIC ACID VIGABATRIN VIGAFYDE VIMPAT XCOPRI ZARONTIN ZONEGRAN ZONISADE ZONISAMIDE ZTALMY Anti-depressants AMITRIPTYLINE AMOXAPINE ANAFRANIL APLENZIN AUVELITY BUPROPION BUPROPION ER

9 Medication class Medication name Anti-depressants (continued) CELEXA CITALOPRAM CYMBALTA DESIPRAMINE DESVENLAFAXINE ER DOXEPIN DRIZALMA SPRINKLE DULOXETINE DR EFFEXOR XR EMSAM ESCITALOPRAM FETZIMA FLUOXETINE FLUOXETINE 60 MG FLUOXETINE DR FORFIVO XL IMIPRAMINE HCL IMIPRAMINE PAMOATE IRENKA LEXAPRO MARPLAN MIRTAZAPINE NARDIL NORPRAMIN NORTRIPTYLINE OLEPTRO PAMELOR PARNATE PAROXETINE HCL PAROXETINE HCL ER PAXIL

10 Medication class Medication name Anti-depressants (continued) PAXIL CR PHENELZINE PRISTIQ PROTRIPTYLINE PROZAC REMERON SERTRALINE TRANYLCYPROMINE TRAZODONE TRIMIPRAMINE TRINTELLIX VENLAFAXINE VENLAFAXINE ER VIIBRYD VILAZODONE WELLBUTRIN SR WELLBUTRIN XL ZOLOFT Anti-estrogens SOLTAMOX TAMOXIFEN Anti-hyperlipidemics ALTOPREV ANTARA ATORVALIQ ATORVASTATIN CHOLESTYRAMINE COLESEVELAM COLESTID COLESTIPOL CRESTOR EZALLOR SPRINKLE EZETIMIBE

11 Medication class Medication name Anti-hyperlipidemics (continued) FENOFIBRATE FENOFIBRIC ACID FENOFIBRIC ACID DR FENOGLIDE FIBRICOR FLOLIPID FLUVASTATIN FLUVASTATIN ER GEMFIBROZIL ICOSAPENT ETHYL LESCOL XL LIPITOR LIPOFEN LIVALO LOPID LOVASTATIN NEXLETOL NEXLIZET NIACIN ER NIACOR PITAVASTATIN PRALUENT PRAVASTATIN PREVALITE QUESTRAN/QUESTRAN LIGHT REPATHA ROSUVASTATIN SIMVASTATIN TRICOR TRILIPIX VASCEPA

12 Medication class Medication name Anti-hyperlipidemics (continued) WELCHOL ZETIA ZOCOR ZYPITAMAG Anti-malarial agents ARAKODA ATOVAQUONE/PROGUANIL CHLOROQUINE MALARONE MEFLOQUINE PRIMAQUINE Anti-manics LITHIUM LITHIUM CARBONATE LITHIUM CARBONATE ER LITHOBID ER Anti-obesity agents CONTRAVE SAXENDA WEGOVY ZEPBOUND Anti-psychotics ABILIFY ABILIFY ASIMTUFII ABILIFY MAINTENA ABILIFY MYCITE ARIPIPRAZOLE ARISTADA ASENAPINE CAPLYTA CHLORPROMAZINE CLOZAPINE CLOZARIL EQUETRO FANAPT

13 Medication class Medication name Anti-psychotics (continued) FLUPHENAZINE FLUPHENAZINE DECANOATE GEODON HALDOL DECANOATE HALOPERIDOL INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA LOXAPINE LURASIDONE LYBALVI OLANZAPINE OLANZAPINE ORALLY DISINTEGRATING TABS PALIPERIDONE PERPHENAZINE PERSERIS QUETIAPINE QUETIAPINE ER REXULTI RISPERDAL RISPERDAL CONSTA RISPERIDONE RYKINDO SAPHRIS SECUADO SEROQUEL SEROQUEL XR THIORIDAZINE THIOTHIXENE TRIFLUOPERAZINE

14 Medication class Medication name Anti-psychotics (continued) UZEDY VERSACLOZ VRAYLAR ZIPRASIDONE ZYPREXA ZYPREXA ZYDIS Anti-retroviral agents APRETUDE DESCOVY EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE 200/300 MG TRUVADA 200/300 MG Aromatase inhibitors ANASTROZOLE ARIMIDEX AROMASIN EXEMESTANE FEMARA LETROZOLE Beta-blockers and combination agents ACEBUTOLOL ATENOLOL ATENOLOL/CHLORTHALIDONE BETAXOLOL BISOPROLOL BISOPROLOL/HYDROCHLOROTHIAZIDE BYSTOLIC CARVEDILOL CARVEDILOL PHOSPHATE ER COREG COREG CR CORGARD INDERAL LA KAPSPARGO

15 Medication class Medication name Beta-blockers and combination agents (continued) LABETALOL LEVATOL LOPRESSOR METOPROLOL METOPROLOL SUCCINATE ER METOPROLOL/HYDROCHLOROTHIAZIDE NADOLOL NEBIVOLOL PINDOLOL PROPRANOLOL PROPRANOLOL ER TENORETIC TENORMIN TIMOLOL MALEATE TOPROL-XL TRANDATE Bowel preparations CLENPIQ GAVILYTE GOLYTELY MOVIPREP OSMOPREP PEG 3350/ELECTROLYTES PLENVU SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE SUFLAVE SUPREP SUTAB Calcium channel blockers and combination agents AMLODIPINE CARDIZEM CARDIZEM CD

16 Medication class Medication name Calcium channel blockers and combination agents (continued) CARDIZEM LA CARTIA XT CONJUPRI DILT-XR DILTIAZEM DILTIAZEM ER DILTIAZEM XR FELODIPINE ER ISOPTIN SR ISRADIPINE KATERZIA LEVAMLODIPINE MATZIM LA NICARDIPINE NIFEDIAC CC NIFEDIPINE NIFEDIPINE ER NISOLDIPINE ER NORLIQVA NORVASC PROCARDIA XL SULAR TIAZAC VERAPAMIL VERAPAMIL ER VERELAN VERELAN PM Combination anti-hyperlipidemics AMLODIPINE/ATORVASTATIN CADUET EZETIMIBE/SIMVASTATIN VYTORIN

17 Medication class Medication name Contraceptives ALL PRESCRIPTION FORMULATIONS Dental caries prevention PEDIATRIC MULTIVITAMINS WITH FLUORIDE - ALL PRESCRIPTION FORMULATIONS SODIUM FLUORIDE Diagnostic agents and supplies BLOOD GLUCOSE STRIPS - ALL FORMULATIONS CONTROL SOLUTIONS INSULIN DELIVERY DEVICES INSULIN SYRINGES, INFUSION SETS, AND NEEDLES - ALL FORMULATIONS KETONE BLOOD TEST STRIPS - ALL FORMULATIONS LANCETS, LANCET DEVICES URINE TESTING STRIPS - ALL FORMULATIONS Diuretics ALDACTAZIDE AMILORIDE/HYDROCHLOROTHIAZIDE CHLORTHALIDONE DIURIL HYDROCHLOROTHIAZIDE INDAPAMIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE THALITONE TRIAMTERENE/HYDROCHLOROTHIAZIDE Hereditary angioedema agents CINRYZE HAEGARDA ORLADEYO TAKHZYRO Immunizations ALL FORMULATIONS Immunosuppressive agents ASTAGRAF XL CELLCEPT CYCLOSPORINE CAPS ENVARSUS XR EVEROLIMUS GENGRAF

18 Medication class Medication name Immunosuppressive agents (continued) MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM DR MYFORTIC MYHIBBIN NEORAL NULOJIX PROGRAF RAPAMUNE SANDIMMUNE SIROLIMUS TACROLIMUS ZORTRESS Inhaled diabetes agents AFREZZA Injectable diabetes agents ADMELOG APIDRA BASAGLAR BYDUREON BCISE BYETTA FIASP HUMALOG HUMULIN INSULIN ASPART INSULIN DEGLUDEC INSULIN GLARGINE INSULIN LISPRO LANTUS LEVEMIR LYUMJEV MOUNJARO MYXREDLIN NOVOLIN

19 Medication class Medication name Injectable diabetes agents (continued) NOVOLOG OZEMPIC REZVOGLAR SEMGLEE SOLIQUA SYMLINPEN TOUJEO TRESIBA TRULICITY VICTOZA XULTOPHY Miscellaneous CHOLECALCIFEROL (D3) INPEFA LODOCO Multiple sclerosis agents AUBAGIO AVONEX BAFIERTAM BETASERON BRIUMVI COPAXONE DIMETHYL FUMARATE DR EXTAVIA FINGOLIMOD GILENYA GLATIRAMER KESIMPTA LEMTRADA MAVENCLAD MAYZENT OCREVUS PLEGRIDY

20 Medication class Medication name Multiple sclerosis agents (continued) PONVORY REBIF TASCENSO ODT TECFIDERA TYSABRI VUMERITY ZEPOSIA Obsessive compulsive disorder CLOMIPRAMINE FLUVOXAMINE FLUVOXAMINE ER Oral anti-anginal agents ISORDIL ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER Oral diabetes agents ACARBOSE ACTOPLUS MET ACTOPLUS MET XR ACTOS ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOGLIPTIN/PIOGLITAZONE AMARYL BEXAGLIFLOZON BRENZAVVY DAPAGLIFLOZIN DAPAGLIFLOZIN/METFORMIN ER DUETACT FARXIGA GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER

21 Medication class Medication name Oral diabetes agents (continued) GLIPIZIDE/METFORMIN GLUCOTROL XL GLUMETZA GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR KAZANO METAGLIP METFORMIN METFORMIN ER MIGLITOL NATEGLINIDE NESINA ONGLYZA OSENI PIOGLITAZONE PIOGLITAZONE/GLIMEPIRIDE PIOGLITAZONE/METFORMIN QTERN REPAGLINIDE RIOMET RYBELSUS SAXAGLIPTIN SAXAGLIPTIN/METFORMIN ER

22 Medication class Medication name Oral diabetes agents (continued) SEGLUROMET SITAGLIPTIN SITAGLIPTIN/METFORMIN STEGLATRO STEGLUJAN SYNJARDY SYNJARDY XR TRADJENTA TRIJARDY XR XIGDUO XR ZITUVIO Osteoporosis ACTONEL ALENDRONATE ATELVIA BINOSTO CALCITONIN CALCITONIN/SALMON EVENITY EVISTA FORTEO FOSAMAX FOSAMAX PLUS D IBANDRONATE MIACALCIN NASAL SPRAY PROLIA RALOXIFENE RECLAST RISEDRONATE TERIPARATIDE TYMLOS ZOLEDRONIC ACID 5 MG/100 ML

23 Medication class Medication name Other anti-hypertensive agents ALISKIREN AMLODIPINE/OLMESARTAN AMLODIPINE/TELMISARTAN AMLODIPINE/VALSARTAN/HCTZ AZOR CATAPRES-TTS CLONIDINE CLONIDINE TRANSDERMAL EXFORGE EXFORGE HCT GUANFACINE HYDRALAZINE HYDROCHLOROTHIAZIDE METHYLDOPA MINOXIDIL OLMESARTAN/AMLODIPINE/HCTZ TEKTURNA TEKTURNA HCT TRIBENZOR TRYVIO Platelet aggregation inhibitors ASPIRIN 81 MG BRILINTA CLOPIDOGREL DIPYRIDAMOLE DIPYRIDAMOLE ER/ASPIRIN EFFIENT PLAVIX PRASUGREL YOSPRALA ZONTIVITY

24 Medication class Medication name Prenatal vitamins ALL PRESCRIPTION FORMULATIONS FOLIC ACID Respiratory agents ACCOLATE ADVAIR ADVAIR HFA AIRDUO RESPICLICK ALVESCO ARNUITY ELLIPTA ASMANEX ASMANEX HFA BEYFORTUS BREO ELLIPTA BREYNA BUDESONIDE SUSPENSION BUDESONIDE/FORMOTEROL CINQAIR CROMOLYN SODIUM NEBULIZER SOLUTION DULERA FASENRA FLUTICASONE FUROATE/VILANTEROL FLUTICASONE PROPIONATE DISKUS FLUTICASONE PROPIONATE HFA FLUTICASONE/SALMETEROL MONTELUKAST NUCALA PULMICORT PULMICORT FLEXHALER QVAR REDIHALER SINGULAIR SPIRIVA RESPIMAT 1.25 MCG SYMBICORT

25 Medication class Medication name Respiratory agents (continued) SYNAGIS TEZSPIRE TRELEGY ELLIPTA WIXELA INHUB XOLAIR ZAFIRLUKAST ZILEUTON ER ZYFLO Respiratory therapy supplies PEAK FLOW METERS SPACER DEVICES SPACER SUPPLIES Smoking deterrents BUPROPION ER NICODERM CQ NICORETTE GUM NICORETTE LOZENGE NICOTINE POLACRILEX NICOTINE TRANSDERMAL NICOTROL INHALER NICOTROL NS VARENICLINE Transdermal/topical anti-anginal agents NITRO-BID NITRO-DUR NITROGLYCERIN TRANSDERMAL

CaremarkPCS Health, LLC (CVS Caremark) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 003181301 55-001546643 (11/24) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ).

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NURSES RIGHT NOW When you call our 24/7 Nurse Line, you can speak to a registered nurse, when you need to, day or night. Because guidance and advice should be available around the clock. YES, YOUR PLAN COVERS IT! comments GET CONNECTED DIRECTLY TO A NURSE calendar-alt 365 DAYS A YEAR, INCLUDING HOLIDAYS HAND-HOLDING-USD THERES NO ADDITIONAL COST *We partner with Carenet Health , an independent health care engagement company, to administer this service. Before you can email a nurse, youll need to create a Carenet Health account using your nine-digit Blue Cross member ID number (without the letter prefix). KNOW WHEN TO CALL Nurses can give you advice on: Treating a fever, cut, headache, or diarrhea Managing a new diagnosis Recognizing signs of a concussion after a head injury Taking over-the-counter medications or prescriptions Upcoming medical tests or appointments Deciding if you need immediate care Caring for a sick child or family member In the case of a life-threatening emergency, call 911 or go to the nearest emergency room. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Nurses are ready around the clock to answer your questions. Call 1-888-247-BLUE (2583) . Call Our 24/7 Nurse Line

Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks, SM Service Marks, and TM Trademarks are the property of their respective owners. 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001188315 32-6765 (11/21) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ).

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Maternity Care Management You dont have to go it alone. Our Care Managers offer specialized pregnancy and postpartum support to help you improve your health and avoid complications. To work with a Care Manger one-on-one, call 1-800-392-0098 Monday through Friday, 8:30 a.m. to 4:30 p.m. ET. Lactation Consultations Our network includes board-certified Lactation Consultants who work with parents and infants to address any breastfeeding challenges, and support breastfeeding for as long as you choose. To see a list of participating lactation consultants, go to bcbsma.info/lactationcounseling . 24/7 Nurse Line If you have questions about your newborn, yourself, or need other medical advice, connect directly to a nurse 24/7. Get immediate adviceno waiting for a callback. Call 1-888-247-BLUE (2583) . baby Breast Pump Savings Easily compare pump features to find the one thats right for you. Many are available at no cost and can be delivered right to your door. Learn more at bluecrossma.com/breast-pump . Childbirth Course Reimbursement Expectant mothers may be eligible for reimbursement up to $90 for completing a childbirth course. Learn more at bcbsma.info/childbirthcourse . hand-holding-heart Maternal Mental Health Support Its normal for new and expectant mothers to experience mental health struggles. If you have symptoms of anxiety, depression, or other mental health issues, our Maternity Mental Health program provides support, education, and treatment referrals. To speak with a Mental Health Care Manager, call 1-800-524-4010 , ext. 62398 , Monday through Friday, 8:30 a.m. to 4:30 p.m. ET. SUPPORT FOR YOUR MATERNITY JOURNEY It has never been more important to make sure youre getting every benefit available to you, throughout your pregnancy and your babys first year. If you have any questions, were here to help with a full range of maternity programs and benefits you can explore as your family grows. To see all your maternity benefits in one place, visit bluecrossma.org/maternity . Learn More Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

55-1235 002108716 (5/23) Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Registered Marks and TM Trademarks are the property of their respective owners. 2023 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). MyBlue is Here To Help MyBlue gives you instant access to your plan benefits, all in one place. Find an in-network provider, see mental health options, check the status of a claim, and more. To sign in or create an account, go to bcbsma.info/signin3 , or scan the QR code with your smartphones camera.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Your new online wellness program, in a nutshell With a healthy me Rewards from Virgin Pulse , an independent company, its easy to make your healthy choices pay off. Track your healthy habits, earn points, and rake in the rewards.* Program is available to Blue Cross Blue Shield of Massachusetts subscribers only. Bring on the rewards Heres a quick look at how to make the most of a healthy me Rewards: Ready to start earning? Sign up at ahealthymerewards.com , then download the Virgin Pulse app. Get Started Earn up to $400 in rewards annually. Create an Account Sign up at ahealthymerewards.com , and download the Virgin Pulse app. Earn Points Track your healthy habits, join challenges, and complete daily tasks to start earning. Claim Your Rewards Use your points to shop exclusive deals, get gift cards, donate to charity, or add to your savings. *Rewards may be considered a taxable form of income, so you should consult your tax advisor.

HEALTHY HABITS From sleeping more to laughing more, you can practice three healthy habits every day, then track them to receive rewards. Themes include: Getting Active Eating Healthy Sleeping Well Reducing Stress Being Productive Learning New Things Contributing to My Community Building Relationships Managing My Finances CHALLENGES Team Challenges Team up with co-workers and use the Virgin Pulse app to take on fun, four- week virtual challenges across a variety of terrains. Personal Challenges Think about how youd like to get healthier, then choose a personal challenge that fits your goals. NUTRITION GUIDE Virgin Pulses Nutrition Guide integrates with MyFitnessPal, the worlds leading on-the-go nutrition tracker. Now you have the personalized nutrition plan you need to track your diet, get recipes, and make positive changes every day. SLEEP GUIDE A good nights sleep can work wonders for your mind and bodybut getting enough Zs is tough for many adults. Use the Sleep Guide to set goals, track your sleep, and take steps to sleep more soundly. BIOMETRIC SCREENING (IF APPLICABLE) Get a snapshot of your health by participating in an on-site or remote screening. So many ways to learn and earn Devices and Apps Connect your device to earn points and rewards. Under Tracking , you can connect all compatible devices and apps. My Interests Choose your interests and well create a program experience around your life and goals. Your To-dos Visit the home page and see all the ways you can earn points and trophies. Daily Cards Complete easy quizzes and pick up fun factsyour daily cards offer an easy way to earn points. Friends Invite co-workers to join in. Make it more fun by creating groups around common interests, like walking or sharing recipes. Earn points when you add friends. My Stats Keep tabs on your progress, from steps taken to calories consumed. Monthly Statement Keep track of your progress and your total points. Navigate to the Rewards tab, click My Earnings and scroll down to see current earnings or select previous months. Your Rewards To redeem, navigate to the Rewards tab, click Spend and choose how to spend your earnings. Journeys Improving your health and wellness begins with adopting new habits. Now you have the digital coaching you needto commit to goals that fit your life, to reinforce good habits, and to achieve real results. a healthy me Rewards makes it easy to earn rewards annually, just for making healthier choices. To make the most of ahealthyme Rewards, download the mobile app.

Heres How to Earn Points What You Do How Often Requirements Points Preventive Health Take a few proactive steps. Annually Biometric screening (on-site or remote) Set a well-being goal Get a flu shot Preventive cancer screening (e.g., mammography, cervical cancer screening, colonoscopy) Routine health checkup Complete your Health Pulse Check 100 200 250 500 500 1,000 Interests Quarterly Set interests 100 Physical Activity Sync your steps. Daily Per 1,000 steps (validated, 14,000 steps max) 15 or more active minutes 30 or more active minutes 45 or more active minutes *Maximum of 140 points per day 10** 70 100 140 Monthly Take 7,000 steps 20 days a month Take 10,000 steps 20 days a month 400 500 Self-Tracking Track healthy habits and activities. Daily Healthy Habit tracking (up to three a day) 10 Monthly Enter your weight or blood pressure Track healthy habits 10 days in a month Track healthy habits 20 days in a month 50 200 300 One-time Track healthy habits five days in one month for the first time 100 Cards Complete, learn, and earn. Daily Complete cards (up to two per day) 20 Monthly Complete 10 daily cards in a month Complete 20 daily cards in a month 100 200 Challenges Set and achieve goals. Personal Challenges Monthly Create a personal challenge Join a personal challenge 50 100 Healthy Habit Challenges Monthly Win the promoted healthy habit challenge 200 Destination-Based Steps Challenges Quarterly Join the company challenge Post a chat comment at least once a week during the challenge period Track steps at least once a week during the challenge period Create and fill a team in the company challenge Unlock a destination Reach the final destination of a challenge 100 100 100 250 100 100 (continued) **Maximum of 140 points per day.

Heres How to Earn Points (Cont.) What You Do How Often Requirements Points Nutrition See how healthy choices add up. Daily Daily calorie tracking using MyFitnessPal Browse healthy recipes 20 10 Weekly Add a recipe to grocery list Favorite a recipe 10 10 Quarterly Select your eating type 250 Monthly Track calories 10 days in a month Track calories 20 days in a month 200 300 One-time Connect calorie tracker to MyFitnessPal 100 Sleep Connect more sleep to better health. Daily Track sleep manually Track sleep nightly (validated) Sleep more than seven hours a night (validated) 10 20 50 Monthly Track sleep 10 days in a month Track sleep 20 days in a month Sleep more than seven hours, 20 days a month 100 200 300 Quarterly Choose your sleep profile 250 Journeys Build healthy habits through self-guided courses. Daily Complete a Journey step 20 Quarterly Complete a Journey 250 One-time Registration Connect first activity device Add profile picture Add your first five friends Add a friend outside of your company Invite up to five colleagues (50 points each) Initial sign-in on your mobile app 100 200 100 250 100 250 250 More Ways to Earn Do the little things. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks, TM Trademarks, and SM Service Marks are the property of their respective owners. 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001301880 (1/22) Chat live at member.virginpulse.com , email [email protected] , or call (toll-free) 1-844-854-7285 . Questions? Validated sleep data is required to earn points.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. WHERE TO GET YOUR SHOT The flu shot is available at no additional cost 2 from in-network providers and locations, like a primary care provider or pharmacy. To find an in-network provider or location near you, go to bluecrossma.com/findadoctor . GET YOUR NO-COST FLU SHOT The flu shot is quick and easy, and will help protect you and everyone around you this flu season. The flu shot reduces your risk of catching the flu and eases your symptoms if you become sick. 1 Get your flu shot today at a convenient location near you. 1. CDC, Seasonal Flu Vaccines, https://www.cdc.gov/flu/prevent/flushot.htm. 2. Flu vaccines recommended by the CDC are covered in full when administered by an in-network provider. Exceptions may apply. Check plan materials for details. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 003105840 55-000626727 (9/24) Learn More Just about everyone six months and older should get the annual flu shot. 1 Learn more about the flu and the flu shot at bluecrossma.org/flu .

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Fitness Reimbursement Get rewarded for your healthy habits! Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Qualified for Reimbursement: A full service health club with cardiovascular and strength-training equipment like treadmills, bikes, weight machines, and free weights A fitness studio with instructor-led group classes such as yoga, Pilates, Zumba , kickboxing, indoor cycling/ spinning, and other exercise programs Online fitness memberships, subscriptions, programs, or classes Cardiovascular and strength-training equipment for fitness that is purchased for use in the home, such as stationary bikes, weights, exercise bands, treadmills, fitness machines Not Qualified for Reimbursement: One-time initiation or termination fees Fees paid for gymnastics, tennis, pool-only facilities, martial arts schools, instructional dance studios, country clubs or social clubs, sports teams or leagues Personal trainer sessions Fitness clothing To submit your reimbursement, sign in to MyBlue at bluecrossma.org . Get Started Save up to Your reimbursement is waiting! $150

Fitness Reimbursement Request Please print all information clearly. To verify that this reimbursement is offered within your plan, or for more information, you can sign in to MyBlue at bluecrossma.org or call the Member Service number on your ID card. All fitness reimbursement requests must be submitted by March 31 of the following year. Subscriber Information (Policyholder) Identification Number on Subscriber ID Card (including fir st 3 characters) Subscriber's Last Name First Name Middle Initial Address Number and Street City State ZIP Code Employers Name Claim Information Member's Last Name First Name Middle Initial Date of Birth ___/ ___/____ Claim is for (choose one and color in the entire box): Subscriber (policyholder) ________________ _____________ ________________ /___ / _ ___ ___ Spouse(of policyholder) Ex-Spouse Dependent (up to age 26) Other (specify): Name, Address, and Phone Number of Qualified Fitness Expense Total Dollars requested for Qualified Fitness Expense: $ Calendar year that fees were paid: Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form. Reimbursement is sent to the member's address on file with Blue Cr oss. Reimbursement may be considered taxable income, so you should consult your tax advisor. Certification and Authorization (This form must be signed and dated below.) I certify that the information provided in support of this submission is complete and correct, and that I have not previously submitted for these services. I enrolled in the qualified pro gram with the full intention of using such program. I understand that Blue Cross Blue Shield of Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about my qualified fitness pr ogram to Blue Cross Blue Shield of Massachusetts. Subscribers or Members Signature: Date: Complete this form and mail it to: Blue Cross Blue Shield of Massachusetts, Local Claims Department, PO Box 986030, Boston, MA 02298 Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarj ta de identificacin (TT Y : 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). 000891752 ( 2 /2 2 ) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 202 2 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Every pregnancy is different, and a helping hand goes a long way. Thats why were working with Maven Clinic, an independent company, to provide 24/7 virtual support personalized for your unique needs and its available to you at no additional cost. PREGNANCY IS A JOURNEY. GET SUPPORT EVERY STEP OF THE WAY. map Comprehensive and compassionate guidance anytime, anywhere Pregnancy brings a lot of questions and emotions. You should feel supported and empowered to make decisions that are right and healthy for you. Maven is there every step of the way. calendar-days Support thats on your schedule Maybe a question comes up at 3 a.m., or your back hurts too much to travel to an appointment. No problem. Maven provides on-demand support around the clock. And its all virtual, so you can get help from the comfort of your home. person-pregnant Personalized guidance through every phase of pregnancy Throughout this journey, your needs change. Whether you just had your first positive test, youre in postpartum, or youre coping with a miscarriage, your personal Care Advocate is there to connect you with the right resources and experts. users Wide-ranging help for a wide range of needs With Maven, you get virtual access to experts across more than 35 specialties, from OB/GYNs and midwives to lactation consultants and pediatricians to career coaches. Plus, vital mental health support. continued

002606864 (2/24) Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks are the property of their respective owners. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). Unlimited video appointments and messaging with experts Access to provider-led classes and pregnancy-related articles A dedicated Care Advocate to help you make the most of Maven The Maven app, with convenient access to the support you need Heres what you get with Maven Get started Sign up for Maven and get no-cost support today. Scan the QR code or go to mavenclinic.com/join/bcbsma

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Weight-Loss Reimbursement Y our reward for healthy behavior: Receive up to $150 annually when you participate in a qualified weight-loss program. 1 Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Contact Member Service by calling the phone number on your member ID card. Questions? Qualified for Weight-Loss Reimbursement Participation fees for: Hospital-based programs and Weight Watchers in-person Weight Watchers online and other non-hospital programs (in-person or online) that combine healthy eating, exercise, and coaching sessions with certified health professionals such as nutritionists, registered dietitians, or exercise physiologists. Not Qualified for Weight-Loss Reimbursement One-time initiation or termination fees Food, supplements, books, scales, or exercise equipment Individual nutrition counseling sessions, doctor/nurse visits, lab tests, or other services that are covered benefits under your medical plan Get Reimbursed in Three Easy Steps 1 Choose Start by picking a qualified weight-loss program. 2 Complete Once you pay for the program, fill out the attached form, or sign in to MyBlue to submit online at member.bluecrossma.com/login . 3 Mail Send the completed form to the address listed. Be sure to check with your doctor before starting any weight-loss program. 1. To verify this reimbursement is offered for your plan, or for more information, sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. Most plans offer the reimbursement shown, but refer to your plan information for specific details.

Weight-Loss Reimbursement Request Please Print All Information Clearly : To verify this reimbursement is offered within your plan, or for more information, please sign in to MyBlue at bluecrossma.com/myblue or call the Member Service number on your ID card. All weight-loss reimbursement requests must be submitted by March 31 of the following year. Complete this form and mail it to: Blue Cross Blue Shield of Massachusetts, Local Claims Department , PO Box 986030, Boston, MA 02298 Subscriber Information (Policyholder) Identification Number on Subscriber ID Card (including first 3 characters) Subscribers Last Name First Name Middle Initial Address - Number and Street City State Zip Code Employers Name Claim Information Member Last Name First Name Middle Initial Gender (color in the entire box) q Male q Female Date of Birth ___/___/____ Claim is for (choose one and color in the entire box): Name, Address, and Phone Number of Qualified Weight-Loss Program q Subscriber (policyholder) q Spouse (of policyholder ) Total dollars requested: $ ________________ q Ex-Spouse Monthly program participation fee: $ ________________ q Dependent (up to age 26) Calendar Year: ___/___/____ q Other (specify): Blue Cross Blue Shield of Massachusetts will make a reimbursement decision within 30 calendar days of receiving a completed request form. Reimbursement is sent to the members address on file with Blue Cross. Reimbursement may be considered taxable income, so consult your tax advisor. Certification and Authorization (This form must be signed and dated below.) I certify that the information provided in support of this submission is complete and correct and that I have not previously submitted for these services. I understand that Blue Cross Blue Shield of Massachusetts may require proof of payment for a reimbursement decision. I authorize the release of any information about my qualified weight-loss program to Blue Cross Blue Shield of Massachusetts. Subscribers or Members Signature: Date: ___/___/____ Important Information: Weight-loss reimbursement can be granted for any single member or combination of members enrolled under the same Blue Cross Blue Shield of Massachusetts health plan. Blue Cross will make a reimbursement decision within 30 days of receiving a completed request. Reimbursement requests must be submitted by March 31 of the following year. Keep copies of proof of payment in case we request it from you. Proof of payment includes: Receipts (cash/check/credit/electronic) for participation fees clearly documenting your name, the weight-loss program name, and individual amounts charged with date paid. Your weight-loss program membership or participation agreement clearly documenting your name and date of enrollment/participation. Your reimbursement may be considered taxable income, so consult a tax advisor. 000414912 55-0774 (5/20) Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ).

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Worldwide Coverage For Foreign and Domestic Travelers An Association of Independent Blue Cross and Blue Shield Plans Urgent Care 1. Call 1-800-810-BLUE (2583) , or visit bcbs.com to find nearby doctors and hospitals anywhere in the world that participate in the Blue Cross Blue Shield network. 2. Show your member ID card when you get care. 3. If youre admitted, or if you have questions about your coverage, call Member Service at the number on the front of your ID card. Your Passport to Good Health Always carry your Blue Cross Blue Shield of Massachusetts ID card. Emergency Care For emergency services, call the local emergency number or go to the nearest hospital immediately. FOLD HERE TEAR HERE Get quality health care no matter where you are in the world. Whether youre traveling within the United States or abroad, BlueCard and Blue Cross Blue Shield Global Core make sure you have access to top doctors and hospitals and concierge-level service. Call 1-800-810-BLUE (2583) for a list of participating doctors and hospitals, or to obtain an international claim form. Take this reference card with you when you travel. When you need care, youll be prepared.

Getting Care in the United States More than 85 percent of all doctors and hospitals in the United States participate in the BlueCard program. If you need care outside your plans service area, call 1-800-810-BLUE (2583) , or visit bcbs.com to find a doctor near you. Be sure to show your ID card before you receive service. When you get service: Theres no paperwork Participating doctors and hospitals submit claims for you All you pay is the copayment, co-insurance, or deductible If you receive care from a non-participating doctor or hospital, you may need to pay for the services up front and submit a claim for reimbursement BlueCard PPO Members Only: If you see this symbol, , on your ID card, youre a BlueCard PPO member. To save the most money when getting service, use a participating BlueCard PPO doctor or hospital. In Case of Emergency For emergency services, call the local emergency number or go to the nearest hospital immediately. Getting Care Outside the United States The Blue Cross Blue Shield Global Core network gives you access to doctors and hospitals around the world. If you need care, call the Service Center at 1-800-810-BLUE (2583) , or call collect at 1-804-673-1177 , 24 hours a day, 7 days a week. An assistance coordinator, along with a medical professional, will arrange a doctors appointment or hospitalization if necessary. You can also visit bcbsglobalcore.com . For Inpatient Services: Call the Service Center at 1-800-810-BLUE (2583) , or Member Service at the number on your ID card, for precertification or preauthorization In most cases, all you pay is the copayment, co-insurance, or deductible The hospital should submit the claim on your behalf For Outpatient Services: Show your ID card Pay the doctor or hospital Fill out a Blue Cross Blue Shield Global Core International Claim form for reimbursement (Call 1-800-810-BLUE (2583) or visit bcbsglobalcore.com for the form) Youre only responsible for copayments, co-insurance, or deductible when seeing in-network doctors and hospitals Youll pay more when seeing out-of-network doctors and hospitals Doctors and Hospitals In most cases, participating doctors and hospitals will file the claim for you. If they need information about eligibility or your coverage, have them call 1-800-676-BLUE (2583) . Your Member Responsibilities As a Blue Cross Blue Shield of Massachusetts member, youre still responsible for any copayments, co-insurance, deductible, or non-covered services. For out-of-country services, Blue Cross Blue Shield of Massachusetts payments will be based on the providers charge. Primary Care Providers Name: Doctors Phone: Doctors Hospital Affiliation: Your Blue Cross Blue Shield Member ID: Member Service Phone Number (from your ID card): FOLD HERE TEAR HERE An Association of Independent Blue Cross and Blue Shield Plans Registered Marks of Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 182617M 32-5585 (02/18) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID Card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ).

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OUR COMMITMENT TO CONFIDENTIALITY (NOTICE OF PRIVACY PRACTICES) AND WOMENS HEALTH AND CANCER RIGHTS ACT (WHCRA) NOTICE THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our Commitment We respect your right to privacy. We will not disclose personally identifiable information about you without your permission, unless the disclosure is necessary to provide our services to you or is otherwise in accordance with the law. Collection of Information We collect only the information about you that we need to operate our business. We collect information from other parties, such as your health care providers and employers. Examples of the information we collect are (i) medical and dental information from providers when they submit claims for services and (ii) personal information such as name, address, and date of birth, which is most often supplied by you or your employer when you enroll in a plan. Use and Disclosure of Information We are required by law to protect the confidentiality of information about you and to notify you in case of a breach affecting your information. We may use and disclose information about you without your written authorization for the following purposes, to the extent otherwise permitted or required by law: You or Your Representatives to you or your personal representative upon request or to help you (or your personal representative) understand treatment options, benefits, or the rights available to you. Your personal representative is a person who has legal authority to make health-related decisions on your behalf, such as a person with a health-care power of attorney. Your request must be in writing. Please complete the Documentation of Legal Representative Status for Members form available on our website. You also may designate a family member or friend to receive information and interact with us on your behalf. Your designation and any subsequent revocation must be in writing. Please complete the Members Designation of an Authorized Representative form on our website. You may also call Member Service for a copy of these forms. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Important Notices

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Treatment to help health care providers manage or coordinate your health care and related services. For example, we may use and disclose information about you to inform providers of medications you take or to remind you of appointments. Payment to obtain payment for your coverage, pay claims for your health benefits, or help another health plan or health care provider in its payment activities. For example, we may use or disclose information about you to make coverage determinations, administer claims, or coordinate benefits with other coverage you may have. Health Care Operations to perform other activities necessary for the operation of our business, including customer service, disease management, and determining how to improve the quality of care. For example, we may use or disclose information about you to respond to your call to customer service, arrange for medical review of your claims, or conduct quality assessment and improvement activities. Legal Compliance to comply with applicable law. For example, we may be required to use or disclose information about you to respond to regulatory authorities responsible for oversight of government benefit programs or our business operations; to parties or courts in the course of judicial or administrative proceedings; or pursuant to workers compensation laws. Government Agencies under limited circumstances established by law, to public health authorities, coroners or medical examiners, law enforcement, or other government officials Research for health-related research studies that meet legal standards for protection of the individuals involved in the studies and their personal information. We may also create a database of our members information that does not include individual identifiers and use the database for research or other purposes, provided that the information cannot be traced back to specific members. To Your Employer (or other plan sponsor), if applicable , for administration of its health plan. This applies only if you receive coverage through an employer-sponsored plan (or plan sponsored by your union or other entity). For example, we may disclose information about you to your employer (or other plan sponsor) to confirm enrollment in the plan or (if the employer or other plan sponsor is self-insured) for claim review and audits. We will disclose your information only to designated individuals. That, along with legal prohibitions on use of your personal information for discriminatory purposes, helps protect your information from unauthorized use. To carry out these purposes, we share information with entities that perform functions for us subject to contracts that limit use and disclosure for intended purposes. We use physical, electronic, and procedural safeguards to protect your privacy. Even when allowed, we limit uses and disclosures of your information to the minimum amount reasonably necessary for the intended task. The Health Insurance Portability and Accountability Act (HIPAA) generally does not override other laws that give people greater privacy protections. As a result, we

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. must comply with any state or federal privacy laws that require us to provide you with more privacy protections. For example, federal law provides special protections for substance use disorder information; Massachusetts state law restricts the disclosure of HIV and AIDS related information. In addition, we will not use (and are prohibited from using) your genetic information for underwriting purposes. Other Disclosures Require Your Written Authorization Except as provided in this notice, we will not use or disclose information about you without your written authorization. For example, we must have your written authorization to use or disclose your information for marketing purposes or (in most cases) to use or disclose psychotherapy notes. Although we would need written authorization to sell information about you, we do not sell members information. You may revoke your authorization at any time. Your authorization must be in writing. Your revocation will not affect any action that we have already taken in reliance on your authorization. If you would like us to disclose information about you to a third party, please complete the Permission for One-Time Disclosure of Information form available on our website or call Member Service for a copy of the form. Your Privacy Rights You have the following rights with respect to information about you. You may exercise any of these rights by calling the Member Service number listed on your member ID card or contacting us at the address listed at the end of this notice. The forms listed below are also available on our website. You have the right to receive information about privacy protections. Your member- education materials include a notice of your rights, and you may request a paper copy of this notice at any time. You have the right to inspect and get copies of information that we use to make decisions about you. This is your designated record set. Your request must be in writing. We may charge a reasonable fee for copying and mailing you this information. Please complete the Request for Access to Copies of Protected Health Information in Designated Record Set form to request copies of your information. You have the right to receive an accounting of certain disclosures that we make of information about you. Your request must be in writing. Please complete the Members Request for an Accounting of Disclosures form. Our response will exclude any disclosures made in support of treatment, payment, and health care operations or that you authorized (among others). An example of a disclosure that would be reported to you is our disclosure of your information in response to a court order. You have the right to ask us to correct or amend information you believe to be incorrect. Your request to correct or amend information must be in writing. Please complete the Members Request to Amend Protected Health Information form. If we deny your request, you may ask us to make your request part of your records. You have the right to ask that we restrict or refuse the disclosure of information about you and that we direct communications to you by alternative means or to alternative locations. While we may not always be able to agree to your request, we will make reasonable

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. efforts to accommodate requests. Unless youve notified us to request a different mailing address, Summary of Health Plan Payments statements for the subscriber, and all members listed on the subscribers plan, are generally delivered to the subscribers address. Under certain circumstances, you can request to not receive statements for a particular service, or to have statements delivered through an alternate method or to an alternate address, when required by state law. If you have concerns about protecting the privacy of your medical information in your statements, you can have these statements delivered to an address other than the plan subscribers address, or have them delivered only via electronic means. For help understanding your delivery options, please call Member Service at the number listed on your member ID card. Your request and any subsequent revocation must be in writing. If you believe your privacy rights have been violated, you have the right to complain to us using the grievance process outlined in your benefit materials, or to the Secretary of the U.S. Department of Health and Human Services, without fear of retaliation. About This Notice The original effective date of this notice was April 14, 2003. The effective date of the most recent revision is indicated in the footer of this notice. We are required by law to provide you with this notice of our legal duties and privacy practices and to abide by the notice for as long as it is in effect. We reserve the right to change this notice. Any changes will apply to all information that we maintain, regardless of when it was created or received. If we make a material change to this notice, we will post the revised notice on our website and notify you of the change and how to obtain the revised notice in our next regular mailing to you. If you have any questions, please call the Member Service number listed on your member ID card, or write us at: Blue Cross Blue Shield of Massachusetts Privacy Officer 101 Huntington Ave. Suite 1300 Boston, MA 02199-7611 WHCRA NOTICE Did you know that your medical plan provides benefits for many mastectomy-related services? This is the case even if you were not covered by Blue Cross Blue Shield of Massachusetts at the time of the mastectomy. Its required by the Womens Health and Cancer Rights Act of 1998. If you are covered for a mastectomy and elect breast reconstruction in connection with a mastectomy, then benefits are also provided for: All stages of reconstruction of the breast on which the mastectomy has been performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas. Coverage will be provided as determined in consultation with you and your attending doctor. The costs that you pay for these services are the same as those you pay for other services in the same category. To learn more, please call the Member Service number on your member ID card.

Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO, Inc. 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 175470M 32-7900 (10/17) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). Spanish/Espaol: ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). Portuguese/Portugus: ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ).

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Glossary of Health Coverage and Medical Terms Page 1 of 6 (DT - OMB control number: 1545 - 0047/Expiration Date: 12/31/2019)(DOL - OMB control number: 1210 - 0147/Expiration date: 5/31/2022) (HHS - OMB control number: 0938-1146/Expiration date: 10/31/2022) Glossary of Health Coverage and Medical Terms x This glossary defines many commonly used terms, but isnt a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan or health insurance policy. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) x Underlined text indicates a term defined in this Glossary. x See page 6 for an example showing how deductibles, coinsurance and out-of-pocket limits work together in a real life situation. Allowed Amount This is the maximum payment the plan will pay for a covered health care service. May also be called eligible expense, payment allowance, or negotiated rate. Appeal A request that your health insurer or plan review a decision that denies a benefit or payment (either in whole or in part). Balance Billing When a provider bills you for the balance remaining on the bill that your plan doesnt cover. This amount is the difference between the actual billed amount and the allowed amount. For example, if the providers charge is $200 and the allowed amount is $110, the provider may bill you for the remaining $90. This happens most often when you see an out-of-network provider (non-preferred provider). A network provider (preferred provider) may not balance bill you for covered services. Claim A request for a benefit (including reimbursement of a health care expense) made by you or your health care provider to your health insurer or plan for items or services you think are covered. Coinsurance Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe. (For example, if the health insurance or plans allowed amount for an office visit is $100 and youve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.) Complications of Pregnancy Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non- emergency caesarean section generally arent complications of pregnancy. Copayment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service (sometimes called copay). The amount can vary by the type of covered health care service. Cost Sharing Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called out-of-pocket costs). Some examples of cost sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and out- of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesnt cover usually arent considered cost sharing. Cost-sharing Reductions Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level, and you choose a Silver level health plan or if you're a member of a federally- recognized tribe, which includes being a shareholder in an Alaska Native Claims Settlement Act corporation. ( See page 6 for a detailed example.) Jane pays 20% Her plan pays 80%

Glossary of Health Coverage and Medical Terms Page 2 of 6 Deductible An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan wont pay anything until youve met your $1000 deductible for covered health care services subject to the deductible.) (See page 6 for a detailed example.) Jane pays 100% Her plan pays 0% Diagnostic Test Tests to figure out what your health problem is. For example, an x-ray can be a diagnostic test to see if you have a broken bone. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. DME may include: oxygen equipment, wheelchairs, and crutches. Emergency Medical Condition An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didnt get medical attention right away. If you didnt get immediate medical attention you could reasonably expect one of the following: 1) Your health would be put in serious danger; or 2) You would have serious problems with your bodily functions; or 3) You would have serious damage to any part or organ of your body. Emergency Medical Transportation Ambulance services for an emergency medical condition. Types of emergency medical transportation may include transportation by air, land, or sea. Your plan may not cover all types of emergency medical transportation, or may pay less for certain types. Emergency Room Care / Emergency Services Services to check for an emergency medical condition and treat you to keep an emergency medical condition from getting worse. These services may be provided in a licensed hospitals emergency room or other place that provides care for emergency medical conditions. Excluded Services Health care services that your plan doesnt pay for or cover. Formulary A list of drugs your plan covers. A formulary may include how much your share of the cost is for each drug. Your plan may put drugs in different cost  sharing levels or tiers. For example, a formulary may include generic drug and brand name drug tiers and different cost  sharing amounts will apply to each tier. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isnt walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and  or outpatient settings. Health Insurance A contract that requires a health insurer to pay some or all of your health care costs in exchange for a premium. A health insurance contract may also be called a policy or plan. Home Health Care Health care services and supplies you get in your home under your doctors orders. Services may be provided by nurses, therapists, social workers, or other licensed health care providers. Home health care usually doesnt include help with non-medical tasks, such as cooking, cleaning, or driving. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. Some plans may consider an overnight stay for observation as outpatient care instead of inpatient care. Hospital Outpatient Care Care in a hospital that usually doesnt require an overnight stay.

Glossary of Health Coverage and Medical Terms Page 3 of 6 In-network Coinsurance Your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services. In-network Copayment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments. Marketplace A marketplace for health insurance where individuals, families and small businesses can learn about their plan options; compare plans based on costs, benefits and other important features; apply for and receive financial help with premiums and cost sharing based on income; and choose a plan and enroll in coverage. Also known as an Exchange. The Marketplace is run by the state in some states and by the federal government in others. In some states, the Marketplace also helps eligible consumers enroll in other programs, including Medicaid and the Childrens Health Insurance Program (CHIP). Available online, by phone, and in-person. Maximum Out-of-pocket Limit Yearly amount the federal government sets as the most each individual or family can be required to pay in cost sharing during the plan year for covered, in-network services. Applies to most types of health plans and insurance. This amount may be higher than the out-of- pocket limits stated for your plan. Medically Necessary Health care services or supplies needed to prevent, diagnose , or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine . Minimum Essential Coverage Minimum essential coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of minimum essential coverage, you may not be eligible for the premium tax credit. Minimum Value Standard A basic standard to measure the percent of permitted costs the plan covers. If youre offered an employer plan that pays for at least 60% of the total allowed costs of benefits, the plan offers minimum value and you may not qualify for premium tax credits and cost-sharing reductions to buy a plan from the Marketplace. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Network Provider (Preferred Provider) A provider who has a contract with your health insurer or plan who has agreed to provide services to members of a plan . You will pay less if you see a provider in the network . Also called preferred provider or participating provider. Orthotics and Prosthetics Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external breast prostheses after a mastectomy. These services include: adjustment, repairs, and replacements required because of breakage, wear, loss, or a change in the patients physical condition. Out-of-network Coinsurance Your share (for example, 40%) of the allowed amount for covered health care services to providers who dont contract with your health insurance or plan. Out-of- network coinsurance usually costs you more than in- network coinsurance. Out-of-network Copayment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments. Out-of-network Provider (Non-Preferred Provider) A provider who doesnt have a contract with your plan to provide services. If your plan covers out-of-network services, youll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called non-preferred or non-participating instead of out- of-network provider.

Glossary of Health Coverage and Medical Terms Page 4 of 6 Out-of-pocket Limit The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your plan doesnt cover. Some plans dont count all of your copayments, deductibles, coinsurance payments, out-of- network payments, or other expenses toward this limit. Physician Services Health care services a licensed medical physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), provides or coordinates. Plan Health coverage issued to you directly (individual plan) or through an employer, union or other group sponsor (employer group plan) that provides coverage for certain health care costs. Also called health insurance plan, policy, health insurance policy, or health insurance. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. Sometimes called prior authorization, prior approval, or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isnt a promise your health insurance or plan will cover the cost. Premium The amount that must be paid for your health insurance or plan. You and  or your employer usually pay it monthly, quarterly, or yearly. Premium Tax Credits Financial help that lowers your taxes to help you and your family pay for private health insurance. You can get this help if you get health insurance through the Marketplace and your income is below a certain level. Advance payments o f the tax credit can be used right away to lower your monthly premium costs. Prescription Drug Coverage Coverage under a plan that helps pay for prescription drugs. If the plans formulary uses tiers (levels), prescription drugs are grouped together by type or cost. The amount you'll pay in cost sharing will be different for each tier of covered prescription drugs. Prescription Drugs Drugs and medications that by law require a prescription. Preventive Care (Preventive Service) Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems. Primary Care Physician A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), who provides or coordinates a range of health care services for you. Primary Care Provider A physician, including an M.D. (Medical Doctor) or D.O. (Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law and the terms of the plan, who provides, coordinates, or helps you access a range of health care services. Provider An individual or facility that provides health care services. Some examples of a provider include a doctor, nurse, chiropractor, physician assistant, hospital, surgical center, skilled nursing facility, and rehabilitation center. The plan may require the provider to be licensed, certified, or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions. (See page 6 for a detailed example.) Jane pays 0% Her plan pays 100%

Glossary of Health Coverage and Medical Terms Page 5 of 6 Referral A written order from your primary care provider for you to see a specialist or get certain health care services. In many health maintenance organizations (HMOs), you need to get a referral before you can get health care services from anyone except your primary care provider . If you dont get a referral first, the plan may not pay for the services. Rehabilitation Services Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and  or outpatient settings. Screening A type of preventive care that includes tests or exams to detect the presence of something, usually performed when you have no symptoms, signs, or prevailing medical history of a disease or condition. Skilled Nursing Care Services performed or supervised by licensed nurses in your home or in a nursing home. Skilled nursing care is not the same as skilled care services, which are services performed by therapists or technicians (rather than licensed nurses) in your home or in a nursing home. Specialist A provider focusing on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. Specialty Drug A type of prescription drug that, in general, requires special handling or ongoing monitoring and assessment by a health care professional, or is relatively difficult to dispense. Generally, specialty drugs are the most expensive drugs on a formulary. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Glossary of Health Coverage and Medical Terms Page 6 of 6 How You and Your Insurer Share Costs - Example Janes Plan Deductible: $1,500 Coinsurance: 20% Out - of - Pocket Limit: $5,000 Januar y 1 st Beginning of Coverage Period December 31 st End of Coverage Period Her plan pays 0% Jane hasnt reached her $1,500 deductible yet Her plan doesnt pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane pays 100% more costs Jane pays 20% Her plan pays 80% Jane reaches her $ 1,500 deductible , coinsurance begins Jane has seen a doctor several times and paid $1,500 in total , reaching her deductible . So h er plan pays some of the costs for her next visit. Office visit costs: $125 Jane pays: 20% of $125 = $2 5 Her plan pays: 80% of $ 125 = $ 100 more costs Jane pays 0% Her plan pays 100% Jane reaches her $5,000 out - of - pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her cove red health care services for the rest of the year. Office visit costs: $125 Jane pays: $0 Her plan pays: $125 PRA Disclosure Statement: Accordin g to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it display s a valid OMB control number. The valid OMB control number for this information collection is 0938 - 1146 . The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4 - 26 - 05, Baltimore, Maryland 21244 - 1850.

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. , SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association. 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 163537 36-3630 (11/17) Thank you for choosing a Blue Cross Blue Shield plan. Please take a few minutes to help us set up your membership by filling out the attached enrollment form. Before You Begin Please carefully read the instructions below. For members of HMO Blue, Network Blue, Blue Choice, HMO Blue New England, SM or Blue Choice New England SM : Youre required to choose a primary care physician (PCP) when you enroll. Please choose a PCP from your plans provider directory. Be sure to read PCP ID # in Section 2. List your PCP choice on your enrollment form. The PCP ID number can also be found by visiting bluecrossma.com and selecting Find a Doctor . For Access Blue SM Members: Although youre not required to choose a PCP, we recommend you choose one by following the instructions in Section 2 on the back of this page. Important: Are you covered by Medicare or other insurance? We need to know if you or any family member listed have Medicare and/or other insurance in addition to your Blue Cross Blue Shield of Massachusetts plan. Please be sure to check either Y (for yes) or N (for no) in the correct box. This information will help us accurately coordinate your benefits. Please follow the instructions in Sections 2 and 3. Please print two copies of your completed application. Keep one for your records and give the other to your employer to sign and mail to Blue Cross Blue Shield of Massachusetts. In order to complete your enrollment request, your employer is required to sign the application. Special Instructions for Student Coverage : If youre seeking coverage for a full-time student dependent over age 19, you may need to fill out a Student Certificate form. Check with your employer to see if this coverage is available. Blue Cross Blue Shield of Massachusetts P.O. Box 986001 Boston, MA 02298 Fax: 1-617-246-7531

Instructions Section 1 To Be Filled Out By Your Employer Your employer will fill out this section. Type of Transaction Check the box(es) that apply. Subscriber Cancellation Codes. If the subscriber wont be continuing any Blue Cross Blue Shield coverage, carefully select one of the following and indicate the three-digit code on the form. Code # Reason for Canceling 041 Changing to other health plan Voluntary termination COBRA cancellation (under 18 months or nonpayment) 042 Over 65, changing to Group Medex plan. (Requires Medicare A and B) Over 65, changing to direct-pay Medex plan. (Requires Medicare A and B) Over 65, changing to Medicare supplement other than Medex plans. 043 Medicare (age =< 65) Code # Reason for Canceling 061 Left employment COBRA ending 063 Transfer 064 Cancellation as of original effective date 070 Deceased 071 Moved out of state (out of HMO service area) 076 Military service Note: If your subscribers are adding or dropping one benefit only (medical/dental), please indicate add medical, add dental, cancel medical, or cancel dental in the Remarks section. If your new hires are subject to a probationary period, please indicate the time frame in the Remarks section, as well as the qualifying events for new enrollees. If a subscriber is being moved from an active group to a retiree group (within the same account), this is a transfer and not a termination. Please include the Medical or Dental Group # transferring to. Cancellation date will be the first day of no coverage. Qualifying EventsRemarks: To assist in the enrollment process, please use check boxes or write in applicable information in the Remarks section of the form. Open EnrollmentCheck this box for open enrollment. New HireCheck this box for new hires to the company. COBRACheck this box if person is continuing coverage under COBRA. Add SpouseCheck this box if spouse is being added. Ensure date of marriage is within approved retroactive period. Add DependentCheck this box if adding any dependent. Loss of CoverageCheck this box if employee lost coverage through spouse or parent. Please include HIPAA Continuous of Coverage Letter from prior company/insurer. If you have questions, contact your account service representative. OtherCheck this box if change to family requires additional explanation. Please write in the reason for change (e.g., court order, adoption, New Dependent Law under HCR, legal guardianship, etc.). Include supporting documentation. If you have questions, contact your account service representative. Section 2 Yourself (Member 1) Please fill in all information that applies to you. (REQUIRED)* PCP ID# If your health plan requires you to choose a primary care physician (PCP), please fill in this section. Write the PCP ID number ( not the telephone number) of the doctor you have chosen to coordinate your health care. Youll find the doctors PCP ID number in the provider directory for your health plan. If you need help choosing a PCP, please call our Physician Selection Service at 1-800-821-1388 . A representative will be happy to help you select a doctor. PCP ID number can be found at bluecrossma.com , select Find a Doctor . Other Insurance Do you have other health insurance or Medicare in addition to your Blue Cross Blue Shield plan? Please be sure to circle either Y (for yes ) or N (for no ) ) in the correct box. If you have other insurance, please write the name of the other insurance company and your member identification number. To Add or Delete a Member Are you adding or deleting a member under your existing membership? If yes, please fill in the areas in Sections 1 and 2. You may need help from your employer to fill in Section 1. Then, give us the details about the members youre adding or deleting in Section 3 and/or Section 4. Section 3 Member 2 If you choose a Family membership, please fill in this section if you want Member 2 to be covered. (REQUIRED)* (Note: Member 2 cannot be covered under an Individual membership.) Other Insurance Does your spouse have other health insurance or Medicare? Please be sure to circle either Y (for yes ) or N (for no ) in the correct box. If your spouse or partner has other insurance, please write the name of the other insurance company and your member identification number. Section 4 Your Eligible Dependents (Members 3, 4, and 5) If you choose a Family membership, please fill in this section for all children or other eligible dependents you want to be covered. (REQUIRED)* (Note: dependents cannot be covered under an Individual membership.) If you have more than three dependents to be covered, please use additional Enrollment Forms as needed. Please indicate on the form that additional forms have been used and write in the total number of dependents you want to be enrolled. Section 5 Personal Savings Account Your employer may have chosen to offer a personal savings account alongside your medical offering. Please consult your open enrollment materials and/or your HR department to determine if this applies to you. For each option: Start Date: Your start date will be considered established for tax purposes as of the start date of your medical plan, provided that you have signed, dated, and submitted the completed application for these accounts on or before that date. End Date: Your end date is the date you choose to stop deposits into the selected financial account. If you have any questions, please see your employer. Note: If you are transferring from one medical/dental plan to another plan, please complete Section 5 of the Enrollment and Change Form to let us know that you will be continuing your personal savings account.. Section 6 Signatures (Employer & Employee) Employee: Please sign and date the application and return it to your employer. Employer: Please sign and date the application and return to Blue Cross Blue Shieldof Massachusetts. Please mail to: P.O. Box 986001 Boston, MA 02298 or fax to 1-617-246-7531 * Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan. Registered Marks of the Blue Cross and Blue Shield Association. 2017 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

1. To Be Filled Out by Your Employer Company Name Current Medical Group #: Medical Group # Transfering To: Current BCBS ID #, If any Requested Effective Date Date of Hire Current Dental Group #: Dental Group # Transferring To MM DD YYYY MM DD YYYY Type of Transaction ADD CANCEL CHANGE Three digit TRANSFER termination code Remarks: (i.e., qualifying event for a new add, change to family or other instruction) Open Enrollment New Hire COBRA Change to Family Add Spouse Add Dependent Loss of Coverage (HIPAA Continuation of Coverage Letter required) Other: __________________________________________ 2. Yourself (Member 1) What products? Access Blue Blue Choice Blue Choice New England Blue Medicare Rx (Part D) Dental Blue HMO Blue HMO Blue New England Managed Blue for Seniors Medex (Group) Network Blue PPO Saver Blue Membership Type (Medical) Individual Family Membership Type (Dental) Individual Family First Name M.I. Last Name Sex Date of Birth Street Address/ P.O. Box # Apt. # City/ Town State Zip Code Home Phone ( ) Cell Phone ( ) Email Social Security # (REQUIRED) 1 Other Insurance? 2 Y / N Other Insurance Company Name Member Identification Number PCP ID # (see instructions) Name of PCP City / State Is this your current PCP? Y / N Are you covered by Medicare? 2 Y / N Part A Effective Date Part B Effective Date Part D Effective Date Medicare # 65+ Disabled ESRD If Retired, Date MM DD YYYY MM DD YYYY MM DD YYYY Actively Working? Y / N 3. Member 2 Please Check One: Spouse Domestic Partner Divorced Spouse (court ordered) Plan Type: Medical Dental First Name M.I. Last Name Sex Date of Birth Social Security # (REQUIRED) 1 Phone ( ) Other Insurance? 1 Y / N Other Insurance Company Name Member Identification Number PCP ID # (see instructions) Name of PCP City / State Is this your current PCP? Y / N Are you covered by Medicare? 2 Y / N Part A Effective Date Part B Effective Date Part D Effective Date Medicare # 65+ Disabled ESRD MM DD YYYY MM DD YYYY MM DD YYYY If Retired, Date Actively Working? Y / N 4. Your Eligible Dependents (Member 3, 4 and 5) Dependents First Name 3.) M.I. Last Name Sex Date of Birth Social Security # (REQUIRED) 1 PCP ID # (see instructions) Name of PCP Is this your current PCP? Y / N Full-time student and aged 19 or older Disabled and aged 26 or older Plan Type: Medical Dental Dependents First Name 4.) M.I. Last Name Sex Date of Birth Social Security # (REQUIRED) 1 PCP ID # (see instructions) Name of PCP Is this your current PCP? Y / N Full-time student and aged 19 or older Disabled and aged 26 or older Plan Type: Medical Dental Dependents First Name 5.) M.I. Last Name Sex Date of Birth Social Security # (REQUIRED) 1 PCP ID # (see instructions) Name of PCP Is this your current PCP? Y / N Full-time student and aged 19 or older Disabled and aged 26 or older Plan Type: Medical Dental Please check if you are using separate forms for additional dependent children Total # of dependents: _________________________________ 5. Personal Savings Account HSA: Health Savings Account Start Date End Date FSA Goal Amount (Please see instructions for limits.): $ FSA: Health Flexible Spending Account Start Date End Date Health: $ FSA: Dependent Care Reimbursement Account Start Date End Date Dependent Care: $ 6. Signature (Employer & Employee) The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to enroll me and my dependents or to make changes to my membership. I understand that I should read the subscriber certificate or benefit booklet provided by my employer to understand my benefits and any restrictions that apply to my health care plan. I understand that Blue Cross and Blue Shield may obtain personal and medical information about me to carry out its business, and that it may use and disclose that information in accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my information in Our Commitment to Confidentiality, Blue Cross and Blue Shields notice of privacy practices. Employees Signature __________________________________ Date _____________ Employers Signature ___________________________________ Date _____________ Please Read the Instructions Before Filling Out This Form. Please TYPE OR PRINT CLEARLY using blue or black ink to avoid coverage delay or type in information Enrollment and Change Form Please mail to: P.O. Box 986001 Boston, MA 02298 or fax to 1-617-246-7531 Blue Cross Blue Shield of Massachusetts is an Independent Licence of the Blue Cross and Blue Shield Association. 1. REQUIRED: Under the Affordable Care Act, we are required to collect the Social Security number for you and any dependent enrolling in your plan.

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Getting more. Now theres a plan. Your plan has more benefits than you probably realize. Tap into all of them, all in one place. The MyBlue App is your key to more features and savings. Plus, up-to-date status for claims, your deductible, account balances, and more. Its like a free upgrade for the plan you already have. UNLOCK THE POWER OF YOUR PLAN The MyBlue App gives you an instant snapshot of your plan, including: COVERAGE AND BENEFITS CLAIMS AND BALANCES FITNESS AND WEIGHT- LOSS REIMBURSEMENT MEDICATION LOOKUP VIDEO DOCTOR VISITS USING WELL CONNECTION Get the App Download the app from the App Store or Google Play TM . Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

99-001093204 (4/22) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks and TM Trademarks are the property of their respective owners. 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001093204 Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). STAY ON TOP OF YOUR COVERAGE Its never been easier, faster, or more convenient. Your medications at a glance Their names, costs, and prescriptions at your fingertips. Fitness and weight-loss reimbursement The online forms are here, along with other savings and offers. Track claims and benefits Keep up to date on benefits and coverage. Check deductible balances End the guesswork and know for sure every time. Once you sign in or create a MyBlue App account, you can see all of your benefits, all in one place. Track your claims, medications, account balances, and more from your device. And, you can easily keep track of reimbursements and savings. Find a Doctor Or a specialist, dentist, or facility. On your phone and on the fly. Need your cards Access your ID cards without opening your wallet. YOUR PLAN IN YOUR HAND Get the myblue app You can download the MyBlue App from the App Store or Google Play TM .

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Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks are the property of their respective owners. 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001973550 (2/23) Coordination of Benefits Ensures Your Best Coverage If youre covered by more than one medical or dental insurance plan, you must inform us which ones you have so we can coordinate your benefits. This will help us work with your other plans, to make sure you get the best coverage when you receive medical or dental services. It will also ensure that your claims are processed correctly. HOW TO KNOW WHEN COORDINATION OF BENEFITS is NEEDED When you have more than one insurance plan, one plan is designated as your primary plan and will pay your claims first. The other plan(s) will pay toward the remaining cost. Federal and state rules will usually determine which plan is primary. You may need coordination of benefits if: You and your spouse each have separate insurance plans through your employers Your child has one insurance plan through school and another through you or an employer Your child has multiple plans as the result of a divorce or custody arrangement You or a family member also have Medicare coverage WHAT TO DO IF YOU HAVE MORE THAN ONE MEDICAL OR DENTAL PLAN Call each insurer to let them know. Each insurer can tell you which plan is primary and which is secondary. When calling, be sure you have your member ID cards ready. When you visit a doctor, dentist, or hospital, present each insurance card to the office on the day of your visit. This information is needed to determine which company should be billed as a primary insurer, and which should be billed as a secondary insurer. If one of your insurance plans is canceled, youll need to inform the other plan(s). If Youre Turning 65 Years Old and Thinking About Medicare Call Medicare directly at 1-800-MEDICARE ( 1-800-633-4227 ). If you sign up for Medicare, call us at 1-888-799-1888 to submit your new plan information. If you dont call us, your claims could be delayed or processed incorrectly. Call Team Blue Let us know if you have more than one plan by calling us at 1-888-799-1888 .

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How to Find Your Primary Care Providers ID Number Instructions for Using Our Find a Doctor & Estimate Costs Tool Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Call Member Service at 1-888-456-1351 . You can also find this number on the front of your ID card and in your Summary of Benefits. Questions? 1 Go to MyBlue at myblue.bluecrossma.com . You can create a new account, sign in to your personalized MyBlue account, or continue without signing in. 2 Click Find a Doctor & Estimate Costs . If your plan requires you to choose a primary care provider (PCP), youll need to enter your PCPs ID number on your enrollment form. You can find this number in your plans provider directory, or by following these steps:

Registered Marks of the Blue Cross and Blue Shield Association. Registered Marks and Trademarks are the property of their respective owners. 2020 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000455437 55-000338326 (5/20) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). 3 Enter your doctors name, and your location. Select Search to bring up your doctors profile page. When you sign in to MyBlue , your network information will appear. Otherwise, members with an HMO plan or Blue Choice should select HMO Blue as the network. 4 If you dont have a PCP, you can search for one by entering Primary Care in the Specialty field. You can then sort based on location, ratings, languages spoken, or other attributes listed along the left-hand side of the page. 5 To find details about a provider, click the providers name. Clicking on Provider Details will show the Identifiers, including the PCPs ID number. John Sampler, MD

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A WHOLE NEW WAY TO do PRIMARY CARE PRIMARY CARE THATS A PRIME EXPERIENCE An innovative way to do primary care thats convenient and comprehensive is here. You can now choose a virtual primary care provider (PCP) to lead your new Virtual Care Team. * Its a new kind of primary care one that comes with a team of experts committed to getting you the care you need. For more information, sign in to your MyBlue account at bluecrossma.org. LEARN MORE CONVENIENT COMPREHENSIVE COORDINATED With virtual visits, theres no need to travel to the doctors office and no waiting room. Your team is here to make sure your physical and mental health needs are met . If you need in-person care, a care coordinator will help find in-network specialists who work for you. Your Virtual Care Team is here *Coverage details may vary. Please check your 2023 plan benefits for more information. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. street-view laptop-mobile chart-network

HERES HOW IT WORKS To get started with your Virtual Care Team, the first step is selecting a virtual PCP. Youll also get access to a care coordinator, and your team may include other experts, such as a mental health specialist, picked based on your health needs. Its the care you need most, in the most convenient way. Scheduling visits is as easy as hopping online, with appointments available in days, not weeks. Plus, you can reach out to your team with questions via talk, text, email, and chat. Its care that works on your terms, on your schedule, wherever you are, with a level of communication, technology, and access that will surprise you. After your first visit, youll receive a welcome kit which may include connected medical devices, like a blood pressure monitor, that make your virtual care as thorough as in-person visits. When you do need in-person care, your team will help find a specialist who works for you and follow up with you after the appointment. START BY PICKING YOUR VIRTUAL PCP ENJOY MORE CONVENIENT CARE GET THE BEST OF BOTH WORLDS + + Registered Marks of the Blue Cross and Blue Shield Association. 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATTENTION: If you dont speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711 ). ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). 002026251 32-6765 (8/24) 8:30 John Smith Tracy Lewis MD Online Mesage

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Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000489593 55-1487 (6/21) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. NONDISCRIMINATION NOTICE If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711) ; fax at 1-617-246-3616 ; or email at [email protected] . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, online at ocrportal.hhs.gov ; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD) . Complaint forms are available at hhs.gov .

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TRANSLATION RESOURCES Proficiency of Language Assistance Services Translation Resources Proficiency of Language Assistance Services Spanish/Espaol: ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia con el idioma. Llame al nmero de Servicio al Cliente que figura en su tarjeta de identificacin (TTY: 711 ). Portuguese/Portugus: ATENO: Se fala portugus, so-lhe disponibilizados gratuitamente servios de assistncia de idiomas. Telefone para os Servios aos Membros, atravs do nmero no seu carto ID (TTY: 711 ). Chinese/ : ID TTY 711 Haitian Creole/Kreyl Ayisyen: ATANSYON: Si ou pale kreyl ayisyen, svis asistans nan lang disponib pou ou gratis. Rele nimewo Svis Manm nan ki sou kat Idantitifkasyon w lan (Svis pou Malantandan TTY: 711 ). Vietnamese/ Ting Vit: LU : Nu qu v ni Ting Vit, cc dch v h tr ngn ng c cung cp cho qu v min ph. Gi cho Dch v Hi vin theo s trn th ID ca qu v (TTY: 711 ). Russian/ : : -, . , (: 711 ). Arabic/ : ) : . .( 711 :TTY Mon-Khmer, Cambodian/ : (TTY: 711 ) French/Franais: ATTENTION : si vous parlez franais, des services dassistance linguistique sont disponibles gratuitement. Appelez le Service adhrents au numro indiqu sur votre carte dassur (TTY : 711 ). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa (TTY: 711 ). Korean/ : : , . ID (TTY: 711 ) . Greek/ : : , , . (ID Card) (TTY: 711 ). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Greek/E: : , , . (ID Card) (TTY: 711 ).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000489691 55-1493 (6/21) Polish/Polski: UWAGA: Osoby posugujce si jzykiem polskim mog bezpatnie skorzysta z pomocy jzykowej. Naley zadzwoni do Dziau obsugi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711 ). Hindi/ : : , , : .. ( ... : 711 ). Gujarati/ : : , . Member Service (TTY: 711 ). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card (TTY: 711 ). Japanese/ : ID TTY: 711 German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Untersttzung zur Verfgung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an (TTY: 711 ). Persian/ : . : .(TTY: 711 ) Lao/ : : , . (TTY: 711 ). Navajo/Din Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 kehj7 y1n7[tigo saad bee y1ti 47 t11j77ke bee n7k1adoowo[go 47 n1ahooti. D77 bee an7tah7g7 ninaaltsoos bined44 n0omba bik17g7ij8 b44sh bee hod77lnih (TTY: 711 ) . Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield Association. 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 164711MB 55-1493 (8/16)