attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate R08-3841 (2023) to be attached to HMO-PPO Page 1 hppo08-3841 Rider Reproductive Health Care Services This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate for easy reference. The below new section for “Reproductive Health Care Services” has been added to Part 5, “Covered Services” as follows: Reproductive Health Care Services Under this health plan, you have the right to access reproductive health care services when they are furnished for you by a covered provider in a location where it is legal to perform such services. As required by state law, this coverage includes: supplies, care and services of a medical, behavioral health, mental health, surgical, psychiatric, therapeutic, diagnostic, preventive, rehabilitative or supportive nature relating to pregnancy; contraception; assisted reproduction; miscarriage management; or termination of pregnancy (abortion). Except as described below for abortion and abortion-related care, your coverage for covered reproductive health care services is provided to the same extent as coverage is provided for similar covered services to treat other physical conditions. (Your Schedule of Benefits describes your cost share amount. Also refer to riders—if there are any—that apply to your coverage in this health plan.) Abortion and Abortion-Related Care This health plan covers abortion and abortion-related care when the services are furnished for you by a covered provider in a location where it is legal to perform such services. Coverage for an abortion includes: surgical services and certain prescription drugs related to a medication abortion (when prescription drug benefits are provided under this health plan); and abortion-related care as defined by Massachusetts Division of Insurance guidance. Covered services for abortion-related care include (but are not limited to): pre- and post-abortion medical services and diagnostic tests. As required by state law, this health plan provides full coverage for these covered services. You pay nothing for in-network and out-of-network benefits. (Any deductible, copayment, and/or coinsurance that you would normally pay will not apply.) The only exception is when you are enrolled in a qualified HSA-compliant high deductible health plan. In this case, your deductible will apply to these covered services. Otherwise, any cost share amounts will not apply. Note: If your employer is a church or qualified church-controlled organization, these services may not be available to you. To find out, you can check with your employer. Also refer to riders—if there are any—that apply to your coverage in this health plan. All other provisions remain as described in your Subscriber Certificate.