attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate R02-3029 (2023) to be attached to HMO-PPO Page 1 hppo02-3029 Rider Virtual Care Team Model This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate for easy reference. The in-network outpatient benefits described in your Subscriber Certificate for certain covered services have been changed. Your health plan includes a tech-enabled care delivery model where virtual care team covered providers furnish certain covered services, including primary care with integrated mental health and/or substance use care within the patient care team, via traditional and/or digital platforms (such as: mobile app; web portal; telephone; and/or text message). This care delivery model offers a comprehensive and coordinated experience and virtual engagement with seamless navigation to in-person care when applicable. For in-network outpatient covered services furnished by a virtual care team primary care provider type such as a family or general practitioner, internist, OB/GYN physician, pediatrician, geriatric specialist, nurse midwife, or by a physician assistant or nurse practitioner designated by the health plan as primary care, you will pay nothing (any deductible, copayment and/or coinsurance does 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 still apply to covered services as described in the Schedule of Benefits and/or riders for your plan option. For in-network outpatient covered services furnished by a virtual care team covered provider not described above or by any other covered provider, you will pay your applicable cost share (deductible, copayment and/or coinsurance). To find a virtual care team covered provider or to learn more about a specific virtual care team’s care delivery model, including information about mental health care management, see “When You Need Help to Find a Health Care Provider” in your Subscriber Certificate or call customer service. The toll free phone number to call is shown on your ID card. This rider does not change the cost share amount you will pay for: telehealth services as described in your Subscriber Certificate, which includes any riders that apply to your coverage in this health plan; or out-of-network outpatient benefits. All other provisions remain as described in your Subscriber Certificate.