Common use of Dependent Benefits Clause in Contracts

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductible

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant midwife • Other covered When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* deductible† $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * 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. ** 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. *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits** Your Cost Plan-year out-of-pocket maximum $1,000 per member $2,000 per family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. Exhibit B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caredentalcare; and any services covered by workersanyservicescoveredbyworkers’ compensation. For a complete list acompletelist of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 Your Care Your Primary Care Provider (member / familyPCP) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caredentalcare; and any services covered by workersanyservicescoveredbyworkers’ compensation. For a complete list acompletelist of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 Your Care Your Primary Care Provider (member / familyPCP) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. MIIA HMO High Deductible Health Plan 7/1/2018 – 6/30/2024 BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible MIIA PPO High Deductible Health Plan 7/1/2018 – 6/30/2024 BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductible

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant midwife • Other covered When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* deductible† $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * 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. ** 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. *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits** Your Cost Plan-year out-of-pocket maximum $1,000 per member $2,000 per family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of completelistof limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. EXHIBIT B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant midwife • Other covered When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* deductible† $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * 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. ** 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. *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits** Your Cost Plan-year out-of-pocket maximum $1,000 per member $2,000 per family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT Your Choice Your Deductible. Exhibit B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. You will pay a higher cost share when you receive inpatient services at or by “yrvice cost share hospitals.p See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syouvid still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliated with one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refers you.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant midwife • Other covered When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* deductible† $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * 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. ** 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. *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits** Your Cost Plan-year out-of-pocket maximum $1,000 per member $2,000 per family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT Your Choice Your Deductible. EXHIBIT B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. You will pay a higher cost share when you receive inpatient services at or by “yrvice cost share hospitals.p See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syouvid still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliated with one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refers you.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered arecoveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caredentalcare; and any services covered by workersanyservicescoveredbyworkers’ compensation. For a complete list acompletelist of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 Your Care Your Primary Care Provider (member / familyPCP) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT Your Care Your Primary Care Provider. MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 NE Benchmark Plan v.2 7/1/2020 – 6/30/2022 • North Shore Medical Center – Salem Campus When you enroll in Network Blue New England, you must choose a primary care provider (member / familyPCP) Out who is available to accept you and your family members and participates in our network of Pocket Maximum Medical providers throughout the New England states. For children, you may designate a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYNs: visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call our Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. We can tell you whether a doctor is male or female, the medical school(s) he or she attended, and Prescription if any languages other than English are spoken in the office. Referrals You Can Feel Better About. Your PCP is the first person you call when you need routine or sick care(seeEmergencyCare–WhereverYouAre for emergency care services). If you and your PCP decide that you need to see a specialist for covered services, your PCP will refer you to an appropriatenetwork specialist, who is probably someone affiliated with your PCPeonhospital or medical group. You will not need prior authorization or referral to see a HMO Blue New England network provider who specializes in OB/GYN services. Your providers may also work with Blue Cross Blue Shield concerning referrals, and the Utilization Review Requirements, which are Pre- Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services: $3,000 , and Individual / $6,000 famlly Preventtve Care Visit $0 Case Management. Information concerning Utilization Review and services requiring referral from your PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered is detailed in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleyour benefit description.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered arecoveredare: 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 benefit description and riders. BENEFIT Your Care Your Primary Care Provider (PCP) Exhibit C Network Blue New England Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN NE Benchmark Plan v.3 7/1/2022 – 6/30/2024 Your Deductible $1,500 / $3,000 (member / family) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care benefitsof yourhealthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise questionsarise concerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete Foracomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered arecoveredare: 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 benefit description and riders. BENEFIT Your Care Your Primary Care Provider (PCP) EXHIBIT C Network Blue New England Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN NE Benchmark Plan v.3 7/1/2022 – 6/30/2024 Your Deductible $1,500 / $3,000 (member / family) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of benefitsof your health care healthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise questionsarise concerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete acomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits • When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant midwife • Other covered When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office • When performed by your PCP or OB/GYN • When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* deductible† $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible * 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. ** 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. *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits** Your Cost Plan-year out-of-pocket maximum $1,000 per member $2,000 per family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. Exhibit B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferredprovider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provideryou are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductible

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of benefitsof your health care healthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete acomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT Your Care Your Primary Care Provider. MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 NE Benchmark Plan v.2 7/1/2020 – 6/30/2022 • North Shore Medical Center – Salem Campus When you enroll in Network Blue New England, you must choose a primary care provider (member / familyPCP) Out who is available to accept you and your family members and participates in our network of Pocket Maximum Medical providers throughout the New England states. For children, you may designate a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYNs: visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call our Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. We can tell you whether a doctor is male or female, the medical school(s) he or she attended, and Prescription if any languages other than English are spoken in the office. Referrals You Can Feel Better About. Your PCP is the first person you call when you need routine or sick care(seeEmergencyCare–WhereverYouAre for emergency care services). If you and your PCP decide that you need to see a specialist for covered services, your PCP will refer you to an appropriatenetwork specialist, who is probablysomeone affiliated with your PCPeonhospital or medical group. You will not need prior authorization or referral to see a HMO Blue New England network provider who specializes in OB/GYN services. Your providers may also work with Blue Cross Blue Shield concerning referrals, and the Utilization Review Requirements, which are Pre- Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services: $3,000 , and Individual / $6,000 famlly Preventtve Care Visit $0 Case Management. Information concerning Utilization Review and services requiring referral from your PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered is detailed in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleyour benefit description.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care benefitsof yourhealthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise questionsarise concerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete Foracomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant • Other covered midwife When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office When performed by your PCP or OB/GYN When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) In other general hospitals (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost InPlan-Network Your Cost Outyear out-of-Network Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) pocket maximum $275 1,000 per admission after deductible* member $1,500 2,000 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. Exhibit B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferredprovider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provideryou are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out-of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits • When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant or pediatrician • Other When performed by other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 20 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when • Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital, or surgical day care unit $20 per visit,*** no deductible $60 per visit,*** no deductible $250 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • In other general hospitals General hospital care (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 1*** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered arecoveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caredentalcare; and any services covered by workersanyservicescoveredbyworkers’ compensation. For a complete list acompletelist of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 Your Care Your Primary Care Provider (member / familyPCP) Out When you enroll in Network Blue New England, you must choose a primary care provider. Be sure to choose a PCP who can accept you and your family members and who participates in the network of Pocket Maximum Medical providers in New England. For children, you may choose a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at xxx.xxxxxxxxxxx.xxx; consult the Provider Directory; or call the Physician Selection Service at 0-000-000-0000. If you have trouble choosing a doctor, the Physician Selection Service can help. They can give you the doctor’s gender, the medical school she or he attended, and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered whether there are languages other than English spoken in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductiblethe office.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant • Other covered midwife When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office When performed by your PCP or OB/GYN When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) In other general hospitals (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost InPlan-Network Your Cost Outyear out-of-Network Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) pocket maximum $275 1,000 per admission after deductible* member $1,500 2,000 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. Exhibit B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibledeductible Prescription Drug Deductible ($100 / $200) (applles to retail and mall) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible applies to retail and mail $20/60/130 after deductible not covered PITTSFIELD PUBLIC SCHOOLS - Custodial Inspection Form DATE TIME SCHOOL/BUILDING CUSTODIAN ON DUTY AREAS INSPECTED AREAS OF CONCERN/ISSUES NOTED DURING INSPECTION ROOM # ROOM # ROOM # ENTRY WAYS LOBBY AREA HALLWAYS STAIRWWELLS Floors, Entry Mats, Stairs Vertical Surfaces, Glass ,Ledges Drinking Fountains RESTROOMS Toilets, Urinals, Sinks & Fixtures Supplies, Paper & Soap Vertical Surfaces, Vents, Partitions,Glass, Mirrors Floors, Trash, Sanitary Receptacles CLASSROOMS, LABS, OFFICE AREAS Floors (Carpet or Tile) Sinks & Counter Surfaces Furniture Lighting Fixtures & Ceiling Tiles Vertical Surfaces, Vents, Doors,Glass Window Xxxxx & Ledges Trash Containers Univents & Heaters BOILER, MECHANICAL, ELECTRICAL ROOMS Floors Panels & Switches Clear Air Handlers Clear Storage Vertical Surfaces, Vents AUDITORIUM & GYM Floors (Cappet, Tile, or Wood) Vertical Surfaces, Vents, Doors,Glass Bleachers & Seats CUSTODIAL CLOSETS & OFFICES Floors, Sink, Vertical Surfaces,Vents Bottles Labeled, Supplies StoredNeatly Equipment, Clean & Working KITCHENS & CAFETERIAS Floors Tables & Chairs Vertical Surfaces & Vents OUTSIDE Entry Ways/Sidewalks/Walk Ways Grass/Mowing/Weed Whacking Trash/Debris Pickup ADDITIONAL COMMENTS: (Attached Additional Pages if Necessary). EMPLOYEE RESPONSE: (Attach Additional Pages if Necessary). Director of Custodial Services Custodian's Signature DATE Presented to Employee GROUNDS Xxxxxxxxx’s signature acknowledges receipt of the Custodial Inspection Form but does not imply his/her agreement with the contents.

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible - 67 - 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call Call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductible

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $300 per member $900 per family Plan-year out-of-pocket maximum $2,500 per member $5,000 per family Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 age 3 and older Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, (one per calendar year) tests Nothing, no deductible 20% coinsurance after deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance after Routine hearing exams Nothing, no deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services–office visits Nothing, no deductible Hearing Care Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) Mental health and substance abuse treatment $100 20 per visit after visit, no deductible (copayment waived if admitted or for observation stay) Office visits, when visits When performed by: • Family or general practitioner, internistby your PCP, OB/GYN physicianGYN, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, network nurse practitioner, or nurse midwife, physician assistant • Other covered midwife When performed by other network providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after Surgery and related anesthesia in an office When performed by your PCP or OB/GYN When performed by other network providers $20 per visit**, no deductible $60 per visit**, no deductible Diagnostic X-rays and lab other imaging tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible*** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance Home health care and hospice services Nothing after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory ambulatory surgical facility, hospitalhospital outpatient department, or surgical day care unit $250 per admission after deductible Inpatient Care (including maternity care) In other general hospitals (as many days as medically necessary) In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible† $1,500 per admission after deductible† Chronic disease hospital care (as many days as medically necessary) Nothing after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 *** Cost share waived for one breast pump per birth. † This copayment applies to mental health admissions in a general hospital. Prescription Drug Benefits* Your Cost InPlan-Network Your Cost Outyear out-of-Network Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) pocket maximum $275 1,000 per admission after deductible* member $1,500 2,000 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible Prescription Drug Benefits** family At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1** $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible for Tier 1 1** $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost Cost share also applies to mental health admissions in a general hospitalwaived for certain orally-administered anticancer drugs. ** Cost share may be waived for certain covered drugs and suppliesbirth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description and riders will govern. Some of the services not covered are: cosmetic surgery; custodial carecustodialcare; most dental caredentalcare; and any services covered servicescovered by workers’ compensation. For a complete list of completelistof limitations and exclusions, refer to your benefit description and riders. BENEFIT Your Choice Your Deductible. EXHIBIT B Blue Care Elect Deductible SM MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible PPO Benchmark Plan v.2 7/1/2020 – 6/30/2022 When You Choose Non-Preferred Providers Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for most benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield. Your deductibles are $1,500 / 300 per member (or $3,000 (member / 900 per family) Out for in-network services and $400 per member (or $800 per family) for out-of-network services. When You Choose PreferredProviders. The plan has two levels of Pocket Maximum Medical and Prescription Serviceshospital benefits for preferred providers. Youwill pay a higher cost share when you receive inpatient services at or by “higher cost share hospitals.” See the chart on the back page for your cost share amounts. Please note: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc XIf a preferred provider refers you to another provider for covered services (such as a specialist), make sure the provider is a preferred provider in order to receive benefits at the in-rays and LabTestsnetwork level. If the provider you are referred to is not a preferred provider, excludlng MRl'syou’re still covered, CT and PET Sansand Nuclear Imaging Covered but your benefits, in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Shortmost situations, will be covered at the out-Term Physical and Occupational Therapy Covered In fun after deductible (up of-network level, even if the preferred provider refers you. It is also important to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up check whether the provider you are referred to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (is affiliatedwith one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTeststhe higher cost share hospitals listed below. Your cost will be greater when you receive certain services at or by these hospitals, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleeven if your preferred provider refersyou.

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of benefitsof your health care healthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise questionsarise concerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete acomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies No deductible Not covered (up to a 30-day formulary supply for each prescription or refill) $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy No deductible Not covered (up to a 90-day formulary supply for each prescription or refill) $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of benefitsof your health care healthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise questionsarise concerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete acomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 Please see your benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Plan Specifics Plan-year deductible $250 per member $750 per family $400 per member $800 per family Plan-year out-of-pocket maximum $2,500 per member/$5,000 per family for in-network and out- of-network services combined Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related routine tests, according to age-based schedule as follows: • 10 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 from age 3 and older through age 18 Nothing, no deductible 20% coinsurance after deductible Routine adult physical exams, including related tests, for members age 19 or older (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 Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Hearing Benefits Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) All charges beyond the maximum, no deductible benefit maximum 20% coinsurance after deductible and all charges beyond the benefit maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance after deductible Family planning services–office visits Nothing, no deductible 20% coinsurance after deductible Other Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for an observation stay) $100 per visit after in-network deductible (copayment waived if admitted or for an observation stay) Office visits, when visits When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, internist, licensed dietitian nutritionist, optometrist, pediatriciannurse midwife, nurse practitioner, nurse midwifeOB/GYN, physician assistant • Other or pediatrician When performed by other covered providers $20 per visit, no deductible $60 35 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar yearyear for members age 16 or older) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 15 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays rays, lab tests, and lab other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests (excluding routine tests) Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per date of service date 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 Prosthetic devices Nothing after deductible 20% coinsurance after deductible Durable medical equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when Office setting – When performed by: • Family by a family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatricianinternist, nurse midwife, nurse practitioner, nursemidwifeOB/GYN, physician assistant • Other or pediatrician – When performed by other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 20 per visit,*** no deductible $35 per visit,*** no deductible $150 per admission after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible * 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. ** Cost In-network cost share waived for one breast pump per birth. *** 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 Inpatient Care care (including maternity care) • s In other general hospitals (as many days as medically necessary) • s In higher cost share hospitals (as many days as medically necessary) $275 300 per admission after deductible* $1,500 700 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 200 per admission, no admission after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance Nothing after deductible 4020% coinsurance after deductible Prescription Drug Benefits** Plan-year out-of-pocket maximum $1,000 per member $2,000 per family None At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) No deductible $10 after deductible for Tier 1 1*** $30 after deductible 25 for Tier 2 $65 after deductible 50 for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) No deductible $25 after deductible 20 for Tier 1 1*** $75 after deductible 50 for Tier 2 $165 after deductible 110 for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and suppliesorally-administered anticancer drugs. *** Cost share waived for birth control. Get the Most from Your Plan Plan. Visit us at xxx.xxxxxxxxxxx.xxx xxx.xxxxxxxxxxx.xxx/xxxxxxxxxxxxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs like those listed below that are available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy $150 per calendar year per policy Blue Care Line LineSM—A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? Call 0-000-000-0000. For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online the website at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us Blue Cross Blue Shield of Massachusetts via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of benefitsof your health care healthcare plan. Your benefit description benefitdescription and riders define the full terms and conditions in greater detail. Should any questions arise concerning ariseconcerning benefits, the benefit description and riders will govern. Some of the services not covered areservicesnot coveredare: cosmetic surgerycosmeticsurgery; custodial carecustodialcare; most dental caremostdentalcare; and any services covered by workersservicescoveredbyworkers’ compensation. For a complete acomplete list of limitations and exclusions, refer to your benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductibleYour Care

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 benefit description (and riders, if any) for exact coverage details. Your Medical Benefits Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including related tests, according to age-based schedule as follows: • 10 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 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 Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance after deductible Hearing aids (up to $5,000 per ear every 36 months) 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 services–office visits Nothing, no deductible 20% coinsurance after deductible Outpatient Care Emergency room visits $100 per visit after deductible (copayment waived if admitted or for observation stay) $100 per visit after deductible (copayment waived if admitted or for observation stay) Office visits, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, licensed dietitian nutritionist, optometrist, pediatrician, nurse practitioner, nurse midwife, physician assistant • Other covered providers $20 per visit, no deductible $60 per visit, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Chiropractors’ office visits (up to 20 visits per calendar year) $20 per visit, no deductible 20% coinsurance after deductible Mental health or substance abuse treatment $10 per visit, no deductible 20% coinsurance after deductible Short-term rehabilitation therapy–physical and occupational (up to 30 visits per calendar year for each type of therapy*) $20 per visit, no deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment–speech therapy $20 per visit, no deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $100 per category per service date 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 equipment–such as wheelchairs, crutches, hospital beds Nothing after deductible** 20% coinsurance after deductible Prosthetic devices Nothing after deductible 20% coinsurance after deductible Surgery and related anesthesia in an office, when performed by: • Family or general practitioner, internist, OB/GYN physician, geriatric specialist, pediatrician, nurse practitioner, nursemidwife, physician assistant • Other covered providers $20 per visit***, no deductible $60 per visit***, no deductible 20% coinsurance after deductible 20% coinsurance after deductible Ambulatory surgical facility, hospital, or surgical day care unit $250 per admission after deductible 20% coinsurance after deductible * 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. ** Cost share waived for one breast pump per birth. *** 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 Inpatient Care (including maternity care) • In other general hospitals (as many days as medically necessary) • In higher cost share hospitals (as many days as medically necessary) $275 per admission after deductible* $1,500 per admission after deductible* 20% coinsurance after deductible 20% coinsurance after deductible Chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance abuse facility care (as many days as medically necessary) $275 per admission, no deductible 20% coinsurance after deductible Rehabilitation hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 45 days per calendar year) 20% coinsurance after deductible 40% coinsurance after deductible 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 $30 after deductible for Tier 2 $65 after deductible for Tier 3 Not covered Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) $25 after deductible for Tier 1 $75 after deductible for Tier 2 $165 after deductible for Tier 3 Not covered * This cost share also applies to mental health admissions in a general hospital. ** Cost share may be waived for certain covered drugs and supplies. Get the Most from Your Plan Visit us at xxx.xxxxxxxxxxx.xxx or call 0-000-000-0000 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Reimbursement for a membership at a health club or for fitness classes This fitness program applies for fees paid to: privately-owned or privately-sponsored health clubs or fitness facilities, including individual health clubs and fitness centers; YMCAs; YWCAs; Jewish Community Centers; and municipal fitness centers. (See your benefit description for details.) $150 per calendar year per policy Reimbursement for participation in a qualified weight loss program This weight loss program applies for fees paid to: a qualified hospital-based weight loss program or a Blue Cross Blue Shield of Massachusetts designated weight loss program. (See your benefit description for details.) $150 per calendar year per policy Blue Care Line —A 24-hour nurse line to answer your health care questions—call 0-000-000-XXXX (2583) ® No additional charge Questions? For questions about Blue Cross Blue Shield of Massachusetts. call 0-000-000-0000, or visit us online at xxx.xxxxxxxxxxx.xxx. Interested in receiving information from us via e-mail? Go to xxx.xxxxxxxxxxx.xxx/xxxxx to sign up. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your benefit description and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the benefit description 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 benefit description and riders. BENEFIT MIIA HMO HIGH DEDUCTIBLE HEALTH PLAN Deductible $1,500 / $3,000 (member / family) Out of Pocket Maximum Medical and Prescription Services: $3,000 Individual / $6,000 famlly Preventtve Care Visit $0 PCP Office Visit Covered In fu ll after deductible Specialist Office Visit Covered In full after deductible Emergency Room Covered In fu ll after deductible lnpatient Hospital Admission Covered In full after deductible Ambulatory Day/Outpatient Surgical Day Covered In full after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible CT and PETscans and Nuclear lmaging Covered in full after deductible Short-Term Physical and Occupational Therapy Covered In fun after deductible (up to 100 visits per CY) Skilled Nursing Facility Care Covered In full after deductible (up to 100 days per CY) Speech Theropy Covered In full after deductible Home Health and Hospice Care Covered In full after deductible Durable Medical Equipment Covered In fun after deductible Chiropractic Services Covered In full after deductible Routine Vision Exam Covered In full after deductible (one visit every 24 months) Prescription Drug Deductible ($100 / $200) (applles to retail and mail) - Retail RX (up to 30-day supply) - Mail Order Drug RX (up to 90-day supply) applies to retail and mail $10/30/65 after deductible $25/75/165 after deductible BENEFIT MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN MIIA PPO HIGH DEDUCTIBLE HEALTH PLAN Network In-Network Out-Of-Network Deductible $1500 / $3000 (Member / Family) * $1500 / $3000 (Member / Family) * Out of Pocket Maximum Medical and Prescription Services: $3000 Individual / $6000 Family Mecical Services: Combined In and Out Preventtve Care Visit $0 20% coinsurance after deductible PCP Office Visit Covered in full after deductible 20% coinsurance after deductible Specialist Office Visit Covered in full after deductible 20% coinsurance after deductible Emergency Room Covered in full after deductible Covered In full after deductible lnpatient Hospital Admission Covered in full after deductible 20% coinsurance after deductible Ambulatory Day/Outpatient Surgical Day Covered in full after deductible 20% coinsurance after deductible Dia1nostlc X-rays and LabTests, excludlng MRl's, CT and PET Sansand Nuclear Imaging Covered in full after deductible 20% coinsurance after deductible MRI, CT and PETscans and Nuclear lmaging Covered in full after deductible 20% coinsurance after deductible Short-Term Physical and Occupational Therapy Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Skilled Nursing Facility Care Covered in full after deductible (up to 100 visits per CY) 20% coinsurance after deductible Speech Theropy Covered in full after deductible 20% coinsurance after deductible Home Health and Hospice Care Covered in full after deductible 20% coinsurance after deductible Durable Medical Equipment Covered in full after deductible 20% coinsurance after deductible Chiropractic Services Covered in full after deductible 20% coinsurance after deductible Routine Vision Exam Covered in full after deductible (one visit every 24 months) 20% coinsurance after deductible