About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia’s Simple Fracture (9 months of in-network prenatal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow-up hospital delivery) controlled condition) care) ■The plan’s overall deductible $4,000 ■The plan’s overall deductible $4,000 ■The plan’s overall deductible $4,000 ■Delivery fee copay $0 ■Specialist visit copay $60 ■Specialist visit copay $60 ■Facility fee copay $1,000 ■Primary care visit copay $60 ■Emergency room copay $750 ■Diagnostic tests copay $0 ■Diagnostic tests copay $0 ■Ambulance services copay $0 This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical Childbirth/Delivery Professional Services disease education) supplies) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray) Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost sharing Cost sharing Cost sharing Deductibles $4,000 Deductibles $4,000 Deductibles $2,800 Copayments $1,000 Copayments $100 Copayments $0 Coinsurance $0 Coinsurance $700 Coinsurance $0 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0 The total Peg would pay is $5,060 The total Joe would pay is $4,820 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 002855723 (4/24) GSP ® Registered Marks of the Blue Cross and Blue Shield Association. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 8 of 8