attached to and made part of Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Preferred Blue PPO Preferred Provider Plan Subscriber Certificate R02-397 (2016 Rev.) to be attached to HMO-PPO Page 1 hppo02-397 Rider Diabetes Management This rider modifies the terms of your health plan. Please keep this rider with your Subscriber Certificate for easy reference. The outpatient benefits described in your Subscriber Certificate have been changed. Full in-network benefits based on the allowed charge are provided for your first two outpatient office visits in each calendar year for diabetes evaluation and management services, diabetic eye exams, and/or diabetic foot care. (Any copayment, deductible, and/or coinsurance is waived for these covered services.) Note: When these covered services are furnished by a non-preferred provider, the out-of-network coinsurance percentage that you will pay for non-emergency covered services will be no more than 20 percentage points greater than the in-network coinsurance percentage described in your Subscriber Certificate for the same covered services (excluding any copayment and deductible). All other provisions remain as described in your Subscriber Certificate.