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 (9 months of in-network prenatal care and a hospital delivery) ■The plan’s overall deductible $4,000 ■Delivery fee copay $0 ■Facility fee copay $1,000 ■Diagnostic tests copay $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost sharing Deductibles $4,000 Copayments $1,000 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) ■The plan’s overall deductible $4,000 ■Specialist visit copay $60 ■Primary care visit copay $60 ■Diagnostic tests copay $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost sharing Deductibles $4,000 Copayments $100 Coinsurance $700 What isn’t covered Limits or exclusions $20 The total Joe would pay is $4,820 Mia’s Simple Fracture (in-network emergency room visit and follow-up care) ■The plan’s overall deductible $4,000 ■Specialist visit copay $60 ■Emergency room copay $750 ■Ambulance services copay $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 003558709 (4/25) RB ® Registered Marks of the Blue Cross and Blue Shield Association. © 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 8 of 8