Access Blue New England Basic Saver II Summary of Benefits

SUMMARY OF BENEFITS Buckingham Browne & Access Blue Nichols School New England basic Saver II Plan-Year Deductible: $4,500/$9,000 UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan: COVERAGE AND CLAIMS AND DIGITAL BENEFITS BALANCES ID CARD Sign in Download the app, or create an account at bluecrossma.org. This health plan meets Minimum Creditable Coverage Standards for Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. An Association of Independent Blue Cross and Blue Shield Plans

Your Care Access Telehealth Services This plan gives you the option to go directly to a specialist or any doctor in the Telehealth services are covered when the same in-person service would be HMO Blue New England network without a referral. Just show your Blue Cross covered by the health plan and the use of telehealth is appropriate. Your health Blue Shield of Massachusetts ID card and receive care. However, some services care provider will work with you to determine if a telehealth visit is medically do require authorization. See your subscriber certificate for details. appropriate for your health care needs or if an in-person visit is required. For a list of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website Primary Care Provider (PCP) at bluecrossma.org, consult Find a Doctor, or call the Member Service number When you enroll in this health plan, you must choose a primary care provider. Be on your ID card. sure to select a doctor who is accepting you and your family members as new patients and participates in our network of providers in New England. For children, Your Virtual Care Team you may designate a participating network pediatrician as the PCP. Your health plan includes the option for a tech-enabled delivery model where virtual care team covered providers furnish certain covered services, including For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross primary care with integrated mental health and/or substance use care within Blue Shield of Massachusetts website at bluecrossma.org; consult Find a Doctor the patient care team, via traditional and/or digital platforms (such as: mobile at bluecrossma.com/findadoctor; or call the Member Service number on your app; web portal; telephone; and/or text message). This care delivery model ID card. offers a comprehensive and coordinated primary care experience with virtual engagement and seamless navigation to in-person care with network providers If you have trouble choosing a doctor, Member Service can help. They can give when applicable. After meeting your deductible, for outpatient covered you the doctor’s gender, the medical school the doctor attended, and whether services furnished by a designated virtual care team primary care or mental there are languages other than English spoken in the office. health care provider type, you will pay nothing (any deductible, copayment, Your provider may also work with Blue Cross Blue Shield of Massachusetts and/or coinsurance does not apply). For outpatient covered services regarding Utilization Review Requirements, including Pre-Admission Review, furnished by a virtual care team covered provider that is not a virtual care Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient team primary care or mental health care provider type, you will pay your Services, and Individual Case Management. For detailed information about applicable cost share (deductible, copayment, and/or coinsurance). To find Utilization Review, see your subscriber certificate. a virtual care team covered provider or to learn more about this care delivery model, visit MyBlue online or see “When You Need Help to Find a Health Care Your Deductible Provider” in your subscriber certificate, or call the Member Service number on Your deductible is the amount of money you pay out-of-pocket each plan your ID card. year before you can receive coverage for certain benefits under this plan. If Service Area you are not sure when your plan year begins, contact Blue Cross Blue Shield The plan’s service area includes all cities and towns in the Commonwealth of of Massachusetts. Your deductible is $4,500 per member (or $9,000 per family). Massachusetts, State of Rhode Island, State of Vermont, State of Connecticut, Your Out-of-Pocket Maximum State of New Hampshire, and State of Maine. Your out-of-pocket maximum is the most that you could pay during a plan year When Outside the Service Area for deductible, copayments (including prescription drug copayments), and If you’re traveling outside the service area and you need urgent or emergency coinsurance for covered services. Your out-of-pocket maximum is $6,450 per care, you should go to the nearest appropriate health care facility. You are member (or $12,900 per family). covered for the urgent or emergency care visit and one follow-up visit while Emergency Room Services outside the service area. See your subscriber certificate for more information. In an emergency, such as a suspected heart attack, stroke, or poisoning, Dependent Benefits you should go directly to the nearest medical f acility or call 911 (or the local This plan covers dependents until the end of the calendar month in which emergency phone number). After meeting your deductible, you pay a copayment they turn age 26, regardless of their financial dependency, student status, or per visit for emergency room services. This copayment is waived if you are employment status. See your subscriber certificate (and riders, if any) for exact admitted to the hospital or for an observation stay. See the chart for your coverage details. cost share. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.

Covered Services Your Cost Preventive Care Well-child care exams Nothing, no deductible Routine adult physical exams, including related tests Nothing, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the maximum after deductible Routine vision exams (one every 24 months) Nothing, no deductible Family planning services—office visits Nothing, no deductible Outpatient Care Emergency room visits $750 per visit after deductible (copayment waived if admitted or for observation stay) Office or health center visits, when performed by: • Your PCP, OB/GYN physician, nurse midwife, limited services clinic, or by a physician assistant or $50 per visit after deductible nurse practitioner designated as primary care • Other covered providers, including a physician assistant or nurse practitioner designated as $75 per visit after deductible specialty care Mental health or substance use treatment $50 per visit after deductible Outpatient telehealth services • With a covered provider Same as in-person visit • With the designated telehealth vendor $50 per visit after deductible Chiropractors’ office visits $75 per visit after deductible Acupuncture visits (up to 12 visits per calendar year) $75 per visit after deductible Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year*) $75 per visit after deductible Speech, hearing, and language disorder treatment—speech therapy $75 per visit after deductible Diagnostic X-rays and lab tests Nothing after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $1,000 per category per service date after deductible Home health care and hospice services Nothing after deductible Oxygen and equipment for its administration Nothing after deductible Durable medical equipment—such as wheelchairs, crutches, hospital beds 20% coinsurance after deductible** Prosthetic devices 20% coinsurance after deductible Surgery and related anesthesia in an office or health center, when performed by: • Your PCP, OB/GYN physician, nurse midwife, or by a physician assistant or nurse practitioner $50 per visit*** after deductible designated as primary care • Other covered providers, including a physician assistant or nurse practitioner designated as $75 per visit*** after deductible specialty care Surgery and related anesthesia in an ambulatory surgical facility, hospital outpatient department, $1,000 per admission after deductible or surgical day care unit Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) $1,000 per admission after deductible Mental hospital or substance use facility care (as many days as medically necessary) $1,000 per admission after deductible Rehabilitation hospital care (up to 60 days per calendar year) $1,000 per admission after deductible Skilled nursing facility care (up to 100 days per calendar year) $1,000 per admission 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, including supplies. *** 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 Prescription Drug Benefits* At designated retail pharmacies $15 after deductible for Tier 1 (up to a 30-day formulary supply for each prescription or refill)** 50% coinsurance after deductible for Tier 2 50% coinsurance after deductible for Tier 3 Through the designated mail service pharmacy $30 after deductible for Tier 1 (up to a 90-day formulary supply for each prescription or refill)** 50% coinsurance after deductible for Tier 2 50% coinsurance after deductible for Tier 3 * Generally, Tier 1 refers to generic drugs; Tier 2 refers to preferred brand-name drugs; Tier 3 refers to non-preferred brand-name drugs. ** Cost share may be waived for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. Get the Most from Your Plan: Visit us at bluecrossma.org or call 1-800-782-3675 to learn about discounts, savings, resources, and special programs available to you, like those listed below. Wellness Participation Program Fitness Reimbursement: a program that rewards participation in qualified fitness $150 per calendar year per policy programs or equipment (See your subscriber certificate for details.) Weight Loss Reimbursement: a program that rewards participation in a qualified $150 per calendar year per policy weight loss program (See your subscriber certificate for details.) 24/7 Nurse Line: Speak to a registered nurse, day or night, to get immediate guidance and advice. Call 1-888-247-BLUE (2583). No additional charge. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org. Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate 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 subscriber certificate and riders. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 002164036 (04/23) LK

NONDISCRIMINATION NOTICE Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does no t discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. If you believe that Blue Cross Blue Shield of Massachusetts has f ailed to provide Blue Cross Blue Shield these services or discriminated in another way on the basis of race, color, national of Massachusetts provides: origin, age, disability, sex, sexual orientation, • Free aids and services to people with or gender identity, you can file a grievance disabilities to communicate effectively with the Civil Rights Coordinator by mail with us, such as qualified sign language at Civil Rights Coordinator, Blue Cross interpreters and written information in other Blue Shield of Massachusetts, formats (large print or other formats). One Enterprise Drive, Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); • Free language services to people whose fax at 1-617-246-3616; or email at primary language is not English, such as [email protected]. qualified interpreters and information written If you need help filing a grievance, the Civil in other languages. Rights Coordinator is available to help you. If you need these services, call Member Service You can also file a civil rights complaint at the number on your ID card. with the U.S. Department of Health and Human Services, Office for Civil Rights, online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001651238 55-1487 (6/22)

Translation Resources TRANSLATION RESOURCES Proficiency of Language Assistance Services Proficiency of Language Assistance Services Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的 号码联系会员服务部（TTY 号码：711）。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711). Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711). Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711). Arabic/برية: فتاهلا زاهج) كتيوه ةقاطب لىع دوجولما مقرلا لىع ءاضعلأا تامدخب لصتا كل ةبسنلاب اناجم ةيوغللا ةدعاسلما تامدخ رفوتتف ،ةيبرعلا ةغللا ثدحتت تنك اذإ ”هابتنا ُ ً .(711 :”TTY“ مكبلاو مصلل صينلا Mon-Khmer, Cambodian/ខ្មែរ: ការជនដណង៖ ូ ំ ឹ ប្រសិនប្រអ្នកនើ ិយាយភាសា ខ្មែរ ំ ួ ិ ឺ ់ ូ ូ ័ ្ន ិ បសវាជនយភាសាឥតគតថ្លៃ គអាចរកបានសបរា្រអ្នក។ សមទរសព្ទបៅខ្កបសវាសរាជកតាមបេ្ បៅបេើ្រ័ណ្ណ សរាេ្លៃគា ់ នរ្រសអ្នក់ (TTY: 711)។ ួ French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré (TTY : 711). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa (TTY: 711). Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, Greek/Eλληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (TTY: 711). (TTY: 711). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711). Hindi/हिंदी: ध्यान द: ्दद आप दिनददी बोलत े ि, तो भयाषया सिया्तया सेवयाएँ, आप क े ललए नन:शलक ें ैं ु उपलब्ध ि। सदस् सेवयाओं को आपक े आई.डी. कयाड ्ड पर ददए गए नंबर पर कॉल कर (टदी.टदी.वयाई.: 711). ैं ें Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ ે ઉપલબ્ધ છ. ે તમયારયા આઈડી કયાડ્ડ પર આપેલયા નંબર પર Member Service ને કૉલ કરો (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card (TTY: 711). Japanese/日本語: お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご 利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください （TTY: 711）。 German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an (TTY: 711). نایسراپ: Persian/ ییاسانش تراک یور رب جردنم نفلت رامش اب .دریگ یم رارق امش رایتخا رد ناگیار تروص ب ینابز کمک تامدخ ،تسا یسراف امش نابز رگا :جوت .(TTY: 711) دیریگب سامت »اضعا تامدخ« شخب اب دوخ ້ ້ ້ ພາສາລາວ: ຂຄວນໃສໃຈ: ຖາເຈາເວາພາສາລາວໄດ, ມການບລການຊວຍເຫ Lao/ ໍ ່ ້ ້ ໍ ່ ຼ ອດານພາສາໃຫທານໂດຍ ່ ົ ົ່ ີ ິ ື ້ ້ ່ ບ ເສຍຄາ. ໂທ ຫາ ຝາຍບລການສະ ມາ ຊກທໝາຍເລກໂທລະສບຢໃນບດຂອງທານ (TTY: 711). ໍ ູ ່ ່ ໍ ິ ິ ີ ັ ່ ັ ່ Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih (TTY: 711). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. 164711MB 55-1493 (8/16) © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001651831 55-1493 (6/22)