Access Blue New England Basic Saver II Summary of Benefits & Coverage

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 06/01/2023 Access Blue New England Basic Saver II: Buckingham Browne & Nichols School Coverage for: Individual and Family | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, see bluecrossma.org/coverage-info. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at bluecrossma.org/sbcglossary or call 1-800-782-3675 to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan What is the overall $4,500 member / $9,000 family. begins to pay. If you have other family members on the plan, each family member must meet their own deductible? individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services This plan covers some items and services even if you haven’t yet met the deductible amount. But a covered before you meet Yes. Preventive care and prenatal copayment or coinsurance may apply. For example, this plan covers certain preventive services without your deductible? care. cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles for specific No. You don’t have to meet deductibles for specific services. services? What is the out-of-pocket The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family limit for this plan? $6,450 member / $12,900 family. members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of- pocket limit has been met. What is not included in Premiums, balance-billing charges, the out-of-pocket limit? and health care this plan doesn't Even though you pay these expenses, they don't count toward the out-of-pocket limit. cover. Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will Will you pay less if you bluecrossma.com/findadoctor or pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the use a network provider? call the Member Service number difference between the provider’s charge and what your plan pays (balance billing). Be aware, your on your ID card for a list of network network provider might use an out-of-network provider for some services (such as lab work). Check providers. with your provider before you get services. Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7