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

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Primary care visit to treat an injury or illness $50 / visit Not covered Deductible applies first; a telehealth cost share may be applicable $75 / visit; $75 / Deductible applies first; limited to 12 Specialist visit chiropractor visit; $75 Not covered acupuncture visits per calendar year; / acupuncture visit a telehealth cost share may be If you visit a health care applicable provider’s office or clinic GYN exam limited to one exam per calendar year; a telehealth cost share may be applicable. You may have to Preventive care/screening/immunization No charge Not covered pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Deductible applies first; pre- Diagnostic test (x-ray, blood work) No charge Not covered authorization required for certain services If you have a test Deductible applies first; copayment Imaging (CT/PET scans, MRIs) $1,000 Not covered applies per category of test / day; pre- authorization required for certain services $15 / retail supply or Deductible applies first; up to 30-day If you need drugs to treat Generic drugs $30 / mail service Not covered retail (90-day mail service) supply; your illness or condition supply cost share may be waived for certain More information about Preferred brand drugs 50% coinsurance Not covered covered drugs and supplies; pre- prescription drug coverage authorization required for certain is available at Non-preferred brand drugs 50% coinsurance Not covered drugs bluecrossma.org/medicatio Applicable cost share Deductible applies first; when n Specialty drugs (generic, preferred, Not covered obtained from a designated specialty non-preferred) pharmacy; pre-authorization required for certain drugs Page 2 of 7

What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) $1,000 / admission Not covered authorization required for certain If you have outpatient services surgery Deductible applies first; pre- Physician/surgeon fees No charge Not covered authorization required for certain services Deductible applies first; copayment Emergency room care $750 / visit $750 / visit waived if admitted or for observation stay If you need immediate Emergency medical transportation No charge No charge Deductible applies first medical attention Deductible applies first; out-of- Urgent care $75 / visit $75 / visit network coverage limited to out of service area; a telehealth cost share may be applicable Deductible applies first; pre- Facility fee (e.g., hospital room) $1,000 / admission Not covered authorization / authorization required If you have a hospital stay for certain services Deductible applies first; pre- Physician/surgeon fees No charge Not covered authorization / authorization required for certain services Deductible applies first; a telehealth Outpatient services $50 / visit Not covered cost share may be applicable; pre- If you need mental health, authorization required for certain behavioral health, or services substance abuse services Deductible applies first; pre- Inpatient services $1,000 / admission Not covered authorization / authorization required for certain services Office visits No charge Not covered Deductible applies first except for Childbirth/delivery professional services No charge Not covered prenatal care; cost sharing does not apply for preventive services; If you are pregnant maternity care may include tests and Childbirth/delivery facility services $1,000 / admission Not covered services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Page 3 of 7

What You Will Pay Common Medical Event Services You May Need In-Network Out-of-Network Limitations, Exceptions, & Other (You will pay the (You will pay the Important Information least) most) Home health care No charge Not covered Deductible applies first; pre- authorization required Deductible applies first; limited to 60 outpatient visits per calendar year $75 / visit for (other than for autism, home health outpatient services; care, and speech therapy); limited to Rehabilitation services $1,000 / admission Not covered 60 days per calendar year for for inpatient services inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Deductible applies first; outpatient If you need help recovering rehabilitation therapy coverage limits or have other special health apply; copayment and coverage limits needs Habilitation services $75 / visit Not covered waived for early intervention services for eligible children; a telehealth cost share may be applicable; pre- authorization required for certain services Deductible applies first; limited to 100 Skilled nursing care $1,000 / admission Not covered days per calendar year; pre- authorization required Deductible applies first; cost share Durable medical equipment 20% coinsurance Not covered waived for one breast pump per birth, including supplies Deductible applies first; pre- Hospice services No charge Not covered authorization required for certain services Children’s eye exam No charge Not covered Limited to one exam every 24 months Children’s glasses Not covered Not covered None If your child needs dental No charge for or eye care Children’s dental check-up members with a cleft Not covered Limited to members under age 18 palate / cleft lip condition Page 4 of 7

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Children's glasses • Long-term care • Private-duty nursing • Cosmetic surgery • Non-emergency care when traveling outside the • Dental care (Adult) U.S. Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Acupuncture (12 visits per calendar year) • Infertility treatment • Weight loss programs ($150 per calendar year per • Bariatric surgery • Routine eye care - adult (one exam every 24 policy) • Chiropractic care months) • Hearing aids ($2,000 per ear every 36 months for • Routine foot care (only for patients with systemic members age 21 or younger) circulatory disease) Page 5 of 7

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform and the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov. Your state insurance department might also be able to help. If you are a Massachusetts resident, you can contact the Massachusetts Division of Insurance at 1-877-563-4467 or www.mass.gov/doi. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. For more information about possibly buying individual coverage through a state exchange, you can contact your state’s marketplace, if applicable. If you are a Massachusetts resident, contact the Massachusetts Health Connector by visiting www.mahealthconnector.org. For more information on your rights to continue your employer coverage, contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.) Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, call 1-800-472-2689 or contact your plan sponsor. (A plan sponsor is usually the member’s employer or organization that provides group health coverage to the member.) You may also contact The Office of Patient Protection at 1-800-436-7757 or www.mass.gov/hpc/opp. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Disclaimer: This document contains only a partial description of the benefits, limitations, exclusions and other provisions of this health care plan. It is not a policy. It is a general overview only. It does not provide all the details of this coverage, including benefits, exclusions and policy limitations. In the event there are discrepancies between this document and the policy, the terms and conditions of the policy will govern. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 7

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 $4,500 ■The plan’s overall deductible $4,500 ■The plan’s overall deductible $4,500 ■Delivery fee copay $0 ■Specialist visit copay $75 ■Specialist visit copay $75 ■Facility fee copay $1,000 ■Primary care visit copay $50 ■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 $4,500 Deductibles $4,500 Deductibles $2,800 Copayments $1,000 Copayments $20 Copayments $0 Coinsurance $0 Coinsurance $500 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 $5,560 The total Joe would pay is $5,040 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 002164019 (04/23) JM ® 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. Page 7 of 7

MCC COMPLIANCE This health plan meets Minimum Creditable Coverage Standards f or Massachusetts residents that went into effect January 1, 2014, as part of the Massachusetts Health Care Reform Law. 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. 001652563 55-0647 (6/22)

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)