BCBS Access Blue New England Basic Saver II - Summary of Benefits

SUMMARY OF BENEFITS 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. Download the app, or create an account at bluecrossma.org. Sign in UNLOCK THE POWER OF YOUR PLAN MyBlue gives you an instant snapshot of your plan: COVERAGE AND BENEFITS CLAIMS AND BALANCES DIGITAL ID CARD An Association of Independent Blue Cross and Blue Shield Plans Access Blue New England basic Saver II Plan-Year Deductible: $4,500/$9,000 Buckingham Browne & Nichols School

Your Care Access This plan gives you the option to go directly to a specialist or any doctor in the HMO Blue New England network without a referral. Just show your Blue Cross Blue Shield of Massachusetts ID card and receive care. However, some services do require authorization. See your subscriber certificate for details. Primary Care Provider (PCP) When you enroll in this health plan, you must choose a primary care provider. Be 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, you may designate a participating network pediatrician as the PCP. For a list of participating PCPs or OB/GYN physicians, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org; consult Find a Doctor at bluecrossma.com/findadoctor; or call the Member Service number on your ID card. If you have trouble choosing a doctor, Member Service can help. They can give you the doctor’s gender, the medical school the doctor attended, and whether there are languages other than English spoken in the office. Your provider may also work with Blue Cross Blue Shield of Massachusetts regarding Utilization Review Requirements, including Pre-Admission Review, Concurrent Review and Discharge Planning, Prior Approval for Certain Outpatient Services, and Individual Case Management. For detailed information about Utilization Review, see your subscriber certificate. Your Deductible Your deductible is the amount of money you pay out-of-pocket each plan year before you can receive coverage for certain benefits under this plan. If you are not sure when your plan year begins, contact Blue Cross Blue Shield of Massachusetts. Your deductible is $4,500 per member (or $9,000 per family). No one member will have to pay more than the per member deductible. Your Out-of-Pocket Maximum Your out-of-pocket maximum is the most that you could pay during a plan year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical and prescription drug benefits is $6,450 per member (or $12,900 per family). Emergency Room Services In an emergency, such as a suspected heart attack, stroke, or poisoning, you should go directly to the nearest medical facility or call 911 (or the local emergency phone number). After meeting your deductible, you pay a copayment per visit for emergency room services. This copayment is waived if you are admitted to the hospital or for an observation stay. See the chart for your cost share. Telehealth Services Telehealth services are covered when the same in-person service would be covered by the health plan and the use of telehealth is appropriate. Your health care provider will work with you to determine if a telehealth visit is medically 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 at bluecrossma.org, consult Find a Doctor, or call the Member Service number on your ID card. Your Virtual Care Team Your health plan includes an option for a tech-enabled primary care delivery model where virtual care team covered providers furnish certain covered services. See your subscriber certificate (and riders, if any) for exact coverage details. Service Area The plan’s service area includes all cities and towns in the Commonwealth of Massachusetts, State of Rhode Island, State of Vermont, State of Connecticut, State of New Hampshire, and State of Maine. When Outside the Service Area If you are traveling outside the service area and you need urgent or emergency care, you should go to the nearest appropriate health care facility. You are covered for the urgent or emergency care visit and one follow-up visit while outside the service area. See your subscriber certificate for more information. Dependent Benefits This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their financial dependency, student status, or employment status. See your subscriber certificate (and riders, if any) for exact coverage details. 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 Mental health wellness exams (at least 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 nurse practitioner designated as primary care $50 per visit after deductible • Other covered providers, including a physician assistant or nurse practitioner designated as specialty care $75 per visit after deductible 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 designated as primary care $50 per visit*** after deductible • Other covered providers, including a physician assistant or nurse practitioner designated as specialty care $75 per visit*** after deductible Surgery and related anesthesia in an ambulatory surgical facility, hospital outpatient department, or surgical day care unit $1,000 per admission after deductible 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 (up to a 30-day formulary supply for each prescription or refill)** $15 after deductible for Tier 1 50% coinsurance after deductible for Tier 2 50% coinsurance after deductible for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill)** $30 after deductible for Tier 1 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, reduced, or increased for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. ® 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. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 003558607 (4/25) JB 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. 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 programs or equipment (See your subscriber certificate for details.) $150 per calendar year per policy Weight Loss Reimbursement: a program that rewards participation in a qualified weight loss program (See your subscriber certificate for details.) $150 per calendar year per policy 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.

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. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 2915351 55-1487 (5/24) Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not 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. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. NONDISCRIMINATION NOTICE If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, 25 Technology Place, Hingham, MA 02043; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected]. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint 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.

TRANSLATION RESOURCES Proficiency of Language Assistance Services Translation Resources 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) كتيوُه ةقاطب لىع دوجولما مقرلا لىع ءاضعلأا تامدخب لصتا .كل ةبسنلاب اًناجم ةيوغللا ةدعاسلما تامدخ رفوتتف ،ةيبرعلا ةغللا ثدحتت تنك اذإ :هابتنا .(711 :”TTY“ مكبلاو مصلل صينلا Mon-Khmer, Cambodian/ខ្មែរ: ការជូនដំណឹ ង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្ បៅបេើ្រ័ណ្ណ សរាគា េ់្លៃួនរ្រស់អ្នក (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, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (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. 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) (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. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001651831 55-1493 (6/23) 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 दें: ्दद आप दिनददी बोलते िैं, तो भयाषया सिया्तया सेवयाएँ, आप के ललए नन:शुलक उपलब्ध िैं। सदस् सेवयाओं को आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल करें (टदी.टदी.वयाई.: 711). Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે. 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). Persian/نایسراپ: 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 Lao/ພາສາລາວ: ຂໍ້ ຄວນໃສ່ ໃຈ: ຖ້ າເຈົ້ າເວົ້ າພາສາລາວໄດ້ , ມີ ການບໍ ລິ ການຊ່ ວຍເຫຼື ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ ບໍ່ ເສຍຄ່ າ. ໂທ ຫາ ຝ່ າຍບໍ ລິ ການສະ ມາ ຊິ ກທ ີ່ ໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (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).