Dental Blue Freedom Summary of Benefits

SUMMARY OF BENEFITS 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: Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association COVERAGE AND BENEFITS CLAIMS AND BALANCES DIGITAL ID CARD Buckingham Browne & Nichols School Dental Blue ® Freedom (WITH ORTHODONTICS)

Dental Blue freedom with Orthodontics Preventive Benefit Group Basic Benefit Group Major Benefit Group No Deductible $50 Per Member/$150 Per Family Calendar Year Deductible** (in-network and out-of-network combined) Full Coverage* 80% Coverage* 50% Coverage* $1,500 Per Member Calendar-Year Benefit Maximum (in-network and out-of-network combined) Diagnostic • One complete initial oral exam, including initial dental history and charting of the teeth and supporting structures • FullmouthX-rays,sevenormorefilms,or panoramic X-ray with bitewing X-rays once each 60 months • Bitewing X-rays twice per calendar year • Single tooth X-rays as needed • Study models and casts used in planning treatment once each 60 months • Periodic or routine oral exams twice per calendar year • Emergency exams Preventive • Routine cleaning, scaling, and polishing of the teeth twice per calendar year • Fluoride treatment twice per calendar year (members under age 19) • Sealants on permanent pre-molar and molar surfaces (members under age 14).Benefitsare provided for one application per bicuspid or molar surface each 48 months. • Space maintainers needed due to premature tooth loss (members under age 19) Restorative • Amalgam(silver)fillings(limitedtoonefillingfor each tooth surface in a 12-month period) • Compositeresin(toothcolor)fillings(limitedtoone fillingforeachtoothsurfaceina12-monthperiod) • Pinretentionforfillings • Stainlesssteelcrownsonbabyteethandonfirst permanent adult molars (members under age 16) Oral Surgery • Tooth extraction • Root removal • Biopsies Periodontics (gum and bone) • Periodontal scaling and root planing once per quadrant each 24 months • Periodontal surgery once per quadrant each 36 months • Periodontal maintenance following active periodontal therapy once each three months Endodontics (roots and pulp) • Root canal therapy (permanent teeth, once in a lifetime per tooth) • Retreatment root canal therapy on permanent teeth, once in a lifetime for each tooth • Therapeutic pulpotomy on primary or permanent teeth (members under age 16) • Other endodontic surgery to treat or remove the dental root Prosthetic Maintenance • Repair of partial or complete dentures, crowns, and bridges once each 12 months • Adding teeth to an existing complete or partial denture • Rebase or reline of dentures once each 36 months • Recementingofcrowns,inlays,onlays,andfixed bridgework once each 12 months Other Services • Occlusal adjustments once each 24 months • Services to treat root sensitivity • General anesthesia when administered in conjunction with covered surgical services • Emergency dental care to treat acute pain or to prevent permanent harm to a member** Prosthodontics (teeth replacement) • Complete or partial dentures (including services to fabricate,measure,fit,andadjustthem)onceeach 60 months for each arch • Fixed bridges (including services to fabricate, measure,fit,andadjustthem)onceeach60 months for each tooth • Replacement of dentures and bridges once each 60 months when the existing appliance can’t be made serviceable • Adding teeth to an existing bridge • Temporary partial dentures to replace any of the six upper or six lower front teeth (only covered if they are installed immediately following the loss of teeth and during the period of healing) Major Restorative (members age 16 or older) • Crowns, once each 60 months for each tooth • Metallic, porcelain, and composite resin inlays. Benefitsareprovidedforanamalgamfillingtoward the cost of a metallic, porcelain, or composite resin inlay, once each 60 months for each tooth. You pay any balance. • Metallic, porcelain, and composite resin onlays, once each 60 months for each tooth • Replacement of crowns, once each 60 months for each tooth • Replacement of metallic, porcelain, and composite resininlays.Benefitsareprovidedforanamalgam fillingtowardthecostofametallic,porcelain,or composite resin inlay, once each 60 months for each tooth. You pay any balance. • Replacement of metallic, porcelain, and composite resin onlays, once each 60 months for each tooth • Post and core or crown buildup, once each 60 months for each tooth Implants (members age 16 or older) • Singletoothdentalendostealimplants(thefixture and abutment portion) in addition to the allowance for the crown for the implant, once each 60 month period, when the implant replaces permanent teeth through the second molars Orthodontic Benefit Group Full coverage** No deductible • Complete orthodontic exam • Comprehensive or limited active orthodontic treatment, including appliances $2,000 Lifetime Benefit Maximum * Benefitsarereducedby20percentwhenservicesarereceivedfromanout-of-networkdentist. ** Emergency care services are not subject to the calendar-year deductible. Whenyourequireemergencycarebyanout-of-networkdentist,benefitsareprovidedatthesamelevelasan in-network dentist. For members under age 13, benefits (except for orthodontic services) are covered in full up to the calendar-year benefit maximum and are not subject to the deductible.

Your Dentist Dental Blue Freedom offers a large network of dentists, including participating dentists in Massachusetts and nationwide. When searching for a network dentist, Dental Blue Freedom members can choose from the Dental Blue PPO (Preferred Dentist) or Dental Blue (Participating Dentist) networks. Using a network dentist will minimize your out-of-pocket expenses. If you would like help choosing a dentist, or already have a dentist and want to know if they participate with your plan, you can call the dentist, look at the current dental provider directory, or call Member Service at the toll-free phone number shown on your Dental Blue ID card. You can also access the online dental provider directory at bluecrossma.org. Your Benefits You will receive the greatest value if you visit a preferred dentist, because you will maximizetheamountofbenefitsreceivedunderyourplan. Thedentalbenefitsyourplancoversaresubjecttothecalendar-yeardeductible andcoinsurance(ifapplicable),andbenefitmaximumamountsshowninthe chart. For members under age 13, these benefits (not including orthodontic services) are covered in full up until the calendar-year benefit maximum. The calendar year begins on January 1 and ends on December 31 of each year. The chart also shows the percentage of costs your plan will pay for covered dental services.Manyofthecoveredserviceshavespecifictimeoragelimits. Pre-Treatment Estimates If your dentist expects that your dental treatment will involve covered services that will cost more than $250, Blue Cross Blue Shield recommends that your dentist send a copy of the “treatment plan” to Blue Cross Blue Shield before services are provided. A treatment plan is a detailed description of the procedures that the dentist plans to perform and includes an estimate of the charge for each service. Once the treatment plan is reviewed, you and your dentistwillbenotifiedofthebenefitsavailable. Remember, the payment estimate is based on your eligibility status and the amountofyourcalendar-yearorlifetimebenefitmaximumatthetimethe estimate is received and reviewed. (The actual payment may differ if your availablecalendar-yearorlifetimebenefitmaximumoreligibilitystatus has changed.) Multi-Stage Procedures Yourdentalplanprovidesbenefitsformulti-stageprocedures(proceduresthat require more than one visit, such as crowns, dentures and root canals) as long as you are enrolled in the plan on the date that the multi-stage procedure is completed. A participating dentist will send a claim for a multi-stage procedure to Blue Cross Blue Shield only after the completion date of the procedure. You will be responsible for all charges for multi-stage procedures if your plan has been cancelled before the completion date of the procedure. How Network Dentists Are Paid - Preferred Dentists You will receive the greatest value if you visit a preferred dentist, because you will maximizetheamountofbenefitsreceivedunderyourplan. Payments are calculated based on the provisions of the Blue Cross Blue Shield preferred dentist’s payment agreement and the dentist’s allowed charge that is in effect at the time the covered dental service is provided. Preferred dentists agree to accept the allowed charge as payment in full. You pay your deductible and coinsurance (if applicable), and any allowed charges beyond your calendar-year orlifetimebenefitmaximum. How Network Dentists Are Paid - Participating Dentists For dentists who participate with Blue Cross Blue Shield, but do not have a BlueCrossBlueShieldpreferredprovidercontract,benefitsarecalculatedbased on the provisions of the participating dentist’s payment agreement and the dentist’s allowed charge. These dentists agree to accept the allowed charge as payment in full. You pay your deductible and coinsurance (if applicable), and any allowedchargesbeyondyourcalendar-yearorlifetimebenefitmaximum. How Out-of-Network Dentists Are Paid - Non-Preferred or Non-Participating Dentists Benefitsforcoveredservicesbyanon-preferredornon-participatingdentistare provided based on the allowed charge or the dentist’s actual charge, whichever is less. The allowed charge is based on a schedule of charges. You may be responsible for any difference between the dentist’s actual charge or the allowed charge, whichever is less. You are also responsible for your deductible and coinsurance (if applicable), and charges beyond your calendar-year or lifetime benefitmaximum. Orthodontic Benefits Yourplanincludesorthodonticcoverage.Thelifetimebenefitmaximumisnot partofyourcalendar-yearbenefitmaximum;itappliesonlytoorthodontic services. You are responsible for your coinsurance (if applicable) and any charges beyondyourlifetimebenefitmaximum.Benefitsareavailableonyoureffective date. If your orthodontic treatment began before you were covered under Dental Blue Freedom, a monthly fee will be paid for your remaining orthodontic visits untileitheryourtreatmentiscompletedorthelifetimebenefitmaximumis exhausted,whichevercomesfirst. Welcome to Dental Blue freedom, A DENTAL PLAN DESIGNED TO MANAGE THE COST OF DENTAL SERVICES.

When Coverage Begins You are covered, without a waiting period, from the date you enroll in the plan. Dependent Benefits This plan covers dependents until the end of the calendar month in which theyturnage26,regardlessoftheirfinancialdependency,studentstatus,or employment status. See your plan description (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. Accumulated Maximum Rollover Benefits ThisdentalplanincludesanAccumulatedMaximumRolloverBenefit.Thisrollover benefitallowsyoutorolloveracertaindollaramountofyourunusedannualdental benefitsforuseinthefuture.Therearelimitsandrestrictionsonthisbenefit.Refer to the Accumulated Dental Maximum Rollover brochure for further information. Enhanced Dental Benefits EnhancedDentalBenefitsforcertaindentalcareservicesareavailablefor members who have been diagnosed with qualifying conditions. To learn more aboutspecificconditionsincludedinthisbenefit,reviewyourplandescription (and riders, if any) on MyBlue at bluecrossma.org. If You Have to File a Claim Network dentists will send claims directly to Blue Cross Blue Shield. All you have to do is show them your Dental Blue ID card. The payment will be sent directly to your dentist as long as the claims are received within one year of the completed service. If you receive care from an out-of-network dentist, you will typically need to submit the claim yourself. Before submitting your claim, get an Attending Dentist’s Statement form from Member Service. Afteryourdentistfillsouttheform,senditandyouroriginalitemizedbillsto Blue Cross Blue Shield of Massachusetts, P. O. Box 986030, Boston, MA 02298. All member-submitted claims must be submitted within two years of the date of service. Ifyouhaveagrievance,seeyourplandescriptionforinstructionsonhowtofile a grievance. Other Information Coordinationofbenefitsappliestoplanmemberswhoarecoveredbyanother planforhealthcareexpenses.Coordinationofbenefitsensuresthatpayments from other insurance or health care plans do not exceed the total charges billed for covered services. Your plan description has a subrogation clause, which means that Blue Cross Blue Shield can recover payments if a member has already been paid for the same claim by a third party. Questions? For questions about Blue Cross Blue Shield of Massachusetts, call 1-800-782-3675, or visit us online at bluecrossma.org. LimitationsandExclusions.Thesepagessummarizethebenefitsofyourdentalplan.Yourplandescriptionandridersdefinethefulltermsandconditionsingreaterdetail.Shouldanyquestionsarise concerningbenefits,theplandescriptionandriderswillgovern.Foracompletelistoflimitationsandexclusions,refertoyourplandescriptionandriders. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. April 2025

Dental Blue ® Accumulated Maximum Rollover At Blue Cross Blue Shield of Massachusetts, we know that oral health is a critical part of overall health. That’s why we offer a dental benefit that will allow you to roll over a portion of your unused dental benefits from year to year. How Maximum Rollover Works Beginning 60 days after the last day of your benefit period, your rollover amount will be added to your maximum benefit amount, increasing it for you to use that year and beyond (see below for amounts and maximums). There is no cost to you. You don’t need to do anything. To figure out the amount of benefit dollars that are eligible to roll over, just use the chart below. Start by searching for your benefit period maximum in the first column. If Blue Cross doesn’t pay out more claims dollars on your behalf than the amount in the second column, your benefit maximum for the next year will increase by the amount in the third column. And, your rollover amount keeps growing and is available for you to use as long as your employer offers this rollover benefit.* The last column will show you the total amount of additional benefit dollars you can earn. It’s one more way we’re working to improve health care for all our members. You can accumulate benefit dollars to help offset higher out-of-pocket costs for complex procedures. This benefit applies to you automatically if: • You receive at least one service during the benefit period • You don’t exceed the claim payment threshold in the • You remain a member of the plan throughout the benefit period benefit period If your dental plan’s annual maximum benefit amount is: $500–$749 $750–$999 $1,000–$1,249 $1,250–$1,499 $1,500–$1,999 $2,000–$2,499 $2,500–$2,999 $3,000 or more And if your total claims don’t exceed this amount for the benefit period:* $200 $300 $500 $600 $700 $800 $900 $1,000 We’ll roll over this amount for you to use next year and beyond:* $150 $200 $350 $450 $500 $600 $700 $750 However, rollover totals will be capped at this amount:* $500 $500 $1,000 $1,250 $1,250 $1,500 $1,500 $1,500 *This is not a flexible spending account (FSA). The amount reflects your benefit maximum for a given year. 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. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). 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). 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). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross 002010701 50-0010 (3/23) and Blue Shield Association.®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

NONDISCRIMINATION NOTICE 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. 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, One Enterprise Drive, Quincy, MA 02171-2126; 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. 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 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៖ ប្រសនប្រអ្នកនយាយភាសា ខ្មែរ បសវាជនយភាសាឥតគតថ្លៃ គអាចរកបានសបរា្រអ្នក។ សមទរសព្ទបៅខ្កបសវាសរាជកតាមបេ្ បៅបេ្រ័ណ្ណ សរាេ្លៃនរ្រសអ្នក (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/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). ُ ً ូ ំ ឹ ិ ើ ិ ំ ួ ិ ឺ ់ ូ ូ ័ ្ន ិ ើ គា ់ ួ ់ 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 सेवयाए, आप क ललए नन:शलक उपलब्ध ि। सदस् सेवयाओं को आपक आई.डी. कयाड 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). 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: ຂຄວນໃສໃຈ: ຖາເຈາເວາພາສາລາວໄດ, ມການບລການຊວຍເຫອດານພາສາໃຫທານໂດຍ ບເສຍຄາ. 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). ें े ैं ँ े ु ैं े ्ड ें ે ે ໍ້ ່ ້ ົ້ ົ້ ້ ີ ໍ ິ ່ ຼື ້ ້ ່ ໍ່ ່ ່ ໍ ິ ິ ີ່ ັ ູ່ ັ ່ 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. 001651831 55-1493 (6/22)