Dental Summary of Benefits

SUMMARY OF BENEFITS ® Buckingham Browne & Dental Blue Nichols School Freedom (WITH ORTHODONTICS) 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. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association

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 Restorative Prosthodontics (teeth replacement) • One complete initial oral exam, including initial • Amalgam(silver)fillings(limitedtoonefillingfor • Complete or partial dentures (including services to dental history and charting of the teeth and each tooth surface in a 12-month period) fabricate,measure,fit,andadjustthem)onceeach supporting structures • Compositeresin(toothcolor)fillings(limitedtoone 60 months for each arch • FullmouthX-rays,sevenormorefilms,or fillingforeachtoothsurfaceina12-monthperiod) • Fixed bridges (including services to fabricate, panoramic X-ray with bitewing X-rays once each • Pinretentionforfillings measure,fit,andadjustthem)onceeach60 60 months • Stainlesssteelcrownsonbabyteethandonfirst months for each tooth • Bitewing X-rays twice per calendar year permanent adult molars (members under age 16) • Replacement of dentures and bridges once each • Single tooth X-rays as needed Oral Surgery 60 months when the existing appliance can’t be • Study models and casts used in planning treatment • Tooth extraction made serviceable once each 60 months • Root removal • Adding teeth to an existing bridge • Periodic or routine oral exams twice per calendar • Biopsies • Temporary partial dentures to replace any of the six year upper or six lower front teeth (only covered if they • Emergency exams Periodontics (gum and bone) are installed immediately following the loss of teeth Preventive • Periodontal scaling and root planing once per and during the period of healing) • Routine cleaning, scaling, and polishing of the teeth quadrant each 24 months Major Restorative (members age 16 or older) twice per calendar year • Periodontal surgery once per quadrant each 36 • Crowns, once each 60 months for each tooth • Fluoride treatment twice per calendar year months • Metallic, porcelain, and composite resin inlays. (members under age 19) • Periodontal maintenance following active Benefitsareprovidedforanamalgamfillingtoward • Sealants on permanent pre-molar and molar periodontal therapy once each three months the cost of a metallic, porcelain, or composite resin surfaces (members under age 14).Benefitsare Endodontics (roots and pulp) inlay, once each 60 months for each tooth. You pay provided for one application per bicuspid or molar • Root canal therapy (permanent teeth, once in a any balance. surface each 48 months. lifetime per tooth) • Metallic, porcelain, and composite resin onlays, once • Space maintainers needed due to premature tooth • Retreatment root canal therapy on permanent teeth, each 60 months for each tooth loss (members under age 19) once in a lifetime for each tooth • Replacement of crowns, once each 60 months for • Therapeutic pulpotomy on primary or permanent each tooth teeth (members under age 16) • Replacement of metallic, porcelain, and composite • Other endodontic surgery to treat or remove the resininlays.Benefitsareprovidedforanamalgam dental root fillingtowardthecostofametallic,porcelain,or Prosthetic Maintenance composite resin inlay, once each 60 months for • Repair of partial or complete dentures, crowns, and each tooth. You pay any balance. bridges once each 12 months • Replacement of metallic, porcelain, and composite • Adding teeth to an existing complete or resin onlays, once each 60 months for each tooth partial denture • Post and core or crown buildup, once each 60 • Rebase or reline of dentures once each months for each tooth 36 months Implants (members age 16 or older) • Recementingofcrowns,inlays,onlays,andfixed • Singletoothdentalendostealimplants(thefixture bridgework once each 12 months and abutment portion) in addition to the allowance Other Services for the crown for the implant, once each 60 month • Occlusal adjustments once each 24 months period, when the implant replaces permanent teeth • Services to treat root sensitivity through the second molars • General anesthesia when administered in Orthodontic Benefit Group conjunction with covered surgical services • Emergency dental care to treat acute pain or to Full coverage* prevent permanent harm to a member** 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.

Welcome to Dental Blue freedom, A DENTAL PLAN DESIGNED TO MANAGE THE COST OF DENTAL SERVICES. Your Dentist How Network Dentists Are Paid - Preferred Dentists Dental Blue Freedom offers a large network of dentists, including dentists in You will receive the greatest value if you visit a preferred dentist, because you will Massachusetts and Rhode Island who participate with Blue Cross Blue Shield maximizetheamountofbenefitsreceivedunderyourplan. of Massachusetts. Dental Blue Freedom members also have access to participating dentists nationwide. When searching for a network dentist, Dental Payments are calculated based on the provisions of the Blue Cross Blue Shield Blue Freedom members can choose from the Dental Blue PPO (Preferred Dentist) preferred dentist’s payment agreement and the dentist’s allowed charge that is in or Dental Blue (Participating Dentist) networks. Using a network dentist will effect at the time the covered dental service is provided. Preferred dentists agree minimize your out-of-pocket expenses. 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 If you would like help choosing a dentist, or already have a dentist and want orlifetimebenefitmaximum. 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 How Network Dentists Are Paid - Participating Dentists number shown on your Dental Blue ID card. You can also access the online dental For dentists who participate with Blue Cross Blue Shield, but do not have a provider directory at bluecrossma.org. BlueCrossBlueShieldpreferredprovidercontract,benefitsarecalculatedbased on the provisions of the participating dentist’s payment agreement and the Your Benefits dentist’s allowed charge. These dentists agree to accept the allowed charge as You will receive the greatest value if you visit a preferred dentist, because you will payment in full. You pay your deductible and coinsurance (if applicable), and any maximizetheamountofbenefitsreceivedunderyourplan. allowedchargesbeyondyourcalendar-yearorlifetimebenefitmaximum. Thedentalbenefitsyourplancoversaresubjecttothecalendar-yeardeductible How Out-of-Network Dentists Are Paid - Non-Preferred or andcoinsurance(ifapplicable),andbenefitmaximumamountsshowninthe Non-Participating Dentists chart. The calendar year begins on January 1 and ends on December 31 of each Benefitsforcoveredservicesbyanon-preferredornon-participatingdentistare year. The chart also shows the percentage of costs your plan will pay for covered provided based on the allowed charge or the dentist’s actual charge, whichever dentalservices.Manyofthecoveredserviceshavespecifictimeoragelimits. 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 Pre-Treatment Estimates charge, whichever is less. You are also responsible for your deductible and If your dentist expects that your dental treatment will involve covered services coinsurance (if applicable), and charges beyond your calendar-year or lifetime that will cost more than $250, Blue Cross Blue Shield recommends that your benefitmaximum. 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 Orthodontic Benefits procedures that the dentist plans to perform and includes an estimate of the Yourplanincludesorthodonticcoverage.Thelifetimebenefitmaximumisnot charge for each service. Once the treatment plan is reviewed, you and your partofyourcalendar-yearbenefitmaximum;itappliesonlytoorthodontic dentistwillbenotifiedofthebenefitsavailable. services. You are responsible for your coinsurance (if applicable) and any charges beyondyourlifetimebenefitmaximum.Benefitsareavailableonyoureffective Remember, the payment estimate is based on your eligibility status and the date. If your orthodontic treatment began before you were covered under Dental amountofyourcalendar-yearorlifetimebenefitmaximumatthetimethe Blue Freedom, a monthly fee will be paid for your remaining orthodontic visits estimate is received and reviewed. (The actual payment may differ if your untileitheryourtreatmentiscompletedorthelifetimebenefitmaximumis availablecalendar-yearorlifetimebenefitmaximumoreligibilitystatus exhausted,whichevercomesfirst. 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.

When Coverage Begins If You Have to File a Claim You are covered, without a waiting period, from the date you enroll in the plan. 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 Dependent Benefits your dentist as long as the claims are received within one year of the This plan covers dependents until the end of the calendar month in which completed service. theyturnage26,regardlessoftheirfinancialdependency,studentstatus,or employment status. See your plan description (and riders, if any) for exact If you receive care from an out-of-network dentist, you will typically need to coverage details. submit the claim yourself. Before submitting your claim, get an Attending Dentist’s Statement form from Member Service. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your Afteryourdentistfillsouttheform,senditandyouroriginalitemizedbillsto plan sponsor for more information. 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 Accumulated Maximum Rollover Benefits of service. ThisdentalplanincludesanAccumulatedMaximumRolloverBenefit.Thisrollover benefitallowsyoutorolloveracertaindollaramountofyourunusedannualdental Ifyouhaveagrievance,seeyourplandescriptionforinstructionsonhowtofile benefitsforuseinthefuture.Therearelimitsandrestrictionsonthisbenefit.Refer a grievance. to the Accumulated Dental Maximum Rollover brochure for further information. Other Information Enhanced Dental Benefits Coordinationofbenefitsappliestoplanmemberswhoarecoveredbyanother EnhancedDentalBenefitsforcertaindentalcareservicesareavailablefor planforhealthcareexpenses.Coordinationofbenefitsensuresthatpayments members who have been diagnosed with qualifying conditions. To learn more from other insurance or health care plans do not exceed the total charges billed aboutspecificconditionsincludedinthisbenefit,reviewyourplandescription for covered services. (and riders, if any) on MyBlue at bluecrossma.org. 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. April 2023

® 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, doesn’t pay out more claims dollars on your behalf than the your rollover amount will be added to your maximum benefit amount in the second column, your benefit maximum for the amount, increasing it for you to use that year and beyond next year will increase by the amount in the third column. (see below for amounts and maximums). And, your rollover amount keeps growing and is available There is no cost to you. You don’t need to do anything. for you to use as long as your employer offers this rollover To figure out the amount of benefit dollars that are eligible benefit.* The last column will show you the total amount of to roll over, just use the chart below. Start by searching for additional benefit dollars you can earn. It’s one more way we’re your benefit period maximum in the first column. If Blue Cross 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 And if your total claims We’ll roll over this However, rollover totals will annual maximum benefit don’t exceed this amount amount for you to use be capped at this amount:* amount is: for the benefit period:* next year and beyond:* $500–$749 $200 $150 $500 $750–$999 $300 $200 $500 $1,000–$1,249 $500 $350 $1,000 $1,250–$1,499 $600 $450 $1,250 $1,500–$1,999 $700 $500 $1,250 $2,000–$2,499 $800 $600 $1,500 $2,500–$2,999 $900 $700 $1,500 $3,000 or more $1,000 $750 $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 and Blue Shield Association. 000668960 50-0010 (12/20) ®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2020 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. If you believe that Blue Cross Blue Shield of Massachusetts has failed 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000489593 55-1487 (6/21)

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: ការជូនដំណឹ ង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្ បៅបេើ្រ័ណ្ណ សរាគា េ់្លៃនរ្រស់អ្នក (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, 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) 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 के ललए नन:शलक ें ैं ु उपलब्ध ि। सदस् सेवयाओं को आपके 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 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). 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) © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 000489691 55-1493 (6/21)