Preferred Blue® PPO Basic Saver - PPO Summary of Benefits and Coverage (9/12)

MCC COMPLIANCE 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. 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. 001652563 55-0647 (6/23)

Preferred Blue® PPO Basic Saver - PPO Summary of Benefits and Coverage - Page 9

Preferred Blue® PPO Basic Saver - PPO Summary of Benefits and Coverage Page 8 Page 10