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

Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 06/01/2024 ® PPO Basic Saver: Buckingham Browne & Nichols School Coverage for: Individual and Family | Plan Type: PPO Preferred Blue 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 $4,000 member / $8,000 family. begins to pay. If you have other family members on the plan, each family member must meet their deductible? ownindividual 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. In-network prenatal care; copayment or coinsurance may apply. For example, this plan covers certain preventive services without your deductible? preventive 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 8

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 $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable 20% coinsurance; Deductible applies first; limited to 12 $60 / visit; $60 / 20% coinsurance / acupuncture visits per calendar year; Specialist visit chiropractor visit; $60 chiropractor visit; a telehealth cost share may be / acupuncture visit 20% coinsurance / applicable acupuncture visit If you visit a health care Limited to age-based schedule and / provider’s office or clinic or frequency; cost share waived for at least one mental health wellness exam per calendar year; a telehealth Preventive care/screening/immunization No charge 20% coinsurance cost share may be applicable. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required If you have a test Deductible applies first; copayment Imaging (CT/PET scans, MRIs) $1,000 20% coinsurance applies per category of test / day; pre- authorization may be required Page 2 of 8

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) $15 / retail supply or $30 / retail supply Generic drugs $30 / mail service and all charges for supply mail service Deductible applies first; up to 30-day 50% coinsurance / retail (90-day mail service) supply; Preferred brand drugs 50% coinsurance retail supply and all cost share may be waived or reduced If you need drugs to treat charges for mail for certain covered drugs and your illness or condition service supplies; pre-authorization required More information about 50% coinsurance / for certain drugs prescription drug coverage Non-preferred brand drugs 50% coinsurance retail supply and all is available at charges for mail bluecrossma.org/medicatio service n Deductible applies first; when Applicable cost share obtained from a designated specialty Specialty drugs (generic, preferred, Not covered pharmacy; cost share may be waived non-preferred) or reduced for certain covered drugs and supplies; pre-authorization required for certain drugs Deductible applies first; pre- Facility fee (e.g., ambulatory surgery center) $1,000 / admission 20% coinsurance authorization required for certain If you have outpatient services surgery Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization required for certain services Deductible applies first; copayment Emergency room care $750 / visit $750 / visit waived if admitted or for observation If you need immediate stay medical attention Emergency medical transportation No charge No charge Deductible applies first Urgent care $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable Page 3 of 8

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., hospital room) $1,000 / admission 20% coinsurance authorization / authorization required If you have a hospital stay for certain services Deductible applies first; pre- Physician/surgeon fees No charge 20% coinsurance authorization / authorization required for certain services Deductible applies first; a telehealth Outpatient services $60 / visit 20% coinsurance 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 20% coinsurance authorization / authorization required for certain services Office visits No charge 20% coinsurance Deductible applies first except for in- Childbirth/delivery professional services No charge 20% coinsurance network prenatal care; cost sharing does not apply for in-network If you are pregnant preventive services; maternity care Childbirth/delivery facility services $1,000 / admission 20% coinsurance may include tests and services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Page 4 of 8

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 20% coinsurance Deductible applies first; pre- authorization required Deductible applies first; limited to 60 outpatient visits per calendar year $60 / visit for 20% coinsurance for (other than for autism, home health outpatient services; outpatient services; care, and speech therapy); limited to Rehabilitation services $1,000 / admission 20% coinsurance for 60 days per calendar year for for inpatient services 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 Habilitation services $60 / visit 20% coinsurance apply; copayment and coverage limits needs waived for early intervention services for eligible children; a telehealth cost share may be applicable Deductible applies first; limited to 100 Skilled nursing care $1,000 / admission 20% coinsurance days per calendar year; pre- authorization required Deductible applies first; in-network Durable medical equipment 20% coinsurance 40% coinsurance cost share waived for one breast pump per birth, including supplies (20% coinsurance for out-of-network) Deductible applies first; pre- Hospice services No charge 20% coinsurance authorization required for certain services Children’s eye exam No charge 20% coinsurance Limited to one exam every 24 months Children’s glasses Not covered Not covered None If your child needs dental No charge for 20% coinsurance for or eye care Children’s dental check-up members with a cleft members with a cleft Limited to members under age 18 palate / cleft lip palate / cleft lip condition condition Page 5 of 8

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 • Dental care (Adult) • Private-duty nursing • Cosmetic surgery • Long-term care 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 • Routine foot care (only for patients with systemic • Bariatric surgery • Non-emergency care when traveling outside the circulatory disease) • Chiropractic care U.S. • Weight loss programs ($150 per calendar year per • Hearing aids ($2,000 per ear every 36 months for • Routine eye care - adult (one exam every 24 policy) members age 21 or younger) months) Page 6 of 8

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 7 of 8

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 $4,000 ■The plan’s overall deductible $4,000 ■The plan’s overall deductible $4,000 ■Delivery fee copay $0 ■Specialist visit copay $60 ■Specialist visit copay $60 ■Facility fee copay $1,000 ■Primary care visit copay $60 ■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 $4,000 Deductibles $4,000 Deductibles $2,800 Copayments $1,000 Copayments $100 Copayments $0 Coinsurance $0 Coinsurance $700 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 $5,060 The total Joe would pay is $4,820 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 002855723 (4/24) GSP ® 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. Page 8 of 8

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)

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 昀椀le a grievance disabilities to communicate effectively with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross with us, such as quali昀椀ed sign language Blue Shield of Massachusetts, interpreters and written information in other One Enterprise Drive, Quincy, MA 02171-2126; formats (large print or other formats). 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]. quali昀椀ed interpreters and information written in other languages. If you need help 昀椀ling a grievance, the Civil Rights Coordinator is available to help you. If you need these services, call Member Service You can also 昀椀le a civil rights complaint at the number on your ID card. with the U.S. Department of Health and Human Services, Of昀椀ce 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. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001651238 55-1487 (3/24)

Translation Resources TRANSLATION RESOURCES Pro昀椀ciency 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 昀椀gura en su tarjeta de identi昀椀cación (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) كتيو ه ةقاطب لىع دوجولما مقرلا لىع ءاضعلأا تامدخب لصتا .كل ةبسنلاب ا ًناجم 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 identi昀椀cativa (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 identy昀椀katorze (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) © 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)