Preferred Blue® PPO Basic Saver - PPO Summary of Benefits

SUMMARY OF BENEFITS ® Buckingham Browne & Preferred Blue PPO Nichols School basic Saver Plan-Year Deductible: $4,000/$8,000 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. 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. An Association of Independent Blue Cross and Blue Shield Plans

Your Choice Your Deductible Telehealth Services Your deductible is the amount of money you pay out-of-pocket each Telehealth services are covered when the same in-person service would be plan year before you can receive coverage for certain bene昀椀ts under this plan. covered by the health plan and the use of telehealth is appropriate. Your health If you are not sure when your plan year begins, contact Blue Cross Blue Shield of care provider will work with you to determine if a telehealth visit is medically Massachusetts. Your deductible is $4,000 per member (or $8,000 per family) appropriate for your health care needs or if an in-person visit is required. For a list for in-network and out-of-network services combined. No one member will of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website have to pay more than the per member deductible. at bluecrossma.org, consult Find a Doctor, or call the Member Service number on your ID card. When You Choose Preferred Providers You receive the highest level of bene昀椀ts under your health care plan when Your Virtual Care Team you obtain covered services from preferred providers. These are called your Your health plan includes an option for a tech-enabled primary care delivery “in-network” bene昀椀ts. See the charts for your cost share. model where virtual care team covered providers furnish certain covered Note: If a preferred provider refers you to another provider for covered services (such as a lab services. See your subscriber certi昀椀cate (and riders, if any) for exact coverage details. or specialist), make sure the provider is a preferred provider in order to receive bene昀椀ts at the in-network level. If the provider you use is not a preferred provider, you’re still covered, but your bene昀椀ts, in most situations, will be covered at the out-of-network level, even if the preferred Utilization Review Requirements provider refers you. Certain services require pre-approval/prior authorization through Blue Cross How to Find a Preferred Provider Blue Shield of Massachusetts for you to have bene昀椀t coverage; this includes non-emergency and non-maternity hospitalization and may include certain To 昀椀nd a preferred provider: • Look up a provider on Find a Doctor at bluecrossma.com/昀椀ndadoctor. If you outpatient services, therapies, procedures, and drugs. You should work with your need a copy of your directory or help choosing a provider, call the Member health care provider to determine if pre-approval is required for any service Service number on your ID card. your provider is suggesting. If your provider, or you, don’t get pre-approval when it’s required, your bene昀椀ts will be denied, and you may be fully responsible for • Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org payment to the provider of the service. Refer to your subscriber certi昀椀cate for requirements and the process you should follow for Utilization Review, including When You Choose Non-Preferred Providers Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge You can also obtain covered services from non-preferred providers, but your Planning, and Individual Case Management. out-of-pocket costs are higher. These are called your “out-of-network” bene昀椀ts. See the charts for your cost share. Dependent Bene昀椀ts This plan covers dependents until the end of the calendar month in which they turn age 26, regardless of their 昀椀nancial dependency, student status, or Payments for out-of-network bene昀椀ts are based on the Blue Cross Blue Shield employment status. See your subscriber certi昀椀cate (and riders, if any) for exact allowed charge as de昀椀ned in your subscriber certi昀椀cate. You may be responsible for any difference between the allowed charge and the provider’s actual billed coverage details. charge (this is in addition to your deductible and/or your coinsurance). Domestic Partner Coverage Your Out-of-Pocket Maximum Domestic partner coverage may be available for eligible dependents. Contact Your out-of-pocket maximum is the most that you could pay during a plan your plan sponsor for more information. year for deductible, copayments, and coinsurance for covered services. Your out-of-pocket maximum for medical and prescription drug bene昀椀ts is $6,450 per member (or $12,900 per family) for in-network and out-of-network services combined. 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 in-network or out-of-network 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.

Covered Services Your Cost In-Network Your Cost Out-of-Network Preventive Care Well-child care exams, including routine tests, according to age-based schedule as follows: Nothing, no deductible 20% coinsurance, no deductible • Ten visits during the 昀椀rst year of life • Three visits during the second year of life (age 1 to age 2) • Two visits for age 2 • One visit per calendar year for age 3 and older Routine adult physical exams, including related tests (one per calendar year) Nothing, no deductible 20% coinsurance, no deductible Routine GYN exams, including related lab tests (one per calendar year) Nothing, no deductible 20% coinsurance, no deductible Mental health wellness exams (at least one per calendar year) Nothing, no deductible Nothing, no deductible Routine hearing exams, including routine tests Nothing, no deductible 20% coinsurance, no deductible Hearing aids (up to $2,000 per ear every 36 months for a member age 21 or younger) All charges beyond the 20% coinsurance after deductible maximum after deductible and all charges beyond the maximum Routine vision exams (one every 24 months) Nothing, no deductible 20% coinsurance, no deductible Family planning services—of昀椀ce visits Nothing, no deductible 20% coinsurance, no deductible Outpatient Care Emergency room visits $750 per visit after deductible $750 per visit after deductible (copayment waived if admitted (copayment waived if admitted or for or for observation stay) observation stay) Of昀椀ce or health center visits $60 per visit after deductible 20% coinsurance after deductible Mental health or substance use treatment $60 per visit after deductible 20% coinsurance after deductible Outpatient telehealth services • With a covered provider Same as in-person visit Same as in-person visit • With the in-network designated telehealth vendor $60 per visit after deductible Only applicable in-network Chiropractors’ of昀椀ce visits $60 per visit after deductible 20% coinsurance after deductible Acupuncture visits (up to 12 visits per calendar year) $60 per visit after deductible 20% coinsurance after deductible Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year*) $60 per visit after deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment—speech therapy $60 per visit after deductible 20% coinsurance after deductible Diagnostic X-rays and lab tests Nothing after deductible 20% coinsurance after deductible CT scans, MRIs, PET scans, and nuclear cardiac imaging tests $1,000 per category per service date 20% coinsurance after deductible after deductible Home health care and hospice services Nothing after deductible 20% coinsurance after deductible Oxygen and equipment for its administration Nothing after deductible 20% coinsurance after deductible Durable medical equipment—such as wheelchairs, crutches, hospital beds 20% coinsurance after 40% coinsurance after deductible** deductible** Prosthetic devices 20% coinsurance after deductible 40% coinsurance after deductible Surgery and related anesthesia • Of昀椀ce or health center services $60 per visit*** after deductible 20% coinsurance after deductible • Ambulatory surgical facility, hospital outpatient department, or surgical day care unit $1,000 per admission after deductible 20% coinsurance 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 20% coinsurance after deductible Mental hospital or substance use facility care (as many days as medically necessary) $1,000 per admission after deductible 20% coinsurance after deductible Rehabilitation hospital care (up to 60 days per calendar year) $1,000 per admission after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) $1,000 per admission after deductible 20% coinsurance 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. ** In-network cost share waived for one breast pump per birth, including supplies (20% coinsurance after deductible out-of-network). *** 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 In-Network Your Cost Out-of-Network Prescription Drug Bene昀椀ts* At designated retail pharmacies $15 after deductible for Tier 1 $30 after deductible for Tier 1 (up to a 30-day formulary supply for each prescription or re昀椀ll)** 50% coinsurance after 50% coinsurance after deductible for Tier 2 deductible for Tier 2 50% coinsurance after 50% coinsurance after deductible for Tier 3 deductible for Tier 3 Through the designated mail service pharmacy $30 after deductible for Tier 1 Not covered (up to a 90-day formulary supply for each prescription or re昀椀ll)** 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 or reduced for certain covered drugs and supplies. Retail drugs are available in a 90-day supply at three times the standard retail cost share. 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 quali昀椀ed 昀椀tness $150 per calendar year per policy programs or equipment (See your subscriber certi昀椀cate for details.) Weight Loss Reimbursement: a program that rewards participation in a quali昀椀ed $150 per calendar year per policy weight loss program (See your subscriber certi昀椀cate for details.) 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. 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 bene昀椀ts of your health care plan. Your subscriber certi昀椀cate and riders de昀椀ne the full terms and conditions in greater detail. Should any questions arise concerning bene昀椀ts, the subscriber certi昀椀cate 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 certi昀椀cate and riders. ® 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. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 002856696 (5/24) GSP

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)