RSI PPO Plan Summary of Benefits

BCBS Health Plan Deductible: Individual: $4,000 Family: $8,000 Member Deductible Responsibility: Member pays the first Individual: $1,000 Family: $2,000 Plan Deductible Responsibility: Plan pays the remaining Individual: $3,000 Family: $6,000 Office Visit: Deductible then; $60 copay per visit Members Responsibility Member Deductible only; plan pays copay Specialist/ Urgent Care: Deductible then; $60 copay per visit Members Responsibility Member Deductible only; plan pays copay Emergency Room (waived if admitted): Deductible then; $750 copay Member Responsibility: Member Deductible only; plan pays copay Inpatient Hospitalization: Deductible then; $1,000 copay Member Responsibility: Member Deductible then; plan pays copay Day Surgery: Deductible then; $1,000 copay Member Responsibility: Member Deductible only; plan pays copay High Tech Imaging (MRI, CT Scans, PET): Deductible then; $1,000 copay Member Responsibility: Member Deductible only; plan pays copay Diagnostic X-Rays/ Labs: Deductible applies Member Responsibility: Member Deductible only PRESCRIPTION DRUGS Use Debit Card Retail - 30 Day Supply— Deductible then; Tier 1: $15 copay Tier 2: 50% Tier 3: 50% Mail Order - 90 Day Supply—Deductible then; Tier 1: $30 copay Tier 2: 50% Tier 3: 50% * BB& N Covers Rx at 100%! Please use RSI Debit Card to pay for Rx Expenses Your employer, Buckingham Brown & Nichols School, has arranged for Reimbursement Specialists, Inc. (RSI) to administer the deductible and select copay portions of your Blue Cross Blue Shield (BCBS) Preferred Blue PPO Basic Saver plan. RSI automatically receives claims information from BCBS on claims that have processed toward all eligible expenses. This information is then processed in our system and claims are paid as outlined below. Eligible expenses will be paid based on in-network benefits and maximums. Any expense that exceed the in-network maximums due to visiting out of network providers will be the responsibility of the member. The benefits shown here are a snapshot of the benefits provided by Buckingham Brown & Nichols School For a detailed explanation of your benefits see the BCBS benefit summaries. June 1, 2025 — May 31, 2026 PFA PPO

Our RSI Client Advocate Claims Team is here to help you. If you or your doctor have a question regarding the plan, a specific claim or a bill please contact us Phone: 855-493-9859 E-mail: claims@rsiadmin.com Reimbursement Specialists, Inc. | 120 Longwater Drive Suite 102 | Norwell, MA 02061 ©2022 Reimbursement Specialists, Inc. HOW THE DEDUCTIBLE AND COPAY PORTIONS OF THE BCBS PREFERRED BLUE PPO BASIC SAVER PLAN WORK  You and/or your family visit a provider (doctor, hospital, ER, etc.)  Show your BCBS ID Card to the provider.  Use your RSI Debit Card at the pharmacy  Provider:  Bills BCBS  BCBS:  Adjudicates claim  Notifies/pays provider  Sends a Summary of Health Plan Payments to you and your provider. The Summary is not a bill and should be saved for your records!  Sends a weekly report to RSI on your claim.  RSI:  Issues payment directly to you for the Buckingham Brown & Nichols School Plan’s share of the deductible and copays applied after the deductible.  You are responsible to pay the deductible and copays to your provider.