RSI Summary of Benefits HMO Blue NE HDP

June 1, 2023- May 31, 2024 Your employer, Buckingham Browne & Nichols School, has arranged for Reimbursement Specialists, Inc. (RSI) to adminis- ter the deductible and select copay portions of your Blue Cross Blue Shield (BCBS) Access Blue NE 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. PFA HMO BLUE NE HDP BCBS Health Plan Deductible: Individual: $4,500 Family: $9,000 Member Deductible Responsibility: Member pays the first Individual: $750 Family: $1,500 Plan Deductible Responsibility: Plan pays the remaining Individual: $3,750 Family: $7,500 Office Visit: Deductible then; $50 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay Specialist: Deductible then; $75 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay Emergency Room (waived if admitted): Deductible then $750 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay Inpatient Hospitalization: Deductible then; $1,000 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay Day Surgery: Deductible then; $1,000 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay High Tech Imaging (MRI, CT Scans, PET): Deductible then; $1,000 copay Member Responsibility: Member deductible only; Plan pays remaining deductible & copay Diagnostic Tests, Labs: Deductible applies Member Responsibility: Member deductible only; Plan pays remaining deductible X-Rays: Deductible applies Member Responsibility: Member deductible only; Plan pays remaining deductible Prescription Drugs Retail - 30 Day Supply: Tier 1: Deductible then; $15 copay Tier 2: Deductible then; 50% coinsurance Tier 3: Deductible then; 50% coinsurance Prescription Drugs Mail Order - 90 Day Supply: Tier 1: Deductible then; $30 copay Tier 2: Deductible then; 50% coinsurance Tier 3: Deductible then; 50% coinsurance BB&N Covers Rx at 100%! Please use RSI Debit Card to pay for Rx Expenses! The benefits shown here are a snapshot of the benefits provided by Buckingham Browne & Nichols School. For a detailed explanation of your benefits see the BCBS benefit summaries.

HOW THE DEDUCTIBLE & COPAY PORTIONS OF THE BCBS ACCESS BLUE NE BASIC SAVER PLAN WORK:  You and/or your family visit a provider (doctor, hospital, ER, etc.) • Show your BCBS ID Card • Use your RSI Rx 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 to your provider directly for the Buckingham Browne & Nichols School Plan’s share of the deductible and select copays. • Notifies you via RSI’s Explanation of Benefits (EOB) of what the Buckingham Browne & Nichols School Plan has paid. • You are responsible to pay your portion of the deductible to your provider as outlined in your RSI EOB. 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: [email protected] Reimbursement Specialists, Inc. | 120 Longwater Drive Suite 102 | Norwell, MA 02061 ©2019 Reimbursement Specialists, Inc.