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

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: on or after 06/01/2025 Preferred Blue® PPO Basic Saver: Buckingham Browne & Nichols School Coverage for: Individual and Family | Plan Type: PPO 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: What is the overall deductible? $4,000 member / $8,000 family. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Yes. In-network prenatal care; preventive care. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without 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 services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $6,450 member / $12,900 family. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other 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 the out-of-pocket limit? Premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See bluecrossma.com/findadoctor or call the Member Service number on your ID card for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

Page 2 of 8 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable Specialist visit $60 / visit; $60 / chiropractor visit; $60 / acupuncture visit 20% coinsurance; 20% coinsurance / chiropractor visit; 20% coinsurance / acupuncture visit Deductible applies first; limited to 12 acupuncture visits per calendar year; a telehealth cost share may be applicable Preventive care/screening/immunization No charge 20% coinsurance Limited to age-based schedule and / or frequency; cost share waived for at least one mental health wellness exam per calendar year; a telehealth 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. If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required Imaging (CT/PET scans, MRIs) $1,000 20% coinsurance Deductible applies first; copayment applies per category of test / day; pre- authorization may be required

Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bluecrossma.org/medicatio n Generic drugs $15 / retail supply or $30 / mail service supply $30 / retail supply and all charges for mail service Deductible applies first; up to 30-day retail (90-day mail service) supply; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs Preferred brand drugs 50% coinsurance 50% coinsurance / retail supply and all charges for mail service Non-preferred brand drugs 50% coinsurance 50% coinsurance / retail supply and all charges for mail service Specialty drugs Applicable cost share (generic, preferred, non-preferred) Not covered Deductible applies first; when obtained from a designated specialty pharmacy; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre- authorization required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) $1,000 / admission 20% coinsurance Deductible applies first; pre- authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If you need immediate medical attention Emergency room care $750 / visit $750 / visit Deductible applies first; copayment waived if admitted or for observation stay 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 4 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) $1,000 / admission 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you need mental health, behavioral health, or substance abuse services Outpatient services $60 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable; pre- authorization required for certain services Inpatient services $1,000 / admission 20% coinsurance Deductible applies first; pre- authorization / authorization required for certain services If you are pregnant Office visits No charge 20% coinsurance Deductible applies first except for in- network prenatal care; cost sharing does not apply for in-network preventive services; maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound); a telehealth cost share may be applicable Childbirth/delivery professional services No charge 20% coinsurance Childbirth/delivery facility services $1,000 / admission 20% coinsurance

Page 5 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you need help recovering or have other special health needs Home health care No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Rehabilitation services $60 / visit for outpatient services; $1,000 / admission for inpatient services 20% coinsurance for outpatient services; 20% coinsurance for inpatient services Deductible applies first; limited to 60 outpatient visits per calendar year (other than for autism, home health care, and speech therapy); limited to 60 days per calendar year for inpatient admissions; a telehealth cost share may be applicable; pre- authorization required for certain services Habilitation services $60 / visit 20% coinsurance Deductible applies first; outpatient rehabilitation therapy coverage limits apply; copayment and coverage limits waived for early intervention services for eligible children; a telehealth cost share may be applicable Skilled nursing care $1,000 / admission 20% coinsurance Deductible applies first; limited to 100 days per calendar year; pre- authorization required Durable medical equipment 20% coinsurance 40% coinsurance Deductible applies first; in-network cost share waived for one breast pump per birth, including supplies (20% coinsurance for out-of-network) Hospice services No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If your child needs dental or eye care Children’s eye exam No charge 20% coinsurance Limited to one exam every 24 months Children’s glasses Not covered Not covered None Children’s dental check-up No charge for members with a cleft palate / cleft lip condition 20% coinsurance for members with a cleft palate / cleft lip condition Limited to members under age 18

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

Page 7 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.

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 (9 months of in-network prenatal care and a hospital delivery) ■The plan’s overall deductible $4,000 ■Delivery fee copay $0 ■Facility fee copay $1,000 ■Diagnostic tests copay $0 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: Cost sharing Deductibles $4,000 Copayments $1,000 Coinsurance $0 What isn’t covered Limits or exclusions $60 The total Peg would pay is $5,060 Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) ■The plan’s overall deductible $4,000 ■Specialist visit copay $60 ■Primary care visit copay $60 ■Diagnostic tests copay $0 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Joe would pay: Cost sharing Deductibles $4,000 Copayments $100 Coinsurance $700 What isn’t covered Limits or exclusions $20 The total Joe would pay is $4,820 Mia’s Simple Fracture (in-network emergency room visit and follow-up care) ■The plan’s overall deductible $4,000 ■Specialist visit copay $60 ■Emergency room copay $750 ■Ambulance services copay $0 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Mia would pay: Cost sharing Deductibles $2,800 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $0 The total Mia would pay is $2,800 The plan would be responsible for the other costs of these EXAMPLE covered services. 003558709 (4/25) RB ® Registered Marks of the Blue Cross and Blue Shield Association. © 2025 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Page 8 of 8

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) 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. MCC COMPLIANCE

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. 2915351 55-1487 (5/24) 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. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, call Member Service at the number on your ID card. NONDISCRIMINATION NOTICE If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, 25 Technology Place, Hingham, MA 02043; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email at [email protected]. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office 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.

TRANSLATION RESOURCES Proficiency of Language Assistance Services Translation Resources 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 figura en su tarjeta de identificación (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) كتيوُه ةقاطب لىع دوجولما مقرلا لىع ءاضعلأا تامدخب لصتا .كل ةبسنلاب اًناجم 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 េ់្លៃួនរ្រស់អ្នក (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 identificativa (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, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (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. 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) (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. © 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) Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711). Hindi/हिंदी: ध्यान दें: ्दद आप दिनददी बोलते िैं, तो भयाषया सिया्तया सेवयाएँ, आप के ललए नन:शुलक उपलब्ध िैं। सदस् सेवयाओं को आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल करें (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). Persian/نایسراپ: 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 Lao/ພາສາລາວ: ຂໍ້ ຄວນໃສ່ ໃຈ: ຖ້ າເຈົ້ າເວົ້ າພາສາລາວໄດ້ , ມີ ການບໍ ລິ ການຊ່ ວຍເຫຼື ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ ບໍ່ ເສຍຄ່ າ. ໂທ ຫາ ຝ່ າຍບໍ ລິ ການສະ ມາ ຊິ ກທ ີ່ ໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (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).