Preferred Blue PPO Saver - Summary of Benefits

SUMMARY OF BENEFITS ® Owl Labs Inc. Preferred Blue PPO Saver Plan-Year Deductible: $2,900/$5,800 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 Emergency Room Services Your deductible is the amount of money you pay out-of-pocket each In an emergency, such as a suspected heart attack, stroke, or poisoning, plan year before you can receive coverage for certain benefits under this plan. you should go directly to the nearest medical facility or call 911 (or the local If you are not sure when your plan year begins, contact Blue Cross Blue Shield emergency phone number). After meeting your deductible, you pay a copayment of Massachusetts. Your deductible is $2,900 per individual membership per visit for in-network or out-of-network emergency room services. This (or $5,800 per family membership) for in-network and out-of-network services copayment is waived if you are admitted to the hospital or for an observation combined. The entire family deductible must be satisfied before benefits are stay. See the chart for your cost share. provided for any one member enrolled under a family membership. Telehealth Services When You Choose Preferred Providers Telehealth services are covered when the same in-person service would be You receive the highest level of benefits under your health care plan when covered by the health plan and the use of telehealth is appropriate. Your health you obtain covered services from preferred providers. These are called your care provider will work with you to determine if a telehealth visit is medically “in-network” benefits. See the charts for your cost share. appropriate for your health care needs or if an in-person visit is required. For a list Note: If a preferred provider refers you to another provider for covered services (such as a lab of telehealth providers, visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org, consult Find a Doctor, or call the Member Service number or specialist), make sure the provider is a preferred provider in order to receive benefits at the in-network level. If the provider you use is not a preferred provider, you are still covered, but your on your ID card. benefits, in most situations, will be covered at the out-of-network level, even if the preferred provider refers you. Your Virtual Care Team How to Find a Preferred Provider Your health plan includes an option for a tech-enabled primary care delivery model where virtual care team covered providers furnish certain covered To find a preferred provider: • Look up a provider on Find a Doctor at bluecrossma.com/findadoctor. If you services. See your subscriber certificate (and riders, if any) for exact need a copy of your directory or help choosing a provider, call the Member coverage details. Service number on your ID card. Utilization Review Requirements • Visit the Blue Cross Blue Shield of Massachusetts website at bluecrossma.org Certain services require pre-approval/prior authorization through Blue Cross Blue Shield of Massachusetts for you to have benefit coverage; this includes When You Choose Non-Preferred Providers non-emergency and non-maternity hospitalization and may include certain You can also obtain covered services from non-preferred providers, but your outpatient services, therapies, procedures, and drugs. You should work with your health care provider to determine if pre-approval is required for any service out-of-pocket costs are higher. These are called your “out-of-network” benefits. See the charts for your cost share. your provider is suggesting. If your provider, or you, don’t get pre-approval when it’s required, your benefits will be denied, and you may be fully responsible for payment to the provider of the service. Refer to your subscriber certificate for Payments for out-of-network benefits are based on the Blue Cross Blue Shield requirements and the process you should follow for Utilization Review, including allowed charge as defined in your subscriber certificate. You may be responsible for any difference between the allowed charge and the provider’s actual billed Pre-Admission Review, Pre-Service Approval, Concurrent Review and Discharge charge (this is in addition to your deductible and/or your coinsurance). Planning, and Individual Case Management. Your Out-of-Pocket Maximum Dependent Benefits Your out-of-pocket maximum is the most that you could pay during a plan This plan covers dependents until the end of the calendar month in which year for deductible, copayments, and coinsurance for covered services. Your they turn age 26, regardless of their financial dependency, student status, or out-of-pocket maximum for medical and prescription drug benefits is $6,450 employment status. See your subscriber certificate (and riders, if any) for exact per member (or $12,900 per family) for in-network and out-of-network coverage details. services combined. Domestic Partner Coverage Domestic partner coverage may be available for eligible dependents. Contact your plan sponsor for more information.

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 first 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—office visits Nothing, no deductible 20% coinsurance, no deductible Outpatient Care Emergency room visits $150 per visit after deductible $150 per visit after deductible (copayment waived if admitted (copayment waived if admitted or for observation stay) or for observation stay) Office or health center visits Nothing after deductible 20% coinsurance after deductible Mental health or substance use treatment Nothing 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 Nothing after deductible Only applicable in-network Diabetic management services (first two visits per calendar year*) Nothing, no deductible 20% coinsurance after deductible Chiropractors’ office visits Nothing after deductible 20% coinsurance after deductible Acupuncture visits (up to 12 visits per calendar year) Nothing after deductible 20% coinsurance after deductible Short-term rehabilitation therapy—physical and occupational (up to 60 visits per calendar year**) Nothing after deductible 20% coinsurance after deductible Speech, hearing, and language disorder treatment—speech therapy Nothing after deductible 20% coinsurance after deductible Diagnostic x-rays and lab tests, including CT scans, MRIs, PET scans, Nothing after deductible 20% coinsurance after deductible and nuclear cardiac imaging tests 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 Nothing after deductible 20% coinsurance after deductible Inpatient Care (including maternity care) General or chronic disease hospital care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Mental hospital or substance use facility care (as many days as medically necessary) Nothing after deductible 20% coinsurance after deductible Rehabilitation hospital care (up to 60 days per calendar year) Nothing after deductible 20% coinsurance after deductible Skilled nursing facility care (up to 100 days per calendar year) Nothing after deductible 20% coinsurance after deductible * These diabetic services are for diabetes evaluation and management services, diabetic eye exams, or diabetic foot care. ** 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).

Covered Services Your Cost In-Network Your Cost Out-of-Network Prescription Drug Benefits* At designated retail pharmacies $10 after deductible for Tier 1 $20 after deductible for Tier 1 (up to a 30-day formulary supply for each prescription or refill)** $25 after deductible for Tier 2 $50 after deductible for Tier 2 $45 after deductible for Tier 3 $90 after deductible for Tier 3 Through the designated mail service pharmacy $20 after deductible for Tier 1 Not covered (up to a 90-day formulary supply for each prescription or refill)** $50 after deductible for Tier 2 $135 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, reduced, or increased 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 qualified fitness $150 per calendar year per policy programs or equipment (See your subscriber certificate for details.) Weight Loss Reimbursement: a program that rewards participation in a qualified $150 per calendar year per policy weight loss program (See your subscriber certificate 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 benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate 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 certificate and riders. ® 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. Printed at Blue Cross and Blue Shield of Massachusetts, Inc. 003409067 (03/25) LK

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 file a grievance disabilities to communicate effectively with the Civil Rights Coordinator by mail at Civil Rights Coordinator, Blue Cross with us, such as qualified sign language Blue Shield of Massachusetts, interpreters and written information in other 25 Technology Place, Hingham, MA 02043; 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]. qualified interpreters and information written in other languages. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. If you need these services, call Member Service You can also file a civil rights complaint at the number on your ID card. 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. 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)

Translation Resources TRANSLATION RESOURCES Proficiency 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 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) 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 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, 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 identyfikatorze (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)