Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: on or after 01/01/2025

HMO Blue Premium Coverage for: Individual and Family | Plan Type: HMO

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/connector. 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 1-800-262-BLUE (2583) to request a copy.

Important Questions Answers Why This Matters:

What is the overall
$0 See the Common Medical Events chart below for your costs for services this plan covers.
deductible?
Are there services
covered before you meet No. You will have to meet the deductible before the plan pays for any services.
your deductible?
Yes. For pediatric essential dental,
Are there other $50 member (no more than $150
You must pay all of the costs for these services up to the specific deductible amount before this plan
deductibles for specific for three or more eligible members
begins to pay for these services.
services? per family). There are no other
specific deductibles.
For medical and prescription drug
benefits, $2,650 member / $5,300
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family
What is the out-of-pocket family; and for pediatric essential
members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-
limit for this plan? dental, $350 member (no more
pocket limit has been met.
than $700 for two or more eligible
members per family).
Premiums, balance-billing charges,
What is not included in
and health care this plan doesn't Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out-of-pocket limit?
cover.
Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will
bluecrossma.com/findadoctor or pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the
Will you pay less if you
call the Member Service number difference between the provider’s charge and what your plan pays (balance billing). Be aware, your
use a network provider?
on your ID card for a list of network network provider might use an out-of-network provider for some services (such as lab work). Check
providers. with your provider before you get services.
Do you need a referral to This plan will pay some or all of the costs to see a specialist for covered services but only if you have a
Yes.
see a specialist? referral before you see the specialist.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 7
 What You Will Pay
In-Network Out-of-Network Limitations, Exceptions, & Other
Common Medical Event Services You May Need
(You will pay the (You will pay the Important Information
least) most)
A telehealth cost share may be
Primary care visit to treat an injury or illness $20 / visit Not covered
applicable
$40 / visit; $40 / Limited to 12 acupuncture visits per
Specialist visit chiropractor visit; $40 Not covered calendar year; a telehealth cost share
/ acupuncture visit may be applicable
If you visit a health care GYN exam limited to one exam per
provider’s office or clinic calendar year; a telehealth cost share
may be applicable. You may have to
Preventive care/screening/immunization No charge Not covered pay for services that aren't preventive.
Ask your provider if the services
needed are preventive. Then check
what your plan will pay for.
Pre-authorization required for certain
Diagnostic test (x-ray, blood work) No charge Not covered
services
If you have a test Copayment applies per category of
Imaging (CT/PET scans, MRIs) $150 Not covered test / day; pre-authorization required
for certain services
$10 / retail supply or
Generic drugs $20 / mail service Not covered
supply Up to 30-day retail (90-day mail
service) supply; cost share may be
$25 / retail supply or
waived, reduced or increased for
If you need drugs to treat Preferred brand drugs $50 / mail service Not covered
certain covered drugs and supplies;
your illness or condition supply
pre-authorization required for certain
More information about $50 / retail supply or drugs
prescription drug coverage Non-preferred brand drugs $150 / mail service Not covered
is available at supply
bluecrossma.org/medicatio When obtained from a designated
n specialty pharmacy; cost share may
Applicable cost share
be waived, reduced or increased for
Specialty drugs (generic, preferred, Not covered
certain covered drugs and supplies;
non-preferred)
pre-authorization required for certain
drugs

Page 2 of 7
 What You Will Pay
In-Network Out-of-Network Limitations, Exceptions, & Other
Common Medical Event Services You May Need
(You will pay the (You will pay the Important Information
least) most)
Pre-authorization required for certain
Facility fee (e.g., ambulatory surgery center) $250 / admission Not covered
If you have outpatient services
surgery Pre-authorization required for certain
Physician/surgeon fees No charge Not covered
services
Copayment waived if admitted or for
Emergency room care $150 / visit $150 / visit
observation stay
If you need immediate Emergency medical transportation No charge No charge None
medical attention Out-of-network coverage limited to out
Urgent care $40 / visit $40 / visit of service area; a telehealth cost
share may be applicable
Pre-authorization / authorization
Facility fee (e.g., hospital room) $500 / admission Not covered
required for certain services
If you have a hospital stay
Pre-authorization / authorization
Physician/surgeon fees No charge Not covered
required for certain services
A telehealth cost share may be
If you need mental health, Outpatient services $20 / visit Not covered applicable; pre-authorization required
behavioral health, or for certain services
substance abuse services Pre-authorization / authorization
Inpatient services $500 / admission Not covered
required for certain services
Office visits No charge Not covered Cost sharing does not apply for
Childbirth/delivery professional services No charge Not covered preventive services; maternity care
may include tests and services
If you are pregnant
described elsewhere in the SBC
Childbirth/delivery facility services $500 / admission Not covered (i.e. ultrasound); a telehealth cost
share may be applicable

Page 3 of 7
 What You Will Pay
In-Network Out-of-Network Limitations, Exceptions, & Other
Common Medical Event Services You May Need
(You will pay the (You will pay the Important Information
least) most)
Pre-authorization required for certain
Home health care No charge Not covered
services
Limited to 60 outpatient visits per
calendar year (other than for autism,
$40 / visit for home health care, and speech
outpatient services; therapy); limited to 60 days per
Rehabilitation services Not covered
$500 / admission for calendar year for inpatient
inpatient services admissions; a telehealth cost share
may be applicable; pre-authorization
required for certain services
Limited to 60 visits per calendar year
If you need help recovering
(other than for autism, home health
or have other special health
care, and speech therapy); cost share
needs
and coverage limits waived for early
Habilitation services $40 / visit Not covered
intervention services for eligible
children; a telehealth cost share may
be applicable; pre-authorization may
be required for certain services
Limited to 100 days per calendar
Skilled nursing care $500 / admission Not covered
year; pre-authorization required
Cost share waived for one breast
Durable medical equipment 20% coinsurance Not covered
pump per birth, including supplies
Pre-authorization required for certain
Hospice services No charge Not covered
services
Limited to one exam every 12 months
Children’s eye exam No charge Not covered until the end of the month a member
turns age 19
Limited to one set of prescription
If your child needs dental lenses and / or frames or contact
Children’s glasses 35% coinsurance Not covered
or eye care lenses per calendar year until the end
of the month a member turns age 19
Limited to twice per calendar year
Children’s dental check-up No charge Not covered until the end of the month a member
turns age 19

Page 4 of 7
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.)
• Cosmetic surgery • Long-term care • Private-duty nursing
• Dental care (Adult) • Non-emergency care when traveling outside the U.S.
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Abortion • Hearing aids ($2,000 per ear every 36 months for • Routine foot care (only for patients with systemic
• Acupuncture (12 visits per calendar year) members age 21 or younger) circulatory disease)
• Bariatric surgery • Infertility treatment • Weight loss programs ($150 per calendar year per
• Chiropractic care • Routine eye care - adult (one exam every 24 months) policy)

Page 5 of 7
Your Rights to Continue Coverage:
If you have Individual health insurance:
There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 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 the state marketplace, please contact the Massachusetts Health Connector at www.mahealthconnector.org. For more information on your rights to continue
coverage, you can contact the Member Service number listed on your ID card or call 1-800-262-BLUE (2583).
OR
If you have Group health 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.

Page 6 of 7
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 Managing Joe's Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network prenatal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow-up
hospital delivery) controlled condition) care)

■The plan’s overall deductible $0 ■The plan’s overall deductible $0 ■The plan’s overall deductible $0
■Delivery fee copay $0 ■Specialist visit copay $40 ■Specialist visit copay $40
■Facility fee copay $500 ■Primary care visit copay $20 ■Emergency room copay $150
■Diagnostic tests copay $0 ■Diagnostic tests copay $0 ■Ambulance services copay $0

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost sharing Cost sharing Cost sharing
Deductibles $0 Deductibles $0 Deductibles $0
Copayments $500 Copayments $1,100 Copayments $400
Coinsurance $0 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $560 The total Joe would pay is $1,120 The total Mia would pay is $400

The plan would be responsible for the other costs of these EXAMPLE covered services. 002941036 80-0242CON1-1-25 (9/24)

Page 7 of 7
® 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.
 MCC COMPLIANCE

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.

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)
Pediatric essential
Dental benefits
Your health plan coverage includes a dental policy that covers pediatric dental services as
required under the federal Patient Protection and Affordable Care Act.

This separate dental policy covers pediatric essential dental benefits for members until the
end of the calendar month in which they turn age 19 as required by federal law.

You must meet a plan-year deductible for certain covered To find participating dental providers, visit the
dental services. Your deductible is $50 per member (no more Blue Cross Blue Shield of Massachusetts website at
than $150 for three or more members enrolled under the same bluecrossma.com/findadoctor or call the Member Service
family membership). number on your ID card.
Your out-of-pocket maximum is the most that you could pay
during a plan year for deductible and coinsurance for covered
dental services. Your out-of-pocket maximum is $350 per
member (no more than $700 for two or more members
enrolled under the same family membership).

Pediatric Essential Dental Benefits* Your Cost In-Network**

Group 1: Preventive and Diagnostic Services: oral exams, X-rays, and routine dental care Nothing, no deductible
Group 2: Basic Restorative Services: fillings, root canals, stainless steel crowns, periodontal care, 25% coinsurance after deductible
oral surgery, and dental prosthetic maintenance
Group 3: Major Restorative Services: tooth replacement, resin crowns, and occlusal guards 50% coinsurance after deductible
Orthodontic Services: medically necessary orthodontic care pre-authorized for a qualified member 50% coinsurance, no deductible
* All covered services are limited to members until the end of the month they turn age 19, and may be subject to an age-based schedule or frequency. For a complete list of covered
services or additional information, refer to your subscriber certificate.
** There are no out-of-network benefits for dental services.

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.
001653000 55-000964542 (6/23)
 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,
or gender identity, you can file a grievance
• Free aids and services to people with with the Civil Rights Coordinator by mail
disabilities to communicate effectively 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);
fax at 1-617-246-3616; or email at
• Free language services to people whose [email protected].
primary language is not English, such as
qualified interpreters and information written If you need help filing a grievance, the Civil
in other languages. 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).
Este aviso tiene información importante. Este aviso tiene información importante sobre su solicitud
o su cobertura de Blue Cross Blue Shield of Massachusetts. Es posible que deba tomar medidas
antes de ciertas fechas límite para mantener su cobertura médica o recibir ayuda con los costos.
Tiene derecho a recibir esta información y ayuda en su idioma de manera gratuita. 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).
Este Aviso contém Informação Importante. Este aviso contém informação importante acerca do
seu pedido ou cobertura através da Blue Cross Blue Shield of Massachusetts. Poderá ter de agir em
função de determinadas datas-limite para manter a sua cobertura de saúde ou ajudar nos custos. Tem
o direito de obter esta informação e auxílio no seu idioma, sem qualquer custo. Telefone para o Serviço
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）。
此通知包含重要信息。此通知包含有关您通过 Blue Cross Blue Shield of Massachusetts 提交的申请
或享有的承保服务的重要信息。您可能需要在特定截止日期前采取行动，以保持您的健康保险，或
获得费用相关的帮助。您有权免费获得这些信息，及以您的语言提供的帮助。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, gratis
ap disponib pou ou. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan. 711).
Avi sa a gen Enfòmasyon Enpòtan ladann. Avi sa a gen enfòmasyon enpòtan osijè demann
aplikasyon ou oswa pwoteksyon Blue Cross Blue Shield of Massachusetts bay. Ou gendwa bezwen
aji anvan sèten dat limit pou kenbe pwoteksyon asirans ou oswa pou ede ak depans yo. Ou gen
dwa jwenn enfòmasyon sa a ak asistans nan lang ou gratis. Rele nimewo Sèvis Manm nan ki sou kat
Idantitifkasyon w lan. 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).
Thông báo này có Thông tin Quan trọng. Thông báo này có thông tin quan trọng về đơn đăng ký hoặc
phạm vi bao trả thông qua Blue Cross Blue Shield of Massachusetts. Quý vị có thể cần có hành động trước
thời hạn nhất định để duy trì phạm vi bao trả y tế hoặc được trợ giúp về phí tổn. Quý vị có quyền được
nhận thông tin này và được trợ giúp bằng ngôn ngữ của quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số
trên thẻ ID của quý vị (TTY: 711).
Blue Cross
Blue Cross Blue
Blue Shield
Shield of
of Massachusetts
Massachusettsisisan
anIndependent
IndependentLicensee
Licenseeofofthe
theBlue
BlueCross
Crossand
andBlue
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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).
В этом уведомлении содержится важная информация. В этом уведомлении содержится важная
информация о Вашем заявлении на страхование или страховке при участии компании Blue Cross
Blue Shield of Massachusetts. Чтобы сохранить медицинскую страховку или получить помощь в связи
с какими-то выплатами, Вам может потребоваться предпринять какие-то действия к определенному
сроку. У Вас есть право на бесплатные услуги переводчика для получения этой информации.
Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте
(телетайп: 711).
Arabic/‫ةيرب‬:
‫ اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات املساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النيص للصم والبكم‬
.Blue Cross Blue Shield of ‫ يحتوي هذا اإلشعار عىل معلومات مهمة حول استخدامك أو تغطيتك من خالل رشكة‬.‫يتضمن هذا اإلشعار معلومات مهمة‬
‫ يحق لك الحصول‬.‫ قد تحتاج إىل اتخاذ إجرا ًء ما بحلول مواعيد نهائية معينة لالحتفاظ بتغطيتك الصحية أو لتلقي املساعدة فيام يتعلق بالتكاليف‬Massachusetts
.(711 :”TTY“ ‫ اتصل بخدمات األعضاء عىل الرقم املوجود عىل بطاقة ُهويتك )جهاز الهاتف النيص للصم والبكم‬.‫أي تكلفة‬ ّ ‫عىل هذه املعلومات واملساعدة بلغتك دون‬
Mon-Khmer, Cambodian/ខ្មែរ: ការជូនដំណឹង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណ្ណសរាគាេ់្ួនរ្រស់
លៃ អ្នក (TTY: 711)។
កំណតស
់ ម្គាលន់ េះម្េពត
័ ម្ ់ កំណត់សរាគាេ់បនះរានព័ត៌រានសំខាន់អំពីការដាក់ពាក្យ
៌ េសំខាេ។
រ្រស់អ្នក ឬការបគ្រដណ្ត្រ់តាមរយៈ Blue Cross Blue Shield ថន Massachusetts។ អ្នកអាចបតរូ
វការចាត់វ ិធានការបតឹមកាេ្ររ ិបចឆេទ្ុតកំណត់ជាក់លាក់នានាបដើម្ីរកសាការបគ្រដណ្ត្រ់រ្រស់
អ្នក ឬបដើម្ីទទួេបានជំនួយជាមួយថ្លៃចំណាយប្សេងៗ។ អ្នករានសិទិទ ្ ទួេបានព័ត៌រានបនះ
និងជំនួយជាភាសារ្រស់អ្នកបដាយឥតគិតថ្លៃ។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្បៅបេើ្រ័
ណ្ណ សរាគាេ់្ួនរ្រស់
លៃ អ្នក (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).
Cet avis contient des informations importantes. Cet avis contient des informations importantes
concernant votre demande ou votre couverture avec Blue Cross Blue Shield of Massachusetts. Il se
peut que vous deviez réagir avant certaines dates limites pour conserver votre couverture santé ou
recevoir une assistance concernant vos frais. Vous êtes en droit d’obtenir gratuitement les présentes
informations et une assistance dans votre langue. Appelez le Service adhérents au numéro indiqué sur
votre carte d’assuré (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.
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).
Il presente avviso contiene informazioni importanti. Il presente avviso contiene informazioni
importanti riguardanti la vostra domanda o copertura Blue Cross Blue Shield of Massachusetts.
Potrebbe essere necessario agire entro precisi termini per non perdere la copertura sanitaria o ottenere
assistenza con i costi. Avete diritto a ricevere gratuitamente queste informazioni e assistenza nella
vostra lingua. 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.
본 통지서에는 중요한 정보가 담겨 있습니다. 본 통지서에는 Blue Cross Blue Shield of
Massachusetts를 통한 귀하의 가입 신청 또는 보험보장에 관한 중요한 정보가 담겨 있습니다.
귀하께서는 특정 마감 기한까지 조치를 취하셔야 계속 건강 보험 적용을 받거나 비용 지원을
받으실 수 있습니다. 귀하는 무료로 본 정보를 입수하고 귀하의 모국어로 지원을 받으실 수
있는 권리가 있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에
전화하십시오.
Greek/Eλληνικά:ΠΡΟΣΟΧΗ:
Greek/λληνικά: ΠΡΟΣΟΧΗ:Εάν
Εάνμιλάτε
μιλάτε Ελληνικά,
Ελληνικά, διατίθενται γιασας
διατίθενται για σαςυπηρεσίες
υπηρεσίεςγλωσσικής
γλωσσικήςβοήθειας,
βοήθειας,
δωρεάν. Καλέστε
Καλέστε την
τηνΥπηρεσία
ΥπηρεσίαΕξυπηρέτησης
ΕξυπηρέτησηςΜελών
Μελώνστον
στον αριθμό
αριθμό τηςτης κάρτας
κάρτας μέλους
μέλους σαςσας
(ID (ID Card)
Card)
(TTY: 711).
Η παρούσα κοινοποίηση περιέχει σημαντικές πληροφορίες. Η παρούσα κοινοποίηση περιέχει σημαντικές
πληροφορίες σχετικά με την αίτηση ή την κάλυψή σας μέσω της Blue Cross Blue Shield of Massachusetts.
Μπορεί να χρειαστεί να προβείτε σε συγκεκριμένες ενέργειες σε συγκεκριμένες προθεσμίες, ώστε να
διατηρήσετε την κάλυψη της υγείας σας ή να βοηθήσετε στο θέμα του κόστους. Έχετε το δικαίωμα να
λάβετε αυτές τις πληροφορίες και τη βοήθεια στη γλώσσα σας χωρίς κόστος. Καλέστε την Υπηρεσία
Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card) (TTY: 711).
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).
To powiadomienie zawiera ważne informacje. To powiadomienie zawiera ważne informacje na
temat złożonego wniosku lub ochrony ubezpieczeniowej zapewnianej przez Blue Cross Blue Shield of
Massachusetts. Konieczne może być podjęcie pewnych działań w określonych terminach, by utrzymać
ochronę ubezpieczeniową lub uzyskać pomoc w pokryciu kosztów. Ubezpieczonemu przysługuje prawo
do uzyskania tych informacji i pomocy w jego języku bez żadnych kosztów. 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).
इस नोदटस में मितवपूर्ड जयानकयारदी िै । इस नोदटस में Blue Cross Blue Shield of Massachusetts के
मयाध्म से आपके आवेदन ्या कवरे ज के बयारे में मितवपर ू ्ड जयानकयारदी िै । अपनया सवयास्थ् कवरे ज बनयाए
रखने ्या लयागतों में मदद पयाने के ललए आपको कुछ ननश्चित सम्-सीमयाओं के अंदर कदम उठयाने
की आवश्कतया िो सकती िै । आपके पयास ्ि जयानकयारदी एवं मदद अपनी भयाषया में ननःशुलक पयाने कया
अध्धकयार िै । सदस् सेवया को आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल करें (टदी.टदी.वयाई.: 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.
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).
આ નોટિસમાં મહત્ત્વની માહહતી છે . આ નોટિસમયાં Blue Cross Blue Shield of Massachusetts મયારફતે તમયારી અરજી કે
કવચ વવશે મહત્વની મયાવહતી છે . તમને તમયારં આરોગ્ કવચ ચયાલુ રયાખવયા કે ખચયા્ડઓમયાં મદદ મયાિે ચોકકસ અંવતમ તયારીખો સુ્ધીમયાં
કયા્્ડવયાહી કરવયાની જરૂર પડી શકે. તમને તમયારી ભયાષયામયાં આ મયાવહતી અને મદદ વવનયા મૂલ્ે મેળવવયાનો અવ્ધકયાર 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).
Ang Paunawang ito ay naglalaman ng Mahalagang Impormasyon. Ang paunawang ito ay
naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagkakasaklaw sa Blue Cross
Blue Shield of Massachusetts. Maaaring kailanganin mong magsagawa ng mga pagkilos na aabot sa
mga deadline upang mapanatili ang iyong pagkakasaklaw sa kalusugan o upang matulungan ka sa
iyong mga gastusin. Karapatan mong matanggap ang impormasyong ito at matulungan ka sa iyong
wika nang libre. 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）。
この通知には重要な情報が記載されています。この通知にはBlue Cross Blue Shield of
Massachusettsでのあなたの申請や保険についての重要な情報が記載されています。健康保険を維持
する、 または費用について支援を受けるには、期限日までに行動を起こす必要があります。 あなたは母
国語で、 この情報を入手し、支援を受ける権利があり、 それについて費用はかかりません。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).
Diese Mitteilung enthält wichtige Informationen. Diese Mitteilung enthält wichtige Informationen zu
Ihrem Antrag oder zur Abdeckung durch Blue Cross Blue Shield of Massachusetts. Sie müssen unter
Umständen innerhalb gewisser Fristen bestimmte Handlungen ergreifen, damit Ihr Gesundheitsschutz
bestehen bleibt oder Sie Kostenunterstützung erhalten. Sie sind berechtigt, diese Informationen sowie
kostenlos Hilfe in Ihrer Muttersprache zu erhalten. Rufen Sie den Mitgliederdienst unter der Nummer auf
Ihrer ID-Karte an (TTY: 711).
Persian/‫پارسیان‬:
‫ با شمار تلفن مندرج بر روی کارت‬.‫ خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد‬،‫ اگر زبان شما فارسی است‬:‫توج‬
.(TTY: 711) ‫شناسایی خود با بخش «خدمات اعضا» تماس بگیر ید‬
Blue Cross Blue ‫ این اطالعی حاوی اطالعات ممی دربار درخواست شما یا پوشش شما از طر یق‬.‫این اطالعی حاوی اطالعات ممی است‬
‫ اقدامات الزم را تا ملت ای‬،‫ ممکن است الزم باشد ک برای حفظ پوشش درمانی یا کمک ای مالی‬.‫ است‬Shield of Massachusetts
‫ با شمار تلفن مندرج بر روی‬.‫ شما حق دار ید ک این اطالعات و رانمایی را ب زبان خود و ب صورت رایگان در یافت کنید‬.‫مشخص شد انجام دید‬
.(TTY: 711) ‫کارت شناسایی خود با بخش «خدمات اعضا» تماس بگیر ید‬

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.
Lao/ພາສາລາວ: ໍຂ ້ ຄວນໃສ ່ ໃຈ: ຖ ້ າເຈົ ້ າເວ ົ ້ າພາສາລາວໄດ ້ , ີມການບ ໍ ິ ລການຊ ່ ວຍເຫ ື ຼ ອດ ້ ານພາສາໃຫ ້ ທ
່ ານ
ໂດຍບ ່ໍ ເສຍເງ ິ ນ. ໂທ ຫາ ຝ່ າຍບໍ ິ ລ ການສະ ມາ ິ ຊກຕາມໝາຍເລກໂທລະສ ບຢ
ັ ູ່ ໃນບັ ດຂອງທ ່ ານ (TTY: 711).
ແຈ ້ ງການີ ນ ້ ີມໍຂ ້ ມູ ນທ ່ີ ໍສາຄັນ. ແຈ ້ ງການສະບັບນ ີ ້ ີມໍຂ້ ມູ ນສ ໍ າຄັນກ ່ ຽວກັບການສະໝັກຂອງທ ່ ານ ຫລ ື
ປະກັນສັງຄັມໂດຍລວມຂອງອ ົ ງການ Blue Cross Blue Shield ຂອງ Massachusetts. ທ່ ານ ອາດ ຈະ ຕ
້ ອງໍດາ
ເນ
ີ ນການຕາມກ ໍ ານ ົ ດເວລາສະເພາະ ເພ ່ ື ອຮັກສາຄວາມຄ ຸ ້ ມຄອງປະກັນໄພຂອງທ ່ ານໄວ ້ ືຫຼ ເພ ່ ື ອຮັບເອ ົ າການ
ຊ
່ ວຍເຫ ື ຼ ອເລ ່ ື ອງຄ ່ າໃຊ ້ ຈ
່ າຍ. ທ ່ ານມ ີ ິສດໄດ ້ ຮັບຂ ້
ໍ ມ ູ ນນ ້
ີ ແລະ ໄດ ້ ຮັບການຊ ່ ວຍເຫ ື ຼ ອດ ້ ານພາສາ ໂດຍບ ່ ໍ ເສຍຄ ່ າ.
ໂທຫາຝ ່ າຍບ ໍ ິ ລການສະມາິ ຊກຕາມໝາຍເລກໂທລະສັບຢ ູ່ ໃນບັດຂອງທ ່ ານ (TTY: 711).
Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: D77 Din4, k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47
t’11j77k’e bee n7k1’a’doowo[go bee n1haz’3. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’
b44sh bee hod77lnih (TTY: 711).
D77 bee 44h0zin7g7 t’11 77yiis7 baa 1kon7n7zin doo. D77 bee 44h0znin7g7 47 d77 ninaaltsoos Blue Cross Blue
Shield of Massachusetts bii’ bee naa’1h1y1n7g7 47 b7deet’i’ d00 baa 1kon7n7zin doolee[. D77 [a’ 1adoo
ii[kaah7 d77 naah’4’4l’7n77 bee n1’ahoot’i’8g8 b7dad47t’i’ d00 [ahd00 n1 bik’4 ni’dooly44[go 1t’4. D77
bee 44h0zin7g7 nich’8’ 77shj1n7 1alzindoogo 47 bee n1haz’3 d00 t’11 ninizaad k’ehj7 t’11 j77k’e bee nik1’
a’doowo[. 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.
© 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
001651802
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross 55-1491 (6/23)
and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
164696MB 55-1491 (8/16)