BCBSMA PDP Sales Kit Book 11/01/2018 Approved by Jazmin 10/26/2018 1:44 PM

Blue MedicareRx (PDP) Plans

Coverage you need
From a name you can trust

Blue MedicareRx (PDP) 2019

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and
Blue Shield Association.

S2893_18139_M
(11/01/18)



Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont

Dear Medicare Beneficiary: Choosing the Plan
That’s Best for You
Thank you for your interest in the Blue MedicareRx
prescription drug plan (PDP). It’s important to understand each
plan before you can determine
Blue MedicareRx (PDP) delivers comprehensive which one is right for you. That’s
drug coverage to Medicare beneficiaries like you. why we’ve enclosed the following
We offer two plans to choose from: materials to help assist you with
Blue MedicareRx Value Plus (PDP) and your decision:
Blue MedicareRx Premier (PDP).
• Plan Brochure: Answers
Key Features of our 2019 Plans Include: questions about Medicare Part
D, and highlights key features of
• $1-$2 copayments on Tier 1 generic drugs at network the Blue MedicareRx plans
retail pharmacies that offer preferred cost sharing
• Summary of Benefits: Gives you
• $0 annual deductible on generic and Preferred generic an overview of Blue MedicareRx
drugs for Blue MedicareRx Value Plus members plan options

• $0 annual deductible on all drugs for Blue MedicareRx • Medicare Star Rating Sheet:
Premier members Shows you the Medicare
program’s summary rating of
• Opportunity to save with lower cost sharing at more than Blue MedicareRx’s overall plan
36,000 preferred retail pharmacies quality and performance

• Prescription mail order service that saves you money, • Top 100 Drug List: Gives you a
and delivers your prescriptions directly to you. Get a list of the 100 most commonly
three-month supply of your drugs but pay for only one used brand-name and generic
month! drugs we cover

• Network Chain Pharmacies:
Gives you a list of our extensive
network of chain pharmacies

S2893_1829_M continued

P.O. Box 30011 | Pittsburgh, PA 15222-0330 | rxmedicareplans.com
Independent licensees of the Blue Cross and Blue Shield Association.

Learn More Today!

Visit www.RxMedicarePlans.com, or call us today, and let our team of experts help guide you.

Connecticut Residents: Massachusetts Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711) 10/1–3/31, 8:00 a.m. to
24 hours a day, 7 days a week 8:00 p.m., 7 days a week, 4/1–9/30, 8:00 a.m. to
Rhode Island Residents: 8:00 p.m., Monday through Friday
1-800-505-2583 (TTY: 711) Vermont Residents:
Monday through Friday, 8:00 a.m. to 8:00 p.m. 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week

Questions About How Medicare Works?

Call Medicare at 1-800-633-4227 (TTY: 1-877-486-2048), 24 hours a day, 7 days a week or
visit www.medicare.gov.

We look forward to providing you with convenient, high-quality prescription drug coverage.
If you have any questions, don’t hesitate to call us.

Sincerely,

Blue MedicareRx

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of
Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise

with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP)
plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends
on contract renewal.

Coverage is available to residents of the service area or members of an employer or union group and separately issued
by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of
Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information. For residents of
Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748; Vermont: 1-888-620-

1746. TTY users call: 711

187090M PL-8580-19 (08/18)

In This Booklet

01 Plan Information

• Sales Brochure
• Pre-Enrollment Checklist
• Plan Rating Sheet

02 Resources

• Seminar Information
• Top 100 Drugs
• Network Chain Pharmacy List

03 Disclosures

• Nondiscrimination Notice and
Translation Resources Notice

• Confidentiality Flyer

04 Enrollment

• Enrollment Forms



01

Plan
Information



Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont Prescription Drug Plan (PDP)

2019 Prescription Drug
Plan Information

Top-rated and affordable
coverage to fit your needs

Independent licensees of the Blue Cross and Blue Shield Association

S2893_18137_M

Thank you for your interest in our
2019 Prescription Drug Plans.

Contents 1
1
Two Plans to 2
Choose From 6
7
90-Day Supply 8
for as Low as $1
10
Why Choose 12
Blue MedicareRx?

Pharmacy
Network

Formulary
Coverage

2019 Blue
MedicareRx Plan
Comparison Chart

What Is
Medicare Part D?

Frequently
Asked Questions

Two Plans to Choose From

Our Blue MedicareRx Value Plus (PDP) and Blue MedicareRx
Premier (PDP) plans include the following features:

Blue MedicareRx Blue MedicareRx
Value Plus Premier

0$ Annual 0$ Annual
Deductible Deductible

on Tier 1 preferred generic drugs on all
and Tier 2 generic drugs covered drugs

– Also – – Also –
Cost savings through preferred Additional plan coverage of Tier 1
preferred generic drugs and Tier 2
cost sharing at participating generic drugs in the Coverage Gap
network retail pharmacies
Cost savings through preferred cost sharing
at participating network retail pharmacies

Get a 90-Day Supply for as Low as $1

When you order a Tier 1 preferred generic prescription medication through our mail order
pharmacy, you’ll pay the same amount for a 90-day supply as you would for a 30-day supply
purchased from a preferred cost sharing retail pharmacy. See below:

Preferred Generic Blue MedicareRx Value Plus Blue MedicareRx Premier
Prescription Drug Plan
Copayment for $2 $1
a 90-day supply

1

Why Choose Blue MedicareRx?

Our Blue MedicareRx plans are standalone prescription drug
plans that give you the flexibility, service, and support that
you need in a Medicare Part D plan.

They’re offered to residents of Connecticut, Massachusetts,
Rhode Island, and Vermont who qualify for Medicare.

Great service and support

Through Blue MedicareRx, your prescription drug coverage is backed by
the Blue Cross and Blue Shield Association and a long-standing history
of offering you high-quality service and support. Our representatives are
available to answer your questions and offer suggestions, so whether you’re
new to Medicare Part D or switching plans, we make it easy for you to get the
coverage that’s right for you. Just call us at one of the numbers below.

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents:1-866-832-9702 (TTY: 711) 4/41–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week Vermont Residents: 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week
Rhode Island Residents: 1-800-505-2583 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Online: rxmedicareplans.com

More pharmacies to choose from nationwide

With more than 67,000 pharmacies in our network—including national
chains and independent pharmacies—you’ll have the freedom to travel
anywhere in the United States with the confidence that you can use your
coverage when and where you need it. Check page 6 for more details
on our pharmacy network.

You’ll have the security of knowing that the Blue Cross and Blue Shield Association has been providing
peace of mind to over 6.9 million Medicare members like you nationwide.

2

Example: Blue MedicareRx Value Plus

Paul is healthy and only takes Paul’s Choice:
medications on occasion. Blue MedicareRx

He wants more for less: Value Plus
• Lower monthly premium
• $0 deductible on Tier 1 and Tier 2, which

contain some of the most commonly used
generic drugs

3

67,000+

pharmacies in our network

Plans that fit your needs

We offer you a choice of two Blue MedicareRx plans with different premiums, coverage levels,
and out-of-pocket costs: Blue MedicareRx Value Plus and Blue MedicareRx Premier. Our Blue
MedicareRx plans offer great service, access to more than 67,000 network pharmacies nationwide,
and mail order savings.

Blue MedicareRx Blue MedicareRx
Value Plus Premier

Large Network of Retail Pharmacies

Network Retail Pharmacies with
Preferred Cost Sharing

Mail Order Service

Includes most Medicare
Part D-eligible generic drugs
Some of the most commonly used generics
are available at the lowest copayment (Tier 1)
Additional Plan Coverage for Tier 1 preferred
generic drugs and Tier 2
generic drugs in the Coverage Gap

4

Example: Blue MedicareRx Premier

Martha takes a lot of expensive Martha’s Choice:
drugs and hits the coverage gap. Blue MedicareRx

She wants the most coverage: Premier
• A plan with no annual deductible
• More extensive coverage of her generic

medications even after she’s reached the
coverage gap

5

Pharmacy Network

What pharmacies can I use?

You must use a network pharmacy to access your prescription drug benefits, except under non-routine
circumstances (e.g., a medical emergency or urgent care, or when a network pharmacy is unavailable).
Quantity limitations and restrictions may apply.

What is preferred cost sharing for the Blue MedicareRx plans?

More than 36,000 of the total 67,000 pharmacies in our network offer preferred cost sharing
for both of the Blue MedicareRx plans. You pay lower copays at these pharmacies than at network
pharmacies that offer standard cost sharing.

Which pharmacies offer preferred cost sharing?1

Enjoy cost savings in the form of lower copays at network retail preferred cost sharing pharmacies,
which include:

Pharmacy

1Other pharmacies are available in our network.

Types of network pharmacies

• Retail pharmacies
• Mail order pharmacies
• Long-term care pharmacies
• Home-infusion pharmacies
• Indian Health/Tribal pharmacies

Visit our website RxMedicarePlans.com to locate a pharmacy in our network.

6

Formulary Coverage

We offer coverage for a comprehensive number of generic
and brand-name drugs. The chart below outlines the
formulary tiering structure for the Blue MedicareRx plans.

2019 Drug Blue MedicareRx Blue MedicareRx
Tier Label Value Plus covers: Premier covers:

Tier 1: Certain generic drugs available at the lowest copayment.
Preferred Generic

Tier 2: Higher cost generic drugs available at a higher copayment than Tier 1 generic drugs.
Generic

Tier 3: Many common brand name drugs and Many common brand name drugs and
Preferred Brand some higher cost generic drugs, many some higher cost generic drugs
Tier 4: of which may have lower cost options Higher cost generic and non-preferred
Non-preferred Drug available on Tier 1 or Tier 2 drugs, many of which may have lower
Higher cost generic and non-preferred cost options available on Tier 1, Tier 2, and
drugs, many of which may have lower cost Tier 3.
options available on Tier 1, Tier 2, and Tier 3.

Tier 5: Unique and/or very high-cost brand and some generic drugs of which you pay a
Specialty Tier percentage of the total drug cost, which may require special handling and/or close
monitoring.

Remember: In general, many drugs in the higher tiers have lower-cost options available in the lower
tiers. Ask your doctor if they could work for you.

Convenient mail order service: You can get prescription drugs shipped to your home through our
network mail order delivery program. For refills of your mail order prescriptions, you have the option to
sign up for an automatic refill program. Typically, you should expect to receive your prescription drugs
within 10 calendar days from the time that the mail order pharmacy receives the order.

You’ll pay the same amount for a 90-day supply of a Tier 1 prescription drug ordered through
mail order as you would pay for a 30-day supply purchased from a retail preferred cost sharing
pharmacy.

7

2019 Blue MedicareRx

Plan Comparison Chart

Blue MedicareRx Value Plus

Monthly Premium1 $37.80
Annual Deductible $0 (Tier 1 and Tier 2)
Initial Coverage $350 (Tier 3, Tier 4, and Tier 5)
A copayment or co-insurance for covered prescription Network Retail Pharmacy
drugs, until the annual cost of prescription drug with Preferred Cost Sharing
expenses you pay and we pay reaches $3,820. Any 30-Day Supply Retail
deductible, copayments, or co-insurance you pay Tier 1: $2
counts toward the $3,820. Tier 2: $8
Tier 3: $35
Coverage Gap Tier 4: 40%
The cost for covered prescription drug expenses Tier 5: 26%
between $3,820 in drug costs and $5,100 in annual 90-Day Supply Mail Order
out-of-pocket costs. Tier 1: $2
Tier 2: $16
Tier 3: $70
Tier 4: 40%
Tier 5: N/A2
For covered generics, you pay 37% of the costs
For covered brand-names, you pay 25% of the
negotiated price (excluding the dispensing fee)

Catastrophic Coverage For covered generics (including drugs treated
The cost for covered prescription drugs after you as generics), you pay $3.40 or 5%, whichever is greater
and others on your behalf have paid $5,100 in annual For all other covered drugs, you pay $8.50 or
out-of-pocket costs. You pay a flat-dollar amount or 5%, whichever is greater
5%, whichever is greater.

1. You must continue to pay your Medicare Part B premium.
2. Specialty Tier drugs are not available at an extended day supply.

8

Blue MedicareRx Premier

$127.90
$0

Network Retail Pharmacy Network Retail Pharmacy Network Retail Pharmacy
with Standard Cost Sharing with Preferred Cost Sharing with Standard Cost Sharing
30-Day Supply Retail 30-Day Supply Retail 30-Day Supply Retail
Tier 1: $7 Tier 1: $1 Tier 1: $6
Tier 2: $19 Tier 2: $7 Tier 2: $12
Tier 3: $45 Tier 3: $30 Tier 3: $40
Tier 4: 50% Tier 4: $70 Tier 4: $80
Tier 5: 26% Tier 5: 33% Tier 5: 33%

90-Day Supply Mail Order
Tier 1: $1
Tier 2: $14
Tier 3: $60
Tier 4: $140
Tier 5: N/A2

For covered generics, on Tier 1 and Tier 2 you pay:

30-Day Supply 30-Day Supply 90-Day Supply
Retail with Preferred Retail with Standard Mail Order
Cost Sharing Cost Sharing Tier 1: $1
Tier 1: $1 Tier 1: $6 Tier 2: $14
Tier 2: $7 Tier 2: $12

For covered generics on other tiers, you pay 37% of the costs
For covered brands, you pay 25% of the negotiated price (excluding the dispensing
fee)

For covered generics (including drugs treated as generics), you pay $3.40 or 5%,
whichever is greater
For all other covered drugs, you pay $8.50 or 5%, whichever is greater

9

What Is Medicare Part D?

Medicare Part D is prescription drug coverage that is available
to you if you’re eligible for Medicare. This prescription drug
benefit is administered by private insurance companies, like
Blue Cross and Blue Shield, that contract with the Centers for
Medicare and Medicaid Services (CMS).

How Part D works: (Information provided below is specific to 2019)

In addition to the monthly premium, Medicare Part D plans have four different stages:

Annual Deductible (if applicable), Initial Coverage, Coverage Gap, and Catastrophic Coverage.

Annual Deductible Here's how they work:
(if applicable)
Initial Coverage The Blue MedicareRx Value Plus plan has an annual deductible only on Tiers 3, 4, and 5.
Coverage Gap The Blue MedicareRx Premier plan has no annual deductible.
Refer to the Plan Comparison Chart on pages 8-9 for more details.
Catastrophic There is a $3,820 initial coverage limit. This includes your copayments, co-insurance,
Coverage and payments made by the plan for covered prescriptions.
There is a coverage gap that starts once total drug costs (member and plan
payments) reach $3,820 and ends when your out-of-pocket prescription drug costs
reach $5,100.

When you're in the Coverage Gap stage, you pay 37% of the costs of generic
drugs. For brand-name drugs, you pay 25% of the negotiated price (excluding
the dispensing fee). You continue paying 37% for generic drugs and 25% of the
negotiated price (excluding the dispensing fee) for brand-name drugs until yearly out-
of-pocket costs paid by you and others on your behalf reach $5,100. The payments
made on your behalf (excludes payments made by Blue MedicareRx) count toward
your out-of-pocket costs.

Refer to the Plan Comparison Chart on pages 8-9 for your costs in the Coverage Gap
for each of the Blue MedicareRx plans.
Takes effect after you and others on your behalf have paid $5,100 in annual
out-of-pocket prescription costs.

10

Am I eligible?

You’re eligible for Medicare prescription drug coverage and Blue MedicareRx membership if:
• You have Medicare Part A or Medicare Part B (or you have both Part A and Part B)

» and—you’re a United States citizen or are lawfully present in the United States
» and—you live in our geographic service area

What if I already have drug coverage?

Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time. If you already have
a Medicare Advantage plan or other insurance that includes Part D coverage, enrolling in this plan will
automatically disenroll you from your current plan.
If you get your health care benefits from TRICARE®´ or the U.S. Department of Veterans Affairs,
joining a Medicare Prescription Drug Plan might not be a cost-effective option, unless you qualify for
Extra Help. If you get your coverage through your employer or union, contact your benefits administrator
to compare your options.

11

Frequently Asked Questions

Enrolling in a Blue MedicareRx Plan

Q: How can I enroll?
A: You can enroll by:

• Filling out and mailing a paper application.

• Filling out a secure online application on our website at rxmedicareplans.com.

• Complete an application by phone:

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents:1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m. 24 hours a day, 7 days a week
Online: rxmedicareplans.com

• Calling 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day,
7 days a week. Visiting the CMS Medicare Online Enrollment Center located at medicare.gov.

Q: When can I enroll?
A: You can enroll in a Blue MedicareRx plan only during specific times of the year unless you're newly 65.

Q: Is financial assistance available?
A: If you need financial assistance covering your Prescription Drug Plan costs, you may be eligible

to receive Extra Help, including reduced premiums, deductibles, copayments, and co-insurance.
If you qualify for Extra Help, Medicare will tell us how much assistance you'll receive when you enroll
in our plan, and we'll inform you of the amount you'll be responsible for paying. To see if you qualify for
Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day, 7 days a week.

• The Social Security Administration at 1-800-772-1213, TTY: 1-800-325-0778 between 7:00 a.m.
and 7:00 p.m. ET., Monday through Friday.

• Your state Medicaid office.

Q: What is the late enrollment penalty?
A: If you choose not to enroll in a Medicare Prescription Drug Plan during your initial enrollment

period or had a continuous period of 63 days or more without “creditable” prescription drug
coverage, (“Creditable” means the drug coverage is expected to pay, on average, at least as
much as Medicare’s standard prescription drug coverage) you may be subject to a late enrollment
penalty when you do enroll. The penalty is 1% of the national average monthly premium for each
month you were eligible, but weren't enrolled. The penalty will be added to your premium for as
long as you're enrolled in a Medicare Prescription Drug Plan.

12

Drug Coverage

Q: What drugs are covered?
A: For a full listing of covered drugs, visit rxmedicareplans.com, or call us at the number on the

back page. If drugs are removed from the list during the year, we'll notify affected members
of the change in writing and online at rxmedicareplans.com at least 60 days before the change
is effective.

Q: What if I’m currently taking a drug that isn't on the drug list?
A: You should first contact us and confirm that your drug isn't covered. You can ask us for a list of similar

drugs that are covered by our plan. You can also ask us to make an exception to cover your drug. We
encourage you to talk to your doctor to determine the course of action that best suits your needs. We
may cover your drug in certain cases during the first 90 days you're a new member of our plan. Visit
rxmedicareplans.com, or call us at the number on the back page for details about how to request a
prescription drug exception and to find out about our transition supply policy.

Common Terms

Initial Enrollment Period

The Initial Enrollment Period is the period when you first become Medicare eligible because:
• You turn 65 (beginning 3 months before your birthday and extending to 3 months after your birthday).
• You qualify due to disability or End-Stage Renal Disease (3 months before to 3 months after your 25th

month of disability).

Annual Election Period

The Annual Election Period occurs from October 15 through December 7 each year. During this time,
you may enroll in or change Medicare prescription drug plans. Coverage will be effective January 1
of the following year.

Special Enrollment Period

A Special Enrollment Period is available in certain situations, such as:
• Permanently moving into our plan’s service area, losing employer group prescription drug coverage,

qualifying for Extra Help, or if you become eligible for both Medicare and Medicaid. If you think you
may be eligible for a Special Enrollment Period, contact your current plan, or call us at the number
on the back page.
• Medicare Advantage enrollees may disenroll from their plan and return to Original Medicare
between January 1 and March 31. If you're a Medicare Advantage enrollee and you decide to leave
the plan to return to Original Medicare during this period, you may join a standalone prescription
drug plan like Blue MedicareRx.

13

We’re here when you need us

We’re dedicated to providing you with outstanding service.
If you have any questions about Blue MedicareRx, contact
us today!

Please call us today! Massachusetts Residents:1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents: 1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week Vermont Residents: 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week
Rhode Island Residents:1-800-505-2583 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m.
ONLINE: rxmedicareplans.com

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRx Value Plus (PDP) and
Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut,
Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately issued by one
of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue
Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information. For residents of
Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746.
TTY users call: 711

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode
Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the
Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint
enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Blue MedicareRx 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.

Connecticut | Massachusetts
Rhode Island | Vermont

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and
Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners.
© 2018 All Rights Reserved.

184096M BRC-8580-19 55-0597-19 (09/18)

Connecticut | Massachusetts Blue MedicareRx (PDP)
Rhode Island | Vermont

2019 Summary of Benefits

Blue MedicareRx Value Plus (PDP)
Blue MedicareRx Premier (PDP)

Independent Licensees of the Blue Cross and Blue Shield Association.
S2893_1846_M

Blue MedicareRx Value Plus (PDP)
Blue MedicareRx Premier (PDP)

(a Medicare Prescription Drug Plan (PDP) offered by
ANTHEM INSURANCE CO. & BCBSMA & BCBSRI & BCBSVT
with a Medicare contract)

Summary of Benefits

January 1, 2019 – December 31, 2019

This booklet gives you a summary of what we cover and what you pay. It doesn’t list
every service that we cover or list every limitation or exclusion. To get a complete list of
services we cover, call us and ask for the “Evidence of Coverage.”

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents:1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week Vermont Residents: 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week
Rhode Island Residents: 1-800-505-2583 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Online: rxmedicareplans.com

For More Information

If you want to know more about the coverage and costs of Original Medicare, look in your current
“Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.

This document is available in other
formats such as Braille and large print.

1

Summary of Benefits: Introduction

Who can join?

To join Blue MedicareRx Value Plus or Blue MedicareRx Premier, you must be
entitled to Medicare Part A, and/or be enrolled in Medicare Part B, be a U.S. citizen or
be lawfully present in the United States and live in our service area.
Our service area includes the following: Central New England
(Connecticut, Massachusetts, Rhode Island, and Vermont).

Which drugs are covered?

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on
our website (www.rxmedicareplans.com). Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs? Which pharmacies can I use?

Our plans group each medication into one of We have a network of pharmacies and you
five “tiers.” You will need to use your formulary must generally use these pharmacies to fill
to locate what tier your drug is on to determine your prescriptions for covered Part D drugs.
how much it will cost you. The amount you
pay depends on the drug’s tier and what Some of our network pharmacies have
stage of the benefit you have reached. There preferred cost-sharing. You may pay less if
are four benefit stages in your Medicare you use these pharmacies.
prescription drug coverage: Deductible Stage,
Initial Coverage Stage, Coverage Gap Stage, You can see our plans’ pharmacy directories
and Catastrophic Coverage Stage. For more at our website (www.rxmedicareplans.com).
information about formulary tiers and stages or, call us and we will send you a copy of the
of the benefit, please see the plan’s formulary pharmacy directory.
and the Evidence of Coverage on our website
at www.rxmedicareplans.com, or contact
Customer Care.

2

Summary of Benefits: Stage 1: Annual Deductible

How much is the Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)
monthly premium? $37.80 per month $127.90 per month
How much is the
deductible? $350.00 per year for Part D prescription drugs This plan does not have a deductible.
except for drugs listed on Tier 1 and Tier 2
which are excluded from the deductible.

3

Summary of Benefits: Stage 2: Initial Coverage Stage

4

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Initial Coverage After you pay your yearly deductible, you You pay the following until your total yearly

pay the following until your total yearly drug drug costs reach $3,820. Total yearly drug

costs reach $3,820. Total yearly drug costs costs are the total drug costs paid by both

are the total drug costs paid by both you and you and our Part D plan.

our Part D plan. You may get your drugs at network retail

You may get your drugs at network retail pharmacies and mail order pharmacies.

pharmacies and mail order pharmacies. If you reside in a long-term care facility,

If you reside in a long-term care facility, you pay the same as at a standard retail

you pay the same as at a standard retail pharmacy.

pharmacy. You may get drugs from an out-of-network

You may get drugs from an out-of-network pharmacy, but may pay more than you pay

pharmacy, but may pay more than you pay at an in-network pharmacy.

at an in-network pharmacy.

Preferred Retail Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)
Cost-Sharing

Tier One-month supply Three-month supply One-month supply Three-month supply

Tier 1 (Preferred Generic) $2 copay $6 copay $1 copay $3 copay
$24 copay $7 copay $21 copay
Tier 2 (Generic) $8 copay $105 copay $30 copay $90 copay
$40% of the cost $70 copay $210 copay
Tier 3 (Preferred Brand) $35 copay N/A 33% of the cost N/A

Tier 4 (Non-Preferred Drug) 40% of the cost

Tier 5 (Specialty Tier) 26% of the cost

Standard Retail Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)
Cost-Sharing

Tier One-month supply Three-month supply One-month supply Three-month supply

Tier 1 (Preferred Generic) $7 copay $21 copay $6 copay $18 copay
$57 copay $12 copay $36 copay
Tier 2 (Generic) $19 copay $135 copay $40 copay $120 copay
$50% of the cost $80 copay $240 copay
Tier 3 (Preferred Brand) $45 copay N/A 33% of the cost N/A

Tier 4 (Non-Preferred Drug) 50% of the cost

Tier 5 (Specialty Tier) 26% of the cost

Mail Order Cost-Sharing Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Tier One-month supply Three-month supply One-month supply Three-month supply

Tier 1 (Preferred Generic) $2 copay $2 copay $1 copay $1 copay
$16 copay $7 copay $14 copay
Tier 2 (Generic) $8 copay $70 copay $30 copay $60 copay
$40% of the cost $70 copay $140 copay
Tier 3 (Preferred Brand) $35 copay N/A 33% of the cost N/A

Tier 4 (Non-Preferred Drug) 40% of the cost

Tier 5 (Specialty Tier) 26% of the cost

5

Summary of Benefits: Stage 3: Coverage Gap Stage

6

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Coverage Gap Most Medicare drug plans have a coverage Most Medicare drug plans have a coverage gap

Preferred Retail gap (also called the “donut hole”). This (also called the “donut hole”). This means that
Cost-Sharing
Tier means that there’s a temporary change there’s a temporary change in what you will pay
Tier 1
(Preferred Generic) in what you will pay for your drugs. The for your drugs. The coverage gap begins after the
Tier 2 (Generic)
Standard Retail coverage gap begins after the total yearly total yearly drug cost (including what our plan has
Cost-Sharing
Tier drug cost (including what our plan has paid paid and what you have paid) reaches $3,820.
Tier 1
(Preferred Generic) and what you have paid) reaches $3,820. After you enter the coverage gap, you pay 25%
Tier 2 (Generic)
After you enter the coverage gap, you pay of the plan’s cost for covered brand name drugs

25% of the plan’s cost for covered brand and 37% of the plan’s cost for covered generic

name drugs and 37% of the plan’s cost for drugs until your costs total $5,100, which is the

covered generic drugs until your costs total end of the coverage gap. Not everyone will enter

$5,100, which is the end of the coverage the coverage gap.

gap. Not everyone will enter the coverage Under this plan, you may pay even less for the
gap. brand and generic drugs on the formulary. Your

cost varies by tier. You will need to use your

formulary to locate your drug’s tier. See the chart

that follows to find out how much it will cost you.

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

One-month supply Three-month supply One-month supply Three-month supply
$3 copay
After you enter the coverage gap, you pay $1 copay
25% of the plan’s cost for covered brand $21 copay
name drugs and 37% of the plan’s cost for
covered generic drugs until your costs total $7 copay
$5,100, which is the end of the coverage gap.
Not everyone will enter the coverage gap.

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

One-month supply Three-month supply One-month supply Three-month supply
$18 copay
After you enter the coverage gap, you pay $6 copay
25% of the plan’s cost for covered brand $36 copay
name drugs and 37% of the plan’s cost for
covered generic drugs until your costs total $12 copay
$5,100, which is the end of the coverage gap.
Not everyone will enter the coverage gap.

Mail Order Cost-Sharing Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Tier One-month supply Three-month supply One-month supply Three-month supply
Tier 1 $1 copay
(Preferred Generic) After you enter the coverage gap, you pay $1 copay
25% of the plan’s cost for covered brand $14 copay
Tier 2 (Generic) name drugs and 37% of the plan’s cost for
covered generic drugs until your costs total $7 copay
$5,100, which is the end of the coverage gap.
Not everyone will enter the coverage gap.

7

Summary of Benefits: Stage 4: Catastrophic Coverage Stage

Catastrophic Coverage Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

After your yearly out-of-pocket drug costs (including drugs purchased through your retail
pharmacy and through mail order) reach $5,100, you pay the greater of:
• 5% of the cost,
• or $3.40 copay for generic (including brand drugs treated as generic) and a

$8.50 copay for all other drugs.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRx Value Plus (PDP) and
Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut,
Massachusetts, Rhode Island, and Vermont.
Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield
of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield
of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint
enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue
MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx
(PDP) depends on contract renewal.
This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748;
Vermont: 1-888-620-1746. TTY users call: 711

8



Connecticut | Massachusetts
Rhode Island | Vermont

®Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and Trademarks are property of their

respective owners. ©2018 All Rights Reserved.

187162M SB-8580-19 (08/18)

Connecticut | Massachusetts Pre-Enrollment Checklist
Rhode Island | Vermont

Before making an enrollment decision, it is important that you fully understand our
benefits and rules. If you have any questions, you can call and speak to a Customer
Service representative at the phone numbers listed below.

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents:1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week Vermont Residents: 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week
Rhode Island Residents: 1-800-505-2583 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Online: rxmedicareplans.com

Understanding the Benefits
■ Review the full list of benefits found in the Evidence of Coverage (EOC), especially for

those services for which you routinely see a doctor. Visit rxmedicareplans.com to view a
copy of the EOC or call Customer Service (phone number listed above).

■ Review the pharmacy directory to make sure the pharmacy you use for any prescription

medicines is in the network. If the pharmacy is not listed, you will likely have to select a
new pharmacy for your prescriptions.

Understanding Important Rules
■ In addition to your monthly plan premium, you must continue to pay your Medicare Part B

premium. This premium is normally taken out of your Social Security check each month.

■ Benefits, premiums and/or copayments/co-insurance may change on January 1, 2020

Independent Licensee of the Blue Cross and Blue Shield Association. S2893_18103_C

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield
of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that have contracted as a joint
enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue
MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx
(PDP) depends on contract renewal.
This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748;
Vermont: 1-888-620-1746. TTY users call: 711
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.

Connecticut | Massachusetts Independent Licensees of the Blue Cross and Blue Shield Association ®Registered Marks of
Rhode Island | Vermont the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are
property of their respective owners. © 2018 All Rights Reserved.

188518M (9/18) 55-2048-19

Blue MedicareRx - S2893

2019 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and
performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star
Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are:

1. An Overall Star Rating that combines all of our plan's scores.

2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for these ratings include:
• How our members rate our plan's services and care;
• How well our doctors detect illnesses and keep members healthy;
• How well our plan helps our members use recommended and safe prescription medications.

For 2019, Blue MedicareRx received the following Overall Star Rating from Medicare.

5 Stars

We received the following Summary Star Rating for Blue MedicareRx's health/drug plan services:

Health Plan Services: Not Offered
Drug Plan Services: 5 Stars

This plan got Medicare's highest rating (5 stars)

The number of stars shows how well our plan performs.

5 stars - excellent
4 stars - above average
3 stars - average
2 stars - below average
1 star - poor
Learn more about our plan and how we are different from other plans at www.medicare.gov.
You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 877-479-2227 (toll-free) or
711 (TTY).
Current members please call 888-543-4917 (toll-free) or 711 (TTY).
*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the
next.

S2893_18145_M



02

Resources



Join us for a FREE informational
meeting in your neighborhood.

When Medicare seems overwhelming or confusing, we’ll be there to make it easier.

Get answers to your questions about Call 1-800-262-BLUE (2583)
Medicare and supplemental insurance
coverage, and hear what other people (TTY/TDD 711) 7:00 a.m.–12:00 a.m.,
who are in your shoes are asking us at 7 days a week (Excluding holidays).
one of our informational meetings.
You can also make your reservation online anytime,
24 hours a day, seven days a week by visiting
www.bluecrossma.com/seminar.

Reserve your seat at the location nearest you.

RESERVE We are always adding and updating seminars on an ongoing basis.
NOW
Visit our website at bluecrossma.com/seminars to see the most
up-to-date list.

Comprehensive Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works and all the coverage options available to fit your budget and lifestyle. This seminar will
review supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Hyannis 11/05/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Cambridge 11/05/2018 10:30 AM-12:30 PM Courtyard by Marriott 777 Memorial Drive
Watertown 11/06/2018 10:30 AM-12:30 PM Residence Inn 570 Arsenal Street
Peabody 11/06/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Middleboro 11/07/2018 10:30 AM-12:30 PM Lorenzo's Italian Restaurant 500 West Grove Street
Braintree 11/07/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Fall River 11/08/2018 10:30 AM-12:30 PM McGovern's Family Restaurant 310 Shove Street
Westborough 11/08/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive

Blue Cross Blue Shield of Massachusetts is an Independent Continued
Licensee of the Blue Cross and Blue Shield Association.
Y0014_18211_M
S2893_18136_M

Comprehensive Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works and all the coverage options available to fit your budget and lifestyle. This seminar will
review supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Hadley 11/09/2018 10:30 AM-12:30 PM Hadley Farms Meeting House 41 Russell Street
Taunton 11/09/2018 10:30 AM-12:30 PM Holiday Inn 700 Myles Standish Blvd
Springfield 11/12/2018 10:30 AM-12:30 PM La Quinta Inn & Suites 100 Congress Street
Leominster 11/12/2018 10:30 AM-12:30 PM DoubleTree by Hilton 99 Erdman Way
Dedham 11/13/2018 10:30 AM-12:30 PM Holiday Inn 55 Ariadne Road
Salem 11/13/2018 10:30 AM-12:30 PM Hawthorne Hotel 18 Washington Square West
Natick 11/14/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Concord 11/14/2018 10:30 AM-12:30 PM Residence Inn 320 Baker Avenue
Worcester 11/15/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Boston 11/15/2018 10:30 AM-12:30 PM Sheraton Boston Hotel 39 Dalton Street
Newton 11/16/2018 10:30 AM-12:30 PM Marriott 2345 Commonwealth Avenue
Andover 11/17/2018 10:30 AM-12:30 PM Courtyard by Marriott 10 Campanelli Drive
Plymouth 11/19/2018 10:30 AM-12:30 PM John Carver Inn 25 Summer Street
New Bedford 11/19/2018 10:30 AM-12:30 PM Fairfield Inn & Suites 185 MacArthur Drive
Milford 11/20/2018 10:30 AM-12:30 PM DoubleTree by Hilton 11 Beaver Street
Gardner 11/21/2018 10:30 AM-12:30 PM Colonial Hotel 625 Betty Spring Road
Westborough 11/21/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive
Tewksbury 11/27/2018 10:30 AM-12:30 PM Holiday Inn 4 Highwood Drive
Hyannis 11/28/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Braintree 11/29/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Natick 11/29/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Lynnfield 11/30/2018 10:30 AM-12:30 PM Spinelli's Function Facility Route One South
Burlington 12/04/2018 10:30 AM-12:30 PM Marriott One Burlington Mall Road
Worcester 12/04/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Peabody 12/05/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Rockland 12/06/2018 10:30 AM-12:30 PM DoubleTree by Hilton 929 Hingham Street
Waltham 12/07/2018 10:30 AM-12:30 PM Embassy Suites 550 Winter Street

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

A salesperson will be present with information and applications. For accommodations for persons with special needs,
please call 1-800-262-BLUE (2583) (TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., 7 days a week.

A Blue Cross Blue Shield of Massachusetts representative will be present to discuss our Medicare HMO, PPO, PDP and
Medicare Supplement plan options and benefits, answer your questions, and explain how to enroll. Blue Cross Blue Shield of
Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts
depends on contract renewal.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode
Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with
the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx plans. The joint
enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
188947-2M 55-1758 (10/18)



Connecticut | Massachusetts Blue MedicareRx (PDP)
Rhode Island | Vermont

We’ve Got You Covered
Our Most Commonly
Covered Drugs

Below is a list of the most common brand-name and generic drugs
covered in the Blue MedicareRx (PDP) plans.

ADVAIR DISKUS escitalopram oxalate meloxicam
alendronate sodium ezetimibe metformin hcl
allopurinol finasteride metformin hcl er
alprazolam erythromycin methylprednisolone dose p
amlodipine besylate FLOVENT HFA metoprolol succinate er
amos levothyroxine sodium fluoxetine hcl metoprolol tartrate
amoxicillin fluticasone propionate metronidazole
amoxicillin/clavulanate p furosemide mirtazapine
atenolol gabapentin montelukast sodium
atorvastatin calcium glimepiride mupirocin
azithromycin glipizide nitrofurantoin monohydrat
carvedilol glipizide er nitroglycerin
celecoxib hydrochlorothiazide nystatin
cephalexin hydrocodone/acetaminophen ofloxacin
chlorhexidine gluconate ibuprofen omeprazole
ciprofloxacin hcl isosorbide mononitrate er oseltamivir phosphate
ciprofloxacin hydrochloride ketoconazole oxybutynin chloride er
citalopram hydrobromide ketorolac tromethamine oxycodone hcl
clindamycin hcl latanoprost oxycodone/acetaminophen
clonazepam levofloxacin pantoprazole sodium
clopidogrel levothyroxine sodium potassium chloride er
diltiazem hcl er lisinopril pravastatin sodium
donepezil hcl lisinopril/hydrochlorothi prednisolone acetate
doxycycline hyclate lorazepam prednisone
duloxetine hcl losartan potassium ranitidine hcl
ELIQUIS losartan potassium/hydroc rosuvastatin calcium
erythromycin lovastatin sertraline hcl

S2893_1863_C continued

SHINGRIX timolol maleate venlafaxine hcl er
simvastatin tramadol hcl VENTOLIN HFA
spironolactone trazodone hydrochloride warfarin sodium
sulfamethoxazole/trimetho triamcinolone acetonide XARELTO
SYMBICORT triamterene/hydrochloroth zolpidem tartrate
SYNTHROID valacyclovir hcl
tamsulosin hcl valsartan

• Drugs listed in all CAPS identify brand-name drugs (e.g. SYNTHROID).
• Drugs listed in lowercase identify generic drugs (e.g. azithromycin).

Blue MedicareRx plans include most eligible Medicare Part D generic drugs.

This is not a complete list of drugs covered by our plan. For a complete listing, please call us at one of the numbers below.
The comprehensive formulary may be amended at any time throughout the plan year. We will provide notice in advance
to affected members of any formulary changes. You can obtain more information by visiting rxmedicareplans.com for a
complete list of medications or to look up a specific drug.

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents: 1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m. 24 hours a day, 7 days a week
Online: rxmedicareplans.com

The formulary may change at any time. You will receive notice when necessary.
Effective as of January 1, 2019

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRx Value Plus (PDP) and
Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut,
Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of
Massachusetts, Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information. For residents of
Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748; Vermont: 1-888-620-
1746. TTY users call: 711

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of
Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint
enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx
(PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends
on contract renewal.

Independent Licensees of the Blue Cross and Blue Shield Association ®Registered Marks of the Blue Cross and
Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners.
© 2018 All Rights Reserved.

187151M TDL-8580-19 (08/18)

Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont

Network Chain Pharmacies

We have more than 67,000* pharmacies in our network and also contract with many independent
pharmacies for your convenience. Below is a list of the chain pharmacies for our Blue MedicareRx
Value Plus (PDP) and Blue MedicareRx Premier (PDP) plans that may be in your area. The pharmacies
highlighted in blue are our retail network pharmacies that offer preferred cost-sharing. Plan members
pay a lower copay at these pharmacies than at our other network pharmacies.

For a complete and most up-to-date list of our network pharmacies, including many independent
pharmacies, please call us at one of the numbers below.

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents: 1-866-832-9702 (TTY: 711) 4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday - Friday
24 hours a day, 7 days a week Vermont Residents: 1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week
Rhode Island Residents: 1-800-505-2583 (TTY: 711)
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Online: *rxmedicareplans.com

Acme Fresh Markets Copps Food Center Giant Eagle Pharmacy
Acme Pharmacy Costco Pharmacy Giant Pharmacy
AHS-St John Pharmacy Cub Foods Group Health Pharmacy
Albertson's Pharmacy CVS Pharmacy Haggen Pharmacy
Aurora Pharmacy Dierbergs Family Pharmacies Hannaford Food & Drug
Baker's Pharmacy Dillon Pharmacy Harmons Pharmacy
Bartell Drug Discount Drug Mart Harps Food Stores
Bel Air Pharmacy Duane Reade Harris Teeter Pharmacy
Big Y Pharmacy Eaton Apothecary Harvard Vanguard Medical
Bi-Lo Pharmacy Fairview Pharmacy Associates Pharmacy
Bi-Mart Pharmacy Farm Fresh Pharmacy Harveys Supermarkets
Brookshire Brothers Food City Pharmacy HEB Pharmacy
Brookshire Pharmacy Food Lion Pharmacy Hen House Pharmacy
Caremark Specialty Fred Meyer Pharmacy Homeland Pharmacy
Carrs Pharmacy Fred's Pharmacy Horton & Converse
Cashwise Pharmacy Fred's Xpress House Calls Pharmacy
Cigna Healthcare Of Arizona Fresh Market Pharmacy Hy-Vee Pharmacy
City Market Pharmacy Fruth Pharmacy Ingles Markets
Coborn's Pharmacy Fry's Pharmacy Jay C Plus Pharmacy
Community (A Walgreens Pharmacy) Gerbes Pharmacy Kessel Pharmacy

S2893_1864_C continued

King Kullen Pharmacy Patient First Pharmacy Shop 'N Save Pharmacy
King Soopers Pavilion's Pharmacy Shopko Pharmacy
Kinney Drugs Pick N Save Pharmacy Shoppers Pharmacy
Kleins Shoprite Pharmacy Price Chopper ShopRite
Klingensmith's Drug Stores Price Cutter Pharmacy Smith's Pharmacy
Kmart Pharmacy Publix Pharmacy Stop & Shop Pharmacy
Kroger Pharmacy QFC Pharmacy Super 1 Pharmacy
Lewis Family Drug Quick Chek Food Stores Super Rx Pharmacy
Longs Drugs Raley's Drug Center Thrifty White Pharmacy
Marc's Ralphs Pharmacy Times Pharmacy
Mariano's Pharmacy Randall's Pharmacy Tom Thumb
Market 32 Recept Pharmacy Tops Markets
Martins Pharmacy Rite Aid Pharmacy United Market Street Pharmacy
Martin's Super Markets Pharmacy Ritzman Pharmacy United Pharmacy
Med-Fast Pharmacy Roundy's Pharmacy Vons Pharmacy
Medicap Pharmacy Safeway Pharmacy Walgreens
Medicine Shoppe Sam's Club Pharmacy Walmart
Meijer Pharmacy Save Mart Pharmacy Wegmans Pharmacy
Metro Market Pharmacy Sav-On Pharmacy Weis Markets
Navarro Pharmacy Schnucks Pharmacy White Drug
Nob Hill Pharmacy Scotts Pharmacy Winn-Dixie Stores
Osco Pharmacy Shaw's Pharmacy

Pharmacy network may change on January 1, 2020. Please also note that pharmacies may have been added to or
removed from this list since its publication.

Eligible beneficiaries must use network pharmacies to access prescription drug benefits, except under non-routine
circumstances. Quantity limitations and restrictions may apply.

The pharmacy network may change at any time. You will receive notice when necessary.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare Contract. Blue MedicareRx Value Plus (PDP) and
Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut,
Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of
Massachusetts, Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information. For residents of
Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island: 1-888-620-1748;
Vermont: 1-888-620-1746. TTY users call: 711

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of
Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint
enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx
(PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends
on contract renewal.

Independent Licensees of the Blue Cross and Blue Shield Association ®Registered Marks of the Blue Cross and
Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners.
© 2018 All Rights Reserved.

187170M CPL-8580-19 (08/18)