MEDICARE PPO BLUE (PPO) 2023 Coverage You Need From a Name You Can Trust Medicare Advantage Plans Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. MEDICARE PPO BLUE (PPO) 2023 Coverage You Need From a Name You Can Trust Medicare Advantage Plans Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. November 2023 (2307658)
101 Huntington Avenue Suite 1300 Boston, MA 02199-7611 bluecrossma.org Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Dear Prospective Member, Thank you for your interest in our Medicare Advantage PPO Blue plans. We want you to get the coverage you need and the peace of mind you deserve. That’s why our plans may include: Great Coverage Including prescription drug coverage and the freedom to see any doctor or hospital that participates with Medicare Lower Costs $0 copays for primary care visits, and routine dental, hearing, and vision exams Enhanced Benefits Such as fitness and weight-loss reimbursements, telehealth, over-the-counter allowance, comprehensive dental, and more WHY CHOOSE BLUE? Quality, service, and trust. That’s why more people in Massachusetts choose our Medicare plans over any other option.1 Please see the enclosed to learn more. If you have any questions, we’re here to help. Sincerely, Gloria A. Paradiso, Vice President, Government Sales Enclosures Ready to Enroll? By phone: 1-800-678-2265 (TTY: 711) October 1 through March 31: 8:00 a.m. to 8:00 p.m., seven days a week April 1 through September 30: 8:00 a.m. to 8:00 p.m., Monday–Friday Online: bluecrossma.com/medicare By mail: Complete the enclosed enrollment form and return it in the self-addressed envelope. By fax: Complete the enclosed enrollment form and fax to 1-617-246-8506.
1. Represents Medicare Advantage and Medicare Supplemental Individual and Group plan membership based on data from Centers for Medicare & Medicaid Services (cms.gov) and the Massachusetts Department of Insurance (mass.gov). 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. This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information. 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001613327 H2230_2275_M 99-000396684-23 (8/22)
IN THIS BOOKLET 01 Plan Information • Summary of Benefits (including a Pre-Enrollment checklist) • Plan Rating Sheet 02 Resources • Seminar Information • Top 100 Drugs • How to Find a Doctor 03 Disclosures • Nondiscrimination Notice • Translation Resources • Commitment to Confidentiality 04 Enrollment • Enrollment Forms • Business Reply Envelope
Plan Information 01
2023 SUMMARY OF BENEFITS Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. H2230_2293_M Plans 017, 018, 002
This booklet gives you a summary of drug and health services covered by Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO), and what you pay. This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information. To get a complete list of services covered by Blue Cross Blue Shield of Massachusetts, call our Member Service department and ask for the “Evidence of Coverage.” You can also access the “Evidence of Coverage” online at our website, bluecrossma.com/medicare.
1 2023 Summary of Benefits SUMMARY OF BENEFITS January 1, 2023 - December 31, 2023 Choose How You get your Medicare benefits You can choose to: • Get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. • Get your Medicare benefits by joining a Medicare health plan (such as Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), or Medicare PPO Blue PlusRx (PPO)). Tips for comparing your Medicare choices • This Summary of Benefits booklet gives you an overview of what Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO) cover, and what you pay. • To compare our plan with other Medicare health plans’ representatives, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on medicare.gov. • To learn more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at 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. Sections in this booklet • Things to Know About Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO) • Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services • Covered Medical and Hospital Benefits • Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call Member Service at the number shown in the next section.
2 THINGS TO KNOW ABOUT OUR PLANS Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), Medicare PPO Blue PlusRx (PPO) Contact Information and Hours of Operation Members October 1–March 31 1–800–200–4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1–800–200–4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday If you call after business hours, you may leave a message that includes your name, phone number, and the time you called, and a representative will return your call no later than one business day after you leave a message. Member Service also has free language interpreter services available for non-English speakers. Non-Members October 1–March 31 1–800–678–2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1–800–678–2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday Our website: bluecrossma.com/medicare Who can join? To join Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), or Medicare PPO Blue PlusRx (PPO), you must be eligible for Medicare Part A, be enrolled in Medicare Part B, and live in our service area. You must continue to pay your Medicare Part B premium. Our service area includes the following counties in Massachusetts: Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester. Which doctors, hospitals, and pharmacies can I use? Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. bluecrossma.com/medicare-options
3 2023 Summary of Benefits Depending on your plan, you may pay more if you use providers that are not in our network. Out-of-network/non-contracted providers are under no obligation to treat Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO) members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our Member Service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. • You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. • You can view our plan’s provider directory at bluecrossma.com/medicare. • You can view our plan’s pharmacy directory at bluecrossma.com/medicare. • Or, call us and we will send you a copy of the provider and pharmacy directories. The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. What do we cover? We cover everything that Original Medicare covers—and more. • Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. • Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. • Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. • You can view the complete plan formulary (list of Part D prescription drugs) and any restrictions at bluecrossma.com/ medicare-options. • Or, call us and we will send you a copy of the formulary. The formulary may change at any time. You will receive notice when necessary. How will I determine my drug costs? Our plan groups each medication into one of five “tiers.” You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Later in this document, we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible (if applicable). Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible (if applicable). Call us if you would like more information.
4 SUMMARY OF BENEFITS: January 1, 2023 - December 31, 2023 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Monthly Plan Premium Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $0 per month Worcester County: $0 per month Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $75, per month Worcester County: $85, per month Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $254, per month Worcester County: $254, per month You must continue to pay your Medicare Part B premium. Deductibles Medical: These plans do not have a medical deductible. Prescription Drugs: $0 per year $0 per year $200 per year for Tiers 3, 4, 5 Maximum Out-of-Pocket Responsibility (does not include costs related to prescription drugs) Your yearly limit(s) in this plan: $5,600 for services you receive from in-network providers. $8,950 for services you receive from any provider. Your yearly limit(s) in this plan: $4,900 for services you receive from in-network providers. $4,900 for services you receive from any provider. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $5,100 for services you receive from any provider. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your Medicare Part B premium, your plan premium, and any cost sharing for your Part D prescription drugs. bluecrossma.com/medicare-options
5 2023 Summary of Benefits Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Inpatient Hospital Coverage (Per Admission Benefit) Our plan covers an unlimited number of days for an inpatient hospital stay. In-Network: $390 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: $440 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. In-Network: $325 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: $350 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day or days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. In-Network: $125 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: 20% of the cost per stay Authorization rules may apply. Outpatient Hospital Coverage In-Network: $325/visit Out-of-Network: 45% of the total cost In-Network: $250/visit Out-of-Network: 40% of the total cost In-Network: $150/visit Out-of-Network: 20% of the total cost Authorization rules may apply. Ambulatory Surgery Center In-Network: $275/visit Out-of-Network: 45% of the total cost In-Network: $250/visit Out-of-Network: 40% of the total cost In-Network: $150/visit Out-of-Network: 20% of the total cost Authorization rules may apply. Doctor’s Office Visits: (including telehealth visits) Primary Care Provider: In-Network: $0 copay Out-of-Network: $25 copay In-Network: $0 copay Out-of-Network: $20 copay In-Network: $0 copay Out-of-Network: $45 copay
6 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Specialist: In-Network: $45 copay* Out-of-Network: $55 copay In-Network: $40 copay* Out-of-Network: $50 copay In-Network: $35 copay* Out-of-Network: $45 copay *You pay nothing for Medicare-covered specialist services performed in the home furnished by a network provider. Preventive Care You pay nothing You pay nothing In-Network: You pay nothing Out-of-Network: $45 copay or 20% of the cost, depending on the service Our plans cover many preventive services, including: • Abdominal aortic aneurysm screening • Alcohol use counseling • Bone mass measurement • Breast cancer screening (mammogram) • Cardiovascular disease (behavioral therapy) • Cardiovascular screenings • Cervical and vaginal cancer screening • Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)** • Depression screening • Diabetes screenings • Flu shots, pneumococcal shots, Hepatitis B shots (limitations may apply) • HIV screening • Lung cancer screening (low-dose computed tomography (LDCT)) • Medical nutrition therapy services • Obesity screening and counseling • Prostate cancer screenings (PSA) • Sexually transmitted infections screening and counseling • Tobacco-use cessation counseling (counseling for people with no sign of tobacco-related disease) • “Welcome to Medicare” preventive visit (one-time) • Yearly “Wellness” visit • Any additional preventive services approved by Medicare during the contract year will be covered. You pay $0 for a supplemental annual physical exam. Includes a detailed medical/family history and a head to toe assessment with hands-on examination of all body systems to assess overall general health. Authorization rules may apply. **If any other medical condition including polyp or other tissue is found and removed during the procedure this would be considered minimally invasive surgery. Refer to the Outpatient Surgery category for appropriate member cost share. bluecrossma.com/medicare-options
7 2023 Summary of Benefits Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Emergency Care $90 copay $90 copay $75 copay Your copay is waived if you are admitted to the hospital within 24 hours or held overnight for observation. Urgently Needed Services (including telehealth visits) In-Network: $0-$45 copay* Out-of-Network: $55 copay In-Network: $0-$40 copay* Out-of-Network: $50 copay In-Network: $0-$35 copay* Out-of-Network: $45 copay *You pay nothing for Medicare-covered specialist services performed in the home furnished by a network provider. Diagnostic Services/Labs/Imaging Diagnostic Radiology (such as MRIs, CT scans): In-Network: $365 copay per day per category Out-of-Network: $375 copay per day per category In-Network: $250 copay per day per category Out-of-Network: $325 copay per day per category In-Network: $150 copay per day per category Out-of-Network: 40% of the cost per day per category Authorization rules may apply. Diagnostic Tests and Procedures In-Network: $0 copay per day* Out-of-Network: 45% of the cost In-Network: $0 copay per day* Out-of-Network: 40% of the cost In-Network: $10 copay per day* Out-of-Network: 20% of the cost *You pay nothing for covered services performed at home by a network provider. Authorization rules may apply. Lab Services: In-Network: $0 copay per day* Out-of-Network: 45% of the cost In-Network: $0 copay per day* Out-of-Network: 40% of the cost In-Network: $10 copay per day* Out-of-Network: 20% of the cost *You pay nothing for Medicare-covered services performed at home by a network provider Authorization rules may apply. Outpatient X-rays: In-Network: $10 copay per day Out-of-Network: 45% of the cost In-Network: $10 copay per day Out-of-Network: 40% of the cost In-Network: $10 copay per day Out-of-Network: 20% of the cost Authorization rules may apply. Therapeutic Radiology Services: In-Network: $60 copay per visit Out-of-Network: 45% of the cost In-Network: You pay nothing Out-of-Network: 40% of the cost In-Network: You pay nothing Out-of-Network: 20% of the cost Authorization rules may apply.
8 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Hearing Services Routine Exam: (up to 1 every 12 months) In-Network: $0 copay Out-of-Network: $45 copay In-Network: $0 copay Out-of-Network: $45 copay In-Network: $0 copay Out-of-Network: $45 copay Non-Routine Exam: In-Network: $0-$45 copay Out-of-Network: $25-$55 copay In-Network: $0-$40 copay Out-of-Network: $20-$50 copay In-Network: $0-$35 copay Out-of-Network: $45 copay Hearing Aids: $699-$999 copay per hearing aid per year $699-$999 copay per hearing aid per year $699-$999 copay per hearing aid per year You must use a TruHearing™ network provider for all routine hearing exams and the purchase of covered hearing aids. There is no coverage for out-of-network providers. Dental Services Limited Medicare-Covered Dental Services: In-Network: $45 copay. Out-of-Network: $55 copay. In-Network: You pay $40 copay. Out-of-Network: You pay a $50 copay. In-Network: $35 copay Out-of-Network: You pay $45 copay. Dental services—NonMedicare Covered Non-Medicare Covered Dental Services: In-Network: $0 copay for covered preventive services 50% coinsurance for covered comprehensive services Out-of-Network: $60 copay for covered preventive services 50% coinsurance for covered comprehensive services In-Network: $0 copay for covered preventive services 50% coinsurance for covered comprehensive services Out-of-Network: $50 copay for covered preventive services 50% coinsurance for covered comprehensive services $1,000 maximum per calendar year for preventive and comprehensive services combined. See Evidence of Coverage for more details. In-Network: You pay $0 copay. Out-of-network: You pay a $45 copay. Coverage for preventive services only. Maximum of two visits each calendar year. See Evidence of Coverage for more details. bluecrossma.com/medicare-options
9 2023 Summary of Benefits Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Vision Services Medicare-Covered Eye Exam: In-Network: $0-$45 copay Out-of-Network: $25-$55 copay In-Network: $0-$40 copay Out-of-Network: $20-$50 copay In-Network: $0-$35 copay Out-of-Network: $45 copay Eyewear After Cataract Surgery: (for Medicarecovered standard eyewear) In and Out-of-Network: $0 copay In and Out-of-Network: $0 copay In and Out-of-Network: $0 copay Routine Eye Exam: (up to 1 per 12 months) In-Network: $0 copay Out-of-Network: $45 copay In-Network: $0 copay Out-of-Network: $45 copay In-Network: $0 copay Out-of-Network: $45 copay You must use an EyeMed network provider for covered in-network services. Eyewear: (For Covered Eyewear, you pay any balance in excess of the $200 limit.) In and Out-of-Network: Our plan pays up to $200 every 24 months for eyewear In and Out-of-Network: Our plan pays up to $200 every 24 months for eyewear In and Out-of-Network: Our plan pays up to $200 every 24 months for eyewear You must use an EyeMed®´ network provider for covered in-network services. Mental Health Services Inpatient Visit: (per admission) In-Network: $300 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: $400 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond In-Network: $275 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: $325 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond In-Network: $125 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: 20% of the cost per stay Authorization rules may apply per admission.
10 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Outpatient Group Therapy Visit: In-Network: $30 copay Out-of-Network: $40 copay In-Network: $30 copay Out-of-Network: $40 copay In-Network: $25 copay Out-of-Network: 20% of the cost Authorization rules may apply. Outpatient Individual Therapy Visit: (including telehealth visits) In-Network: $30 copay* Out-of-Network: $40 copay In-Network: $30 copay* Out-of-Network: $40 copay In-Network: $25 copay* Out-of-Network: 20% of the cost *You pay nothing for Medicare-covered services performed at home by a network provider. Authorization rules may apply. Additional Services Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. In-Network: You pay nothing per day for days 1 through 20 $170 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Out-of-Network: 20% of the cost per stay Our plan covers up to 100 days in a SNF. In-Network: You pay nothing per day for days 1 through 20 $160 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Out-of-Network: 20% of the cost per stay Our plan covers up to 100 days in a SNF. In-Network: You pay nothing per day for days 1 through 20 $100 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Out-of-Network: 20% of the cost per stay Authorization rules may apply. Physical Therapy In-Network: $40 copay Out-of-Network: 45% of the cost In-Network: $20 copay Out-of-Network: 40% of the cost In-Network: $15 copay Out-of-Network: 20% of the cost Ambulance In-Network: $275 copay per trip Out-of-Network: $275 copay per trip In-Network: $225 copay per trip Out-of-Network: $225 copay per trip In-Network: $100 copay per trip Out-of-Network: $100 copay per trip If you are admitted to the hospital, you do not have to pay for the ambulance services. Authorization rules may apply. Transportation (Including chair vans) Not covered Not covered Not covered bluecrossma.com/medicare-options
11 2023 Summary of Benefits Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Medicare Part B Drugs (Including chemotherapy) In and Out-of-Network: 20% co-insurance In and Out-of-Network: 20% co-insurance In and Out-of-Network: 10% co-insurance Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions. Foot Care (Podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-Network: $0-$45 copay Out-of-Network: $25-$55 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-Network: $0-$40 copay Out-of-Network: $20-$50 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-Network: $0-$35 copay Out-of-Network: $45 copay Diabetes Supplies and Services* Diabetes Monitoring Supplies: In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Authorization rules may apply. Diabetes Self-Management Training: In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Therapeutic Shoes or Inserts: In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost *There is no co-insurance or copayment for the One Touch®´ blood glucose test strips and blood glucose monitors purchased at participating retail and mail service pharmacies; otherwise you pay all costs. Test strips and blood glucose monitors are also available at DME suppliers with no co-insurance or copayment. There is no co-insurance or copayment for members eligible for covered therapeutic molded shoes and inserts, diabetes self-management training preventive benefit, or fasting plasma glucose tests.
12 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Durable Medical Equipment (wheelchairs, oxygen, etc.) In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Authorization rules may apply. Prosthetic Devices (braces, artificial limbs, etc.) Prosthetic Devices: In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Related Medical Supplies: In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 20% of the cost Out-of-Network: 20% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Over-the-counter items (OTC) In-network: Our plan pays up to $65 per quarter (up to $260 per year) changes, towards over-the-counter health & wellness products. Out-of-network: The in-network provider must be used for the OTC items benefit. Not covered. Not covered. CVS will manage the OTC benefit. See the OTC catalog for a list of eligible items. Be sure to use your benefits amount before the end of each quarter (March, June, September, December). Remaining benefit does not roll over. Purchase OTC items by mail, phone, or in participating CVS retail stores. You can find the catalog at cvs.com/otchs/bcbsma. If you have questions or to order by phone, please call 1-888-628-2770 (TTY:711) Monday – Friday 9:00 a.m. to 8:00 p.m. ET. Wellness Programs (See back of this booklet for more details) Fitness: $150 per calendar year $150 per calendar year $250 per calendar year Weight Loss: $150 per calendar year $150 per calendar year $150 per calendar year bluecrossma.com/medicare-options
13 2023 Summary of Benefits REWARDING YOU FOR HEALTHY CHOICES GET REIMBURSED UP TO $300 PER YEAR WHEN YOU ENROLL IN QUALIFIED FITNESS AND WEIGHT-LOSS PROGRAMS. $150-250 FITNESS REIMBURSEMENT $150 WEIGHT-LOSS REIMBURSEMENT WELLNESS PROGRAMS Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), Medicare PPO Blue PlusRx (PPO) Take Control of Your Health With Our Fitness and Weight-Loss Benefits What is the Fitness Benefit? Enroll in a qualified health club or fitness facility and receive up to $250 per calendar year toward your club membership fees and exercise classes. What programs qualify? • Virtual/online fitness memberships, subscriptions, programs, or classes that provide cardiovascular and strength training using a digital platform • Home Fitness Equipment like stationary bikes, weights, exercise bands, treadmills, fitness machines. • Home Fitness Equipment WILL NOT cover wearable fitness trackers or items that are considered “Recreational Equipment” or “Sports Equipment” examples include kayaks, inline skates, bicycles, ice skates, trampolines, fitness clothing, sneakers • Health clubs with a variety of cardiovascular and strength-training exercise equipment, e.g., traditional health clubs, YMCAs, YWCAs, and community fitness centers or facilities that only have a pool. • Fitness classes at participating Councils on Aging (COA) facilities; fitness studios with instructor-led groups such as yoga, Pilates, Zumba®´, kickboxing, CrossFit®´, and indoor cycling/spinning and other exercise classes. • Programs that DO NOT qualify: Martial arts centers; gymnastics facilities; country clubs; tennis, aerobic; social clubs; and sports teams/leagues. You cannot receive the Fitness Benefit for personal training, lessons, coaching, or clothing. What is the Weight-Loss Benefit? Enroll in a qualified weight-loss program and receive up to $150 per calendar year toward your program fees. Employer group benefits may vary. What kinds of programs qualify? • Traditional WW (formerly known as Weight Watchers®´) meetings, WW Online and At Work programs, hospital-based and other non-hospital-based weight-loss programs that combine healthy eating, exercise, and coaching sessions. • Programs that DO NOT qualify: Individual nutrition counseling sessions, pre-packaged meals, books, videos, scales, or other items and supplies.
14 PRESCRIPTION DRUG BENEFITS Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRX (PPO) Deductible $0 per year $0 per year $200 per year for Tiers 3, 4, 5 Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $4,660. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail service pharmacies. Tier 1 = Preferred Generic Tier 2 = Generic Tier 3 = Preferred Brand Tier 4 = Non-Preferred Drug Tier 5 = Specialty Tier Note: Cost sharing may differ relative to the pharmacy’s status as preferred or standard, mail service, Long-Term Care (LTC) or home infusion, and 30-day or 90-day supply. Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Preferred Retail Cost Sharing Drug Tier 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Tier 2 (Generic) $10 copay $20 copay $30 copay $6 copay $12 copay $18 copay $5 copay $10 copay $15 copay Tier 3 (Preferred Brand) $42 copay $84 copay $126 copay $42 copay $84 copay $126 copay $42 copay $84 copay $126 copay Select Insulin $35 $70 $105 $35 $70 $105 $35 $70 $105 Tier 4 (Non-Preferred Drug) $95 copay $190 copay $285 copay $95 copay $190 copay $285 copay $95 copay $190 copay $285 copay Tier 5 (Specialty Tier) 30% of the cost N/A N/A 28% of the cost N/A N/A 29% of the cost N/A N/A bluecrossma.com/medicare-options
15 2023 Summary of Benefits Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Standard Retail Cost Sharing Drug Tier 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply Tier 1 (Preferred Generic) $10 copay $20 copay $30 copay $8 copay $16 copay $24 copay $6 copay $12 copay $18 copay Tier 2 (Generic) $20 copay $40 copay $60 copay $12 copay $24 copay $36 copay $10 copay $20 copay $30 copay Tier 3 (Preferred Brand) $47 copay $94 copay $141 copay $47 copay $94 copay $141 copay $47 copay $94 copay $141 copay Select Insulin $35 $70 $105 $35 $70 $105 $35 $70 $105 Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay $100 copay $200 copay $300 copay $100 copay $200 copay $300 copay Tier 5 (Specialty Tier) 30% of the cost N/A N/A 28% of the cost N/A N/A 29% of the cost N/A N/A Mail Service Cost Sharing Drug Tier 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply 30-day supply 60-day supply 90-day supply Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Tier 2 (Generic) $10 copay $20 copay $20 copay $6 copay $12 copay $12 copay $5 copay $10 copay $10 copay Tier 3 (Preferred Brand) $42 copay $84 copay $84 copay $42 copay $84 copay $84 copay $42 copay $84 copay $84 copay Select Insulin $35 $70 $70 $35 $70 $70 $35 $70 $70 Tier 4 (Non-Preferred Drug) $95 copay $190 copay $190 copay $95 copay $190 copay $190 copay $95 copay $190 copay $190 copay Tier 5 (Specialty Tier) 30% of the cost N/A N/A 28% of the cost N/A N/A 29% of the cost N/A N/A If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.
16 Medicare PPO Blue SaverRx (PPO) Medicare PPO Blue ValueRx (PPO) Medicare PPO Blue PlusRx (PPO) Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,660. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $7,400, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail service) reach $7,400, you pay the greater of: 5% of the cost, or $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copayment for all other drugs. bluecrossma.com/medicare-options
17 2023 Summary of Benefits PRE-ENROLLMENT CHECKLIST Before making an enrollment decision, it’s important that you fully understand our benefits and rules. We’ve put together the checklist below to help you. If you have any questions, you can call and speak to a customer service representative. 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 bluecrossma.com/medicare or call 1-800-678-2265 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. 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. Review the formulary to make sure your drugs are covered. 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, 2024. Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will pay a higher copay for services received by non-contracted providers. Call Us: 1-800-678-2265 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. Independent Licensees of the Blue Cross and Blue Shield Association. H2230_22190_M
18 Contact Information and Hours of Operation Members October 1–March 31 1–800–200–4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1–800–200–4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday If you call after business hours, you may leave a message that includes your name, phone number, and the time you called, and a representative will return your call no later than one business day after you leave a message. Member Service also has free language interpreter services available for non-English speakers. Non-Members October 1–March 31 1–800–678–2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1–800–678–2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday Our website: bluecrossma.com/medicare bluecrossma.com/medicare-options
19 2023 Summary of Benefits GET THE MYBLUE APP YOU CAN DOWNLOAD THE MYBLUE APP FROM THE APP STORE®´ OR GOOGLE PLAYTM
20 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. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Medicare Advantage Appeals and Grievance Manager. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov. bluecrossma.com/medicare-options
TRANSLATION RESOURCES Form Approved OMB# 0938-1421 Proficiency of Language Assistance Services Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association Form CMS-10802 (Expires 12/31/25) English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-200-4255. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-200-4255. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。如果 您需要此翻译服务，请致电 1-800-200-4255。我们的中文工作人员很乐意帮助您。 这是一项免费 服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服務。 如需翻譯服務，請致電 1-800-200-4255。我們講中文的人員將樂意為您提供幫助。這 是一項免費 服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-200-4255. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-200-4255. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-200-4255 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800- 200-4255. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보 또는 약 보에 관 질문에 답 드리고자 무료 역 서비스를 제공고 있습니다. 역 서비스를 이용려면 전 1-800-200-4255 번으로 문의 주십시오. 국어를 는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield depends upon 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. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Form CMS-10802 (Expires 12/31/25) Y0014_23166_C 002336563 | 55-1490B (9/23) Form Approved OMB# 0938-1421 Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-200-4255. Вам окажет помощь сотрудник, который говорит поpусски. Данная услуга бесплатная. Arabic :إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا. للحصول على مترجم فوري، ليس عليك سوى االتصال بنا على 4255-200-800-1 . سيقوم شخص ما يتحدث العربية بمساعدتك. هذه خدمة مجانية. Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब देने के किए हमारे पास मुफ्त दुभाकिया सेवाएँ उपिब्ध हैं. एक दुभाकिया प्राप्त करने के किए~बस हमें 1-800-200-4255 पर फोन करें. कोई व्यक्ति जो कहन्दी बोिता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-200-4255. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portuguese: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-200-4255. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-200-4255. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-200-4255. Ta usługa jest bezpłatna. Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無 料の通訳サービスがありますございます。通訳をご用命になるには、1-800-200-4255 にお電 話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。
NOTES
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. 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. ®´ Registered Marks and TM Trademarks are the property of their respective owners. 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002287500 H2230_2293_M 55-0605-23 (8/23) FOR MORE INFORMATION OR HELP WITH ENROLLMENT Medicare Plan Sales 1-800-678-2265 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. bluecrossma.com/medicare
IMPORTANT INFORMATION: 2023 Medicare Star Ratings Blue Cross Blue Shield of Massachusetts - H2230 For 2023, Blue Cross Blue Shield of Massachusetts - H2230 received the following Star Ratings from Medicare: Overall Star Rating: Health Services Rating: Drug Services Rating: Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings Are Important Medicare rates plans on their health and drug services. This lets you easily compare plans based on quality and performance. Star Ratings are based on factors that include: Feedback from members about the plan’s service and care The number of members who left or stayed with the plan The number of complaints Medicare got about the plan Data from doctors and hospitals that work with the plan More stars mean a better plan – for example, members may get better care and better, faster customer service. The number of stars show how well a plan performs. EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR Get More Information on Star Ratings Online Compare Star Ratings for this and other plans online at medicare.gov/plan-compare. Questions about this plan? Contact Blue Cross Blue Shield of Massachusetts 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 800-678-2265 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 800-200-4255 (toll-free) or 711 (TTY). You can file a complaint if you have if you feel that you received inaccurate, misleading, or inappropriate information. Please call Blue Cross Blue Shield of Massachusetts at 1-800-200-4255 (TTY: 711). If your complaint involves a broker or agent, be sure to include the name of the person when filing your complaint. H2230_2281_M 001994251_PPO | 99-0289-23 (1/23) 1/1 IMPORTANT INFORMATION: 2023 Medicare Star Ratings Blue Cross Blue Shield of Massachusetts - H2230 For 2023, Blue Cross Blue Shield of Massachusetts - H2230 received the following Star Ratings from Medicare: Overall Star Rating: Health Services Rating: Drug Services Rating: Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings Are Important Medicare rates plans on their health and drug services. This lets you easily compare plans based on quality and performance. Star Ratings are based on factors that include: Feedback from members about the plan’s service and care The number of members who left or stayed with the plan The number of complaints Medicare got about the plan Data from doctors and hospitals that work with the plan More stars mean a better plan – for example, members may get better care and better, faster customer service. The number of stars show how well a plan performs. EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR Get More Information on Star Ratings Online Compare Star Ratings for this and other plans online at medicare.gov/plan-compare. Questions about this plan? Contact Blue Cross Blue Shield of Massachusetts 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 800-678-2265 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 800-200-4255 (toll-free) or 711 (TTY). You can file a complaint if you have if you feel that you received inaccurate, misleading, or inappropriate information. Please call Blue Cross Blue Shield of Massachusetts at 1-800-200-4255 (TTY: 711). If your complaint involves a broker or agent, be sure to include the name of the person when filing your complaint. H2230_2281_M 001994251_PPO | 99-0289-23 (1/23) 1/1
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JOIN US AND LEARN MORE ABOUT MEDICARE The best plan is the kind you understand. Join one of our upcoming Medicare seminars to learn more about your options and get answers to your questions. Topics include: Medicare Advantage (HMO and PPO) Original Medicare and Medex®´ (Medicare Supplement) Prescription Drug Plans (PDP) Dental Blue® 65 GeoBlue® Travel Insurance UPCOMING SEMINARS To view the full list of upcoming seminars including in-person and online options and to sign up, scan the QR code, or visit bluecrossma.com/seminar. Seminar Type Date Time Location Dental Blue® 65 Thursday, October 19, 2023 9:00 a.m. - 9:30 a.m. Online Medicare Plan Options* Thursday, October 19, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham Original Medicare & Medex®´ (Medicare Supplement) Friday, October 20, 2023 9:30 a.m. - 10:15 a.m. Online Medicare Plan Options* Friday, October 20, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester Prescription Drug Plans (PDP) Friday, October 20, 2023 10:30 a.m. - 11:15 a.m. Online Medicare Plan Options* Monday, October 23, 2023 10:00 a.m. - 12:00 p.m. Emerald Resort: Irish Village/HyPort Conference Center/Atlantis Sports Club 35 Scudder Avenue, Hyannis Medicare Advantage (HMO & PPO) Monday, October 23, 2023 4:00 p.m. - 5:00 p.m. Online Medicare Plan Options* Tuesday, October 24, 2023 10:00 a.m. - 12:00 p.m. La Quinta Inn & Suites by Wyndham 100 Congress Street, Springfield Medicare Plan Options* Wednesday, October 25, 2023 10:00 a.m. - 12:00 p.m. Marriott 8A Centennial Drive, Peabody Medicare Plan Options* Thursday, October 26, 2023 10:00 a.m. - 12:00 p.m. McGovern’s Family Restaurant 310 Shove Street, Fall River Medicare Plan Options* Friday, October 27, 2023 10:00 a.m. - 12:00 p.m. DoubleTree by Hilton 99 Erdman Way, Leominster 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 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. ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002313605 Y0014_22171_M 99-0645-23 (8/23) Not seeing a date that works for you? There are plenty more to choose from. Check out our full list of events at bluecrossma.com/seminar, or scan the QR Code. NEED HELP SIGNING UP? For assistance signing up for a seminar, or for accommodations for persons with special needs, call 1-800-262-BLUE (2583) (TTY: 711) 7:00 a.m. – 12:00 midnight, seven days a week (excluding holidays). Seminar Type Date Time Location Medicare Plan Options* Saturday, October 28, 2023 10:00 a.m. - 12:00 p.m. Hilton Boston Back Bay 40 Dalton Street, Boston Medicare Plan Options* Monday, October 30, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester Medicare Plan Options* Tuesday, October 31, 2023 10:00 a.m. - 12:00 p.m. Courtyard by Marriott 40 Webster Street, Brookline Medicare Plan Options* Wednesday, November 1, 2023 10:00 a.m. - 12:00 p.m. DoubleTree by Hilton 99 Erdman Way, Leominster Dental Blue 65 Wednesday, November 1, 2023 4:00 p.m. - 4:30 p.m. Online GeoBlue® Travel Insurance Wednesday, November 1, 2023 5:00 p.m. - 5:30 p.m. Online Medicare Plan Options* Thursday, November 2, 2023 10:00 a.m. - 12:00 p.m. Marriott One Burlington Mall Road, Burlington Medicare Advantage (HMO & PPO) Friday, November 3, 2023 9:00 a.m. - 10:00 a.m. Online Medicare Plan Options* Friday, November 3, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham Medicare Plan Options* Saturday, November 4, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester Medicare Plan Options* Monday, November 6, 2023 10:00 a.m. - 12:00 p.m. John Carver Inn & Spa 25 Summer Street, Plymouth Medicare Plan Options* Thursday, November 9, 2023 10:00 a.m. - 12:00 p.m. Courtyard by Marriott 40 Webster Street, Brookline Medicare Plan Options* Monday, November 13, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham *A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits. They can answer your questions and assist with enrollment when you’re ready. Visit the website below to view the agenda.
MEDICARE ADVANTAGE TOP 100 DRUG LIST Looking for one good reason why a Medicare Advantage plan with prescription drug coverage from Blue Cross Blue Shield of Massachusetts is the right plan for you? Here are 100. And this is just a sample of our Medicare Advantage plan’s drug list. We also cover hundreds of other medications. MEDICATION NAME ADVAIR DISKUS® CLOBETASOL PROPIONATE GLIPIZIDE ALBUTEROL SULFATE HFA CLONAZEPAM GLIPIZIDE ER ALENDRONATE SODIUM CLOPIDOGREL HYDROCHLOROTHIAZIDE ALLOPURINOL DICLOFENAC SODIUM HYDROCODONE-ACETAMINOPHEN ALPRAZOLAM DILTIAZEM 24HR ER (CD) IBUPROFEN AMLODIPINE BESYLATE DONEPEZIL HCL IRBESARTAN AMOXICILLIN DORZOLAMIDE-TIMOLOL ISOSORBIDE MONONITRATE ER AMOXICILLIN-CLAVULANATE POTASS DOXYCYCLINE HYCLATE JARDIANCE® ATENOLOL DOXYCYCLINE MONOHYDRATE KETOCONAZOLE ATORVASTATIN CALCIUM DULOXETINE HCL KETOROLAC TROMETHAMINE AZITHROMYCIN ELIQUIS® LANTUS® SOLOSTAR® BUPROPION HCL SR ESCITALOPRAM OXALATE LATANOPROST BUPROPION XL ESTRADIOL LEVOTHYROXINE SODIUM CARVEDILOL EZETIMIBE LISINOPRIL CELECOXIB FAMOTIDINE LISINOPRIL-HYDROCHLOROTHIAZIDE CEPHALEXIN FENOFIBRATE LORAZEPAM CHLORHEXIDINE GLUCONATE FINASTERIDE LOSARTAN POTASSIUM CHLORTHALIDONE FLUOXETINE HCL LOVASTATIN CIPROFLOXACIN HCL FLUTICASONE PROPIONATE MELOXICAM CITALOPRAM HBR FUROSEMIDE METFORMIN HCL CLINDAMYCIN HCL GABAPENTIN METFORMIN HCL ER continued 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 HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615494 Y0014_2277_M 50-0177-23 (9/22) MEDICATION NAME METHYLPREDNISOLONE PANTOPRAZOLE SODIUM TAMSULOSIN HCL METOPROLOL SUCCINATE PAROXETINE HCL TIMOLOL MALEATE METOPROLOL TARTRATE POTASSIUM CHLORIDE TRAMADOL HCL METRONIDAZOLE PRAVASTATIN SODIUM TRAZODONE HCL MIRTAZAPINE PREDNISOLONE ACETATE TRIAMCINOLONE ACETONIDE MONTELUKAST SODIUM PREDNISONE TRIAMTERENE-HYDROCHLOROTHIAZID MUPIROCIN ROSUVASTATIN CALCIUM TRULICITY® NITROFURANTOIN MONO-MACRO SERTRALINE HCL VALACYCLOVIR OFLOXACIN SHINGRIX VALSARTAN OMEPRAZOLE SIMVASTATIN VENLAFAXINE HCL ER OXYBUTYNIN CHLORIDE ER SPIRONOLACTONE WARFARIN SODIUM OXYCODONE HCL SULFAMETHOXAZOLE-TRIMETHOPRIM ZOLPIDEM TARTRATE OXYCODONE-ACETAMINOPHEN This list is subject to change.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Medicare PPO Blue (PPO) IS YOUR PROVIDER OF CHOICE (POC) IN THE MEDICARE PPO BLUE NETWORK? To find your current POC in the Medicare PPO Blue Network, use our Find a Doctor & Estimate Costs tool. You can also search for other in-network doctors, hospitals, and health care professionals by following these three steps: 1. Sign in to your MyBlue account at bluecrossma.org, or open the MyBlue app. 2. Under My Care, select Find a Doctor & Estimate Costs. 3. Enter a doctor, hospital, or type of care, then click Search. To search for a doctor without signing in, go to bluecrossma.com/findadoctor, and enter Medicare PPO Blue under Select a Network. The Easy Way to Find Care Search by name, specialty, facility, keyword, or browse by category. Plus, get cost estimates for more than 1,500 common procedures. Compare up to five doctors at once, use filters to narrow your results, and review provider quality ratings. View in-depth provider profiles, which include specialties, languages, contact information, and whether they’re accepting new patients.
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. The provider network may change at any time. You will receive notice when necessary. 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 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross Blue Shield of Massachusetts HMO Blue, Inc. 001632356 H2230_2283_C 37-1880-23 (9/22) WE’RE HERE TO HELP If you need help finding a doctor, or if you don’t have Internet access, call us at 1-800-678-2265 (TTY: 711). A representative is available to help you: OCTOBER 1 THROUGH MARCH 31: 8:00 a.m. to 8:00 p.m. ET, seven days a week APRIL 1 THROUGH SEPTEMBER 30: 8:00 a.m. to 8:00 p.m. ET, Monday through Friday Did You Know? Your PPO plan gives you access to our nationwide network. To search outside of Massachusetts, go to bcbs.com, select Find a Doctor or Hospital, and follow the easy steps.
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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. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Medicare Advantage Appeals and Grievance Manager. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov. 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615321 55-1490A (9/22)