BCBSMA MEDICARE HMO SalesKit Book 07/01/2021 Approved by Danielle Roy 0/21/2021 4:55 PM

Medicare Advantage Plans

MEDICARE HMO BLUE (HMO) 2021

COVERAGE YOU NEED FROM A NAME YOU CAN TRUST

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2261_2048_C

(07/01/21)



101 Huntington Avenue
Suite 1300
Boston, MA 02199-7611
bluecrossma.org

Dear Prospective Member,
Thank you for your interest in our Medicare Advantage HMO Blue plans. Our team of
dedicated Medicare experts takes pride in delivering an unmatched experience to each
of our members, every day, and providing the level of quality and coverage you expect
from Blue Cross Blue Shield of Massachusetts.

Why Medicare Advantage?

More people in Massachusetts choose Blue Cross than any other plan in the state1
because of our commitment to quality and affordability. Our plans include coverage for
Part D prescription drugs and a preferred pharmacy network. Plus each member gets up to
$300 toward qualified fitness and weight-loss programs (or up to $400 for Medicare HMO
Blue SaverRx members). We also include routine dental, vision, and hearing services in
many of our plans.
Please see the enclosed for more information. If you have any questions, we’re here to help.
Sincerely,

Gloria A. Paradiso, Online: bluecrossma.com/medicare
Executive Director, Medicare Sales
By mail: Complete the enclosed
Enclosures enrollment form and return it in the
self-addressed envelope.
Ready to Enroll?
By fax: Complete the enclosed enrollment
By phone: 1-800-678-2265 (TTY: 711) form and fax to 1-617-246-8506.
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

1. Represents Medicare Advantage and Medicare Supplemental Individual and Group plan membership, based
on data from Centers for Medicare & Medicaid Services (cms.gov) and Massachusetts Division of Insurance
(mass.gov).

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 a 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).

000402204 ® Registered Marks of the Blue Cross and Blue Shield Association. 55-0619-21 (10/20)
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

H2261_2088_M

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



01

Plan
Information



Medicare HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

2021 SUMMARY OF BENEFITS

H2261 PLANS 024, 022, 023, 005

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2261_2092_M

This booklet gives you a summary of drug
and health services covered by Medicare HMO Blue SaverRx
(HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO

Blue FlexRx (HMO-POS) and Medicare HMO Blue
PlusRx (HMO) 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 we cover, 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.

SUMMARY OF BENEFITS • If you want to know more about the coverage
and costs of Original Medicare, look in your
January 1, 2021 - December 31, 2021 current “Medicare & You” handbook. View
it online at medicare.gov or get a copy by
You have choices about how calling 1-800-MEDICARE (1-800-633-4227),
to get your Medicare benefits 24 hours a day, 7 days a week. TTY users
should call 1-877-486-2048.
• One choice is to get your Medicare benefits
through Original Medicare (fee-for-service Sections in this booklet
Medicare). Original Medicare is run directly
by the Federal government. • Things to Know About Medicare HMO
Blue SaverRx (HMO), Medicare HMO
• Another choice is to get your Medicare Blue ValueRx (HMO), Medicare HMO Blue
benefits by joining a Medicare health plan FlexRx (HMO-POS) and Medicare HMO
(such as Medicare HMO Blue SaverRx Blue PlusRx (HMO)
(HMO), Medicare HMO Blue ValueRx
(HMO), Medicare HMO Blue FlexRx • Monthly Premium, Deductible, and Limits
(HMO-POS) and Medicare HMO Blue on How Much You Pay for Covered Services
PlusRx (HMO)).
• Covered Medical and Hospital Benefits
Tips for comparing your • Prescription Drug Benefits
Medicare choices This document is available in other
formats such as Braille and large print.
This Summary of Benefits booklet gives you This document may be available in a
a summary of what Medicare HMO Blue non-English language. For additional
SaverRx (HMO), Medicare HMO Blue ValueRx information, call Member Service at
(HMO), Medicare HMO Blue FlexRx (HMO- the number shown in the next section.
POS) and Medicare HMO Blue PlusRx (HMO)
cover and what you pay.
• If you want to compare our plan with other

Medicare health plans, ask the other plans
for their Summary of Benefits booklets.
Or, use the Medicare Plan Finder on
medicare.gov.

1 2021 Summary of Benefits

THINGS TO KNOW ABOUT

Medicare HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

Contact Information and Hours of Operation

Members

October 1 - March 31 April 1 - September 30
1-800-200-4255 (TTY: 711) 1-800-200-4255 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 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 April 1 - September 30
1-800-678-2265 (TTY: 711) 1-800-678-2265 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 8:00 a.m. to 8:00 p.m., 5 days a week, Monday - Friday

Our website: bluecrossma.com/medicare-options

Who can join? Which doctors, hospitals,
and pharmacies can I use?
To join Medicare HMO Blue SaverRx
(HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue SaverRx (HMO), Medicare
Medicare HMO Blue FlexRx (HMO-POS) HMO Blue ValueRx (HMO), and Medicare HMO
and Medicare HMO Blue PlusRx (HMO), Blue PlusRx (HMO) have a network of doctors,
you must be entitled to Medicare Part A, hospitals, pharmacies, and other providers.
be enrolled in Medicare Part B, and live You must receive your care from a network
in our service area. You must continue provider. In most cases, care you receive
to pay your Medicare Part B premium. from an out-of-network provider (a provider
Our service area includes the following who is not part of our plan’s network) will not
counties in Massachusetts: Barnstable, be covered.
Bristol, Essex, Franklin, Hampden,
Hampshire, Middlesex, Norfolk,
Plymouth, Suffolk, and Worcester.

bluecrossma.com/medicare-options 2

Medicare HMO Blue FlexRx (HMO-POS) has What do we cover?
a network of doctors, hospitals, pharmacies,
and other providers. For some services you Like all Medicare health plans, we cover
can use providers that are not in our network. everything that Original Medicare covers—
As a member of our Medicare HMO Blue and more.
plans, you must choose a network Primary • Our plan members get all of the benefits
Care Physician (PCP). Your PCP will provide
most of your care and will coordinate or help covered by Original Medicare. For some
you arrange the rest of the covered services of these benefits, you may pay more in our
you get as a member of our plan. In most plan than you would in Original Medicare.
situations, your network PCP must give For others, you may pay less.
you approval in advance before you can use • Our plan members also get more than
other providers in the plan’s network, such as what is covered by Original Medicare.
specialists, hospitals, skilled nursing facilities, Some of the extra benefits are outlined
or home health care agencies. This is called in this booklet.
giving you a “referral.” Referrals from your PCP • Plans may offer supplemental benefits
are not required for emergency care or urgently in addition to Part C benefits and Part D
needed services. benefits.
You must generally use network pharmacies to We cover Part D drugs. In addition, we cover
fill your prescriptions for covered Part D drugs. Part B drugs such as chemotherapy and some
You can see our plan’s provider directory drugs administered by your provider.
at our website (bluecrossma.com/ • You can see the complete plan formulary
findadoctor). (list of Part D prescription drugs)
You can see our plan’s pharmacy and any restrictions on our website,
directory at our website bluecrossma.com/medicare-options.
(bluecrossma.com/medicare-options). • Or, call us and we will send you a copy
Or, call us and we will send you a copy of the formulary. The formulary may change
of the provider and pharmacy directories. at any time. You will receive notice when
The pharmacy network, and/or provider necessary.
network may change at any time.
You will receive notice when necessary. How will I determine
my drug costs?

Our plans group each medication into one of
five or six “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.

3 2021 Summary of Benefits

SUMMARY OF BENEFITS:

January 1, 2021 - December 31, 2021

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Monthly Plan Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol,
Premium Essex, Franklin, Essex, Franklin, Essex, Franklin, Essex, Franklin,
Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire,
Deductibles Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk,
Medical: Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk
Prescription counties: counties: counties: counties:
Drugs: $0 per month $36 per month $267 per month $96 per month

Maximum Worcester County: Worcester County: Worcester County: Worcester County:
Out-of-Pocket $0 per month $56 per month $267 per month $106 per month
Responsibility
(does not You must continue to pay your Medicare Part B premium.
include costs
related to These plans do not have a medical deductible.
prescription
drugs) $320 per year for $320 per year for $200 per year for $260 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

Your yearly limit(s) Your yearly limit(s) Your yearly limit(s) Your yearly limit(s)
in this plan: in this plan: in this plan: in this plan:

$7,550 for services $4,900 for services $3,400 for services $3,900 for services
you receive from you receive from you receive from you receive from
in-network providers. in-network providers. in-network providers. in-network providers.

$9,900 for services
you receive from out-
of-network providers.

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 4

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Our plan covers an unlimited number of days for an inpatient hospital stay.

Inpatient $390 copay per day $300 copay per day $150 copay per day In-Network:
Hospital for days 1 through 5 for days 1 through 5 for days 1 through 5 $225 copay per day
Coverage for days 1 through 5
You pay nothing per You pay nothing per You pay nothing per
day for days 6 day for days 6 day for days 6 You pay nothing
through 90 through 90 through 90 per day for days 6
through 90
You pay nothing You pay nothing You pay nothing
per day for days 91 per day for days 91 per day for days 91 You pay nothing
and beyond and beyond and beyond per day for days 91
and beyond
Per admission benefit. Per admission benefit. Per admission benefit.
Out-of-Network:
20% of the cost
per stay

Authorization rules may apply

Outpatient $325/visit $300/visit $150/visit In-Network:
Hospital $210/visit
Coverage
Out-of-Network:
20% of the total cost

Authorization rules may apply

Ambulatory $280/visit $275/visit $150/visit In-Network:
$200/visit
Surgery Center
Out-of-Network:
20% of the total cost

Authorization rules may apply

Doctor’s Office Visits

Primary Care $10 copay $10 copay $5 copay In-Network:
Physician: $10 copay

Out-of-network:
$65 copay

Specialist: $45 copay $40 copay $35 copay In-Network:
$35 copay

Out-of-Network:
$65 copay

You pay nothing for covered services performed at home by a network provider.
Authorization rules may apply. Referral from your doctor may be required.

5 2021 Summary of Benefits

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

You pay nothing You pay nothing You pay nothing In-Network:
You pay nothing

Out-of-Network:
$65 copay or 20%
of the cost, depending
on the service

Our plans cover many preventive services, including:

Preventive • Abdominal aortic aneurysm screening • Prostate cancer screenings (PSA)
Care • Alcohol misuse counseling
• Bone mass measurement • Sexually transmitted infections screening
• Breast cancer screening (mammogram) and counseling
• Cardiovascular disease (behavioral therapy)
• Cardiovascular screenings • Lung cancer screening (low dose computed
• Cervical and vaginal cancer screening tomography (LDCT))
• Colorectal cancer screenings
• Tobacco use cessation counseling
(Colonoscopy, Fecal occult blood test, (counseling for people with no sign
Flexible sigmoidoscopy)* of tobacco-related disease)
• Depression screening
• Diabetes screenings • Flu shots, pneumococcal shots, Hepatitis B
• HIV screening shots (limitations may apply)
• Medical nutrition therapy services
• Obesity screening and counseling • “Welcome to Medicare” preventive visit
(one-time)

• Yearly “Wellness” visit

Any additional preventive services approved
by Medicare during the contract year will
be covered.

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 6

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Preventive Care You pay $0 for a You pay $0 for a You pay $0 for a You pay $0
(continued) supplemental annual supplemental annual supplemental annual in-network and $65
physical exam. physical exam. physical exam. out-of-network for a
supplemental annual
Includes a detailed Includes a detailed Includes a detailed physical exam.
medical/family history medical/family history medical/family history
and a head to toe and a head to toe and a head to toe Includes a detailed
assessment with assessment with assessment with medical/family history
hands-on examination hands-on examination hands-on examination and a head to toe
of all body systems of all body systems of all body systems assessment with
to assess overall to assess overall to assess overall hands-on examination
general health. general health. general health. of all body systems
to assess overall
general health.

Emergency $90 copay $90 copay $75 copay $90 copay
Care
Your copay is waived if you are admitted to the hospital within 24 hours or held overnight
for observation.

$10-$45 copay $10-$40 copay $5-$35 copay In Network:
per visit per visit per visit $10–$35 copay
per visit
Urgently
Needed Out-of-Network:
Services $65 copay per visit

You pay nothing for covered services performed at home by a network provider.

Diagnostic Services/Labs/Imaging

Diagnostic $275 copay per day $250 copay per day $150 copay per day In Network:
Radiology per category per category per category $200 copay per day
(such as MRIs, per category
CT scans):
Out-of-Network:
40% of the cost

Authorization rules may apply

$10 copay per day $10 copay per day $0 copay per day In Network:
$10 copay per day
Diagnostic
Tests and Out-of-Network:
Procedures 20% of the cost

You pay nothing for covered services performed at home by a network provider.
Authorization rules may apply.

7 2021 Summary of Benefits

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

$10 copay per day $10 copay per day $0 copay per day In Network:
$10 copay per day
Lab services:
Out-of-Network:
20% of the cost

You pay nothing for covered services performed at home by a network provider.
Authorization rules may apply. Referral from your doctor may be required.

$10 copay per day $10 copay per day $5 copay per day In Network:
$10 copay per day
Outpatient
X-rays: Out-of-network:
20% of the cost

Authorization rules may apply

$60 copay per visit You pay nothing You pay nothing In Network:
You pay nothing
Therapeutic
Radiology Out-of-Network:
Services: 20% of the cost

Authorization rules may apply

Hearing Services

$0 copay $0 copay $0 copay In Network:
$0 copay
Routine
Exam— Out-of-Network:
up to one per Not covered
year:

You must use a TruHearing network provider for all routine hearing exams.

$10-$45 copay $10-$40 copay $5–$35 copay In Network:
$10-$35 copay
Non Routine
Exam: Out-of-Network:
$65 copay

Hearing Aids: $699-$999 copay per $699-$999 copay per $699-$999 copay per $699-$999 copay per
hearing aid per year hearing aid per year hearing aid per year hearing aid per year

You must use a TruHearing network provider for the purchase of covered hearing aids.
There is no coverage for out-of-network providers.

Dental Services

Limited $45 copay $40 copay $35 copay In Network:
Medicare- $35 copay
Covered Dental
Services: Out-of-Network:
$65 copay or 20%

bluecrossma.com/medicare-options 8

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
$0 copay
Routine Dental $0 copay $0 copay In Network:
Services: $0 copay
Single copay Out-of-Network:
for visit that $45 copay
includes:
Cleaning (for up
to 2 per year);
prophylaxis
only - does
not include
periodontal
cleaning
Dental x-ray(s)*
(for up to 2
per year)
Oral exam
(for up to 2
per year)

*Dental x-ray(s) coverage is limited to two sets of bitewings per year.

9 2021 Summary of Benefits

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Vision Services

Medicare- $10-$45 copay $10-$40 copay $5-$35 copay In-Network:
Covered Eye $10-$35 copay
Exam:
Out-of-Network:
$65 copay

Eyewear After $0 copay $0 copay $0 copay In and
Cataract Out-of-Network:
Surgery: (for $0 copay
Medicare-
covered
standard
eyewear)

$0 copay $0 copay $0 copay In-Network:
$0 copay
Routine Eye
Exam: (up to Out-of-Network:
1 per year) Not covered

You must use an EyeMed network provider for all routine eye exams.

Eyewear: Our plan pays up to Our plan pays up to Our plan pays up to In Network:
(For covered $200 once every 24 $200 once every 24 $200 once every 24 Our plan pays up to
eyewear, months for prescription months for prescription months for prescription $200 once every 24
you pay any eyewear eyewear eyewear months for prescription
balance in eyewear
excess of the
$200 limit.) Out-of-Network:
Not covered

You must use an EyeMed network provider for the purchase of covered eyewear.
There is no coverage for out-of-network providers.

Mental Health Services

Inpatient Visit: $300 copay per day for $275 copay per day $150 copay per day for In-Network:
days 1 through 5 for days 1 through 5 days 1 through 5 $200 copay per day for
days 1 through 5
You pay nothing per You pay nothing You pay nothing
day for days per day for days per day for days You pay nothing
6 through 90 6 through 90 6 through 90 per day for days
6 through 90
You pay nothing You pay nothing You pay nothing
per day for days 91 per day for days 91 per day for days 91 You pay nothing
and beyond and beyond and beyond per day for days 91
and beyond

Out-of-Network:
20% of the cost
per stay

Authorization rules may apply

bluecrossma.com/medicare-options 10

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

$40 copay $40 copay $35 copay In-Network:
$35 copay
Outpatient
Group Therapy Out-of-Network:
Visit: 20% of the cost
Outpatient
Individual Authorization rules may apply
Therapy Visit:
$40 copay $40 copay $35 copay In-Network:
Skilled $35 copay
Nursing
Facility Out-of-Network:
(SNF) 20% of the cost

You pay nothing for covered services performed at home by a network provider.
Authorization rules may apply.

Our plan covers up to Our plan covers up to Our plan covers up to Our plan covers up to
100 days in a SNF. 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.

You pay nothing You pay nothing $20 copay per day for In-Network:
per day for days 1 per day for days 1 days 1 through 20 You pay nothing per
through 20 through 20 day for days 1
$100 copay per day for through 20
$160 copay per day for $160 copay per day for days 21 through 44
days 21 through 44 days 21 through 44 $140 copay per day for
You pay nothing days 21 through 44
You pay nothing You pay nothing per day for days 45
per day for days 45 per day for days 45 through 100 You pay nothing
through 100 through 100 per day for days 45
through 100

Out-of-Network:
20% of the cost per
stay

Authorization rules may apply

Physical $40 copay $20 copay $15 copay In-Network:
Therapy $15 copay

Out-of-Network:
20% of the cost

Authorization rules may apply. Referral from your doctor may be required

$275 copay per trip $100 copay per trip $75 copay per trip In-Network:
$100 copay per trip
Ambulance
Out-of-Network:
$100 copay per trip

Your copay is waived if you are admitted to the hospital within 24 hours or held overnight for
observation. Authorization rules may apply.

11 2021 Summary of Benefits

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Not covered Not covered Not covered
Transportation
(Including
chair vans) Not covered

Medicare 20% coinsurance 20% coinsurance 10% coinsurance In and
Part B Drugs Out-of-Network:
(Including 20% coinsurance
Chemotherapy)
Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions.

Foot Care Foot exams and Foot exams and Foot exams and Foot exams and
(Podiatry treatment if you have treatment if you have treatment if you have treatment if you have
services) diabetes-related nerve diabetes-related nerve diabetes-related nerve diabetes-related nerve
damage and/or meet damage and/or meet damage and/or meet damage and/or meet
certain conditions: certain conditions: certain conditions: certain conditions:
$10-$45 copay $10-$40 copay $5-$35 copay
In-Network:
$10-$35 copay

Out-of-Network:
$65 copay

Referral from your doctor may be required

Diabetes Supplies and Services*

Diabetes You pay nothing You pay nothing You pay nothing In-Network:
Monitoring You pay nothing You pay nothing You pay nothing
Supplies: You pay nothing You pay nothing Out-of-Network:
20% of the cost
Diabetes Self-
Management You pay nothing In-Network:
Training: You pay nothing
Out-of-Network:
Therapeutic You pay nothing 20% of the cost
Shoes or
Inserts: In-Network:
You pay nothing
Out-of-Network:
20% of the cost

*There is no coinsurance or copayment for the One Touch®´ blood glucose test strips and blood glucose monitors purchased
at participating retail and mail-order pharmacies; otherwise you pay all costs. Test strips and blood glucose monitors are also

available at Durable Medical Equipment suppliers with no coinsurance or copayment. There is no coinsurance or copayment

for members eligible for covered therapeutic molded shoes and inserts, diabetes self-management training preventive

benefit, or fasting plasma glucose tests.

bluecrossma.com/medicare-options 12

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
In-Network:
Durable 20% of the cost 20% of the cost 10% of the cost 10% of the cost
Medical Out-of-Network:
Equipment Authorization rules may apply 20% of the cost
(wheelchairs,
oxygen, etc.) In-Network:
10% of the cost
Prosthetic Devices (braces, artificial limbs, etc.) Out-of-Network:
20% of the cost
20% of the cost 20% of the cost 10% of the cost
In-Network:
Prosthetic 10% of the cost
Devices: Out-of-Network:
20% of the cost
Related 20% of the cost 20% of the cost 10% of the cost
Medical $150
Supplies: $150 per calendar year
per calendar year
Wellness Programs (See back of this booklet for more details)

Fitness: $250 $150
per calendar year per calendar year

Weight Loss: $150 $150 $150 $150
per calendar year per calendar year per calendar year per calendar year

13 2021 Summary of Benefits

WELLNESS PROGRAMS

Medicare HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

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 $150 ($250 for HMO Blue
SaverRx) per calendar year toward your club membership fees and exercise classes.

What programs qualify?

• Health clubs with a variety of cardiovascular and strength-training exercise equipment,
e.g., traditional health clubs, YMCAs, YWCAs, and community fitness centers

• 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, or pool-only facilities; social clubs; and sports teams/ leagues. You cannot receive the
Fitness Benefit for personal training, lessons, coaching, exercise equipment, 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, and 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.

bluecrossma.com/medicare-options 14

PRESCRIPTION DRUG BENEFITS

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Deductible $320 per year $320 per year $200 per year $260 per year
for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5

Initial After you pay your yearly deductible, you pay the following until your total yearly drug costs reach
Coverage $4,130 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 order pharmacies.

Tier 1 = Preferred Generic Tier 2 = Generic Tier 3 = Preferred Brand

Tier 4 = Non-Preferred Brand Tier 5 = Specialty Tier Tier 6 = Select Care

Note: Cost-sharing may differ relative to the pharmacy’s status as preferred or standard, mail-order,
Long Term Care (LTC) or home infusion, and 30 days or 90 days supply.

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Preferred Retail Cost Sharing

Drug Tier 30 60 90 30 60 90 30 60 90 30 60 90
day day day day day day day day day day day day
supply supply supply supply supply supply supply supply supply supply supply supply

Tier 1 $2 $4 $6 $2 $4 $6 $1 $2 $3 $1 $2 $3
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Generic)

Tier 2 $8 $16 $24 $6 $12 $18 $5 $10 $15 $5 $10 $15
(Generic) copay copay copay copay copay copay copay copay copay copay copay copay

Tier 3 $42 $84 $126 $42 $84 $126 $42 $84 $126 $42 $84 $126
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)

Tier 4 $95 $190 $285 $95 $190 $285 $95 $190 $285 $95 $190 $285
(Non-Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)

Tier 5 27% N/A 27% 29% 28% N/A
(Specialty Tier) of the N/A of the N/A N/A of the N/A N/A of the N/A
cost
cost cost cost

Tier 6 $0 $0 $0 $0 $0 $0 N/A N/A N/A N/A N/A N/A
(Select Care)

Standard Retail Cost-Sharing

Drug Tier 30 60 90 30 60 90 30 60 90 30 60 90
day day day day day day day day day day day day
supply supply supply supply supply supply supply supply supply supply supply supply

Tier 1 $8 $16 $24 $8 $16 $24 $6 $12 $18 $6 $12 $18
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Generic)

Tier 2 $16 $32 $48 $12 $24 $36 $10 $20 $30 $10 $20 $30
(Generic) copay copay copay copay copay copay copay copay copay copay copay copay

15 2021 Summary of Benefits

Tier 3 Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
(Preferred SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Brand)
Tier 4 $47 $94 $141 $47 $94 $141 $47 $94 $141 $47 $94 $141
(Non-Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)
$100 $200 $300 $100 $200 $300 $100 $200 $300 $100 $200 $300
Tier 5 copay copay copay copay copay copay copay copay copay copay copay copay
(Specialty Tier)
27% N/A 27% N/A 29% N/A 28% N/A
of the N/A of the N/A of the N/A of the N/A
cost cost cost cost

Tier 6 $5 $5 $5 $5 $5 $5 N/A N/A N/A N/A N/A N/A
(Select Care) copay copay copay copay copay copay

Mail Order Cost-Sharing

Drug Tier 30 60 90 30 60 90 30 60 90 30 60 90
day day day day day day day day day day day day
supply supply supply supply supply supply supply supply supply supply supply supply

Tier 1 $2 $2 $2 $2 $2 $2 $1 $1 $1 $1 $1 $1
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Generic)

Tier 2 $8 $16 $16 $6 $12 $12 $5 $10 $10 $5 $10 $10
(Generic) copay copay copay copay copay copay copay copay copay copay copay copay

Tier 3 $42 $84 $84 $42 $84 $84 $42 $84 $84 $42 $84 $84
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)

Tier 4 $95 $190 $190 $95 $190 $190 $95 $190 $190 $95 $190 $190
(Non-Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)

Tier 5 27% N/A N/A 27% N/A 29% N/A 28% N/A
(Specialty Tier) of the of the N/A of the N/A of the N/A
cost cost cost cost

Tier 6 $0 $0 $0 $0 $0 $0 N/A N/A N/A N/A N/A N/A
(Select Care)

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.

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 $4,130

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 $6,550, which is
the end of the coverage gap. Not everyone will enter the coverage gap.

Catastrophic After your yearly out-of-pocket drug costs (including drugs purchased through your
Coverage retail pharmacy and through mail order) reach $6,550, you pay the greater of:

• 5% of the cost, or

• $3.70 copay for generic (including brand drugs treated as generic) and a $9.20 copayment
for all other drugs.

bluecrossma.com/medicare-options 16

Pre-Enrollment Checklist

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.

Contact 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.

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.
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.

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, 2022

For our HMO Plans: Except in emergency or urgent situations, we do not cover services by out-of-network
providers (doctors who are not listed in the provider directory).
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 co-pay for services received by non-contracted providers.

Independent Licensees of the Blue Cross and Blue Shield Association.
H2261_2094_C

17 2021 Summary of Benefits

Contact Information and Hours of Operation

Members

October 1 - March 31 April 1 - September 30
1-800-200-4255 (TTY: 711) 1-800-200-4255 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 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 April 1 - September 30
1-800-678-2265 (TTY: 711) 1-800-678-2265 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 8:00 a.m. to 8:00 p.m., 5 days a week,

Monday - Friday

Our website: bluecrossma.com/medicare-options

bluecrossma.com/medicare-options 18

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.

19 2021 Summary of Benefits

Proficiency of Language Assistance Services

TRANSLATION RESOURCES

EPnrgolisfhi:cAiTeTEnNcTIyONo: Iff yLouadnong't supeaakgEenglAishs, lsanigsuatgaenasscisetancSe eserrvviceisc, ferese of charge,

are available to you. Call 1-800-200-4255 (TTY: 711).

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

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

Chinese/ : 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-200-4255
(TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành
cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/‫ااﻟﻌﺮﺑﯿﺔ‬:
1-800-200-4255 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻌﺮﺑﯿﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
(711 :‫)ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬.

Mon-Khmer, Cambodian/ :
1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont
proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-800-200-4255 (TTY: 711).
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Hindi/ :
1-800-200-4255 (TTY: 711)

Gujarati/ :
1-800-200-4255 (TTY: 711)

bluecrossma.com/medicare-options 20

FOR MORE INFORMATION
OR HELP WITH ENROLLMENT

bluecrossma.com/Medicare | 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.

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 are the property of their
respective owners. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of

Massachusetts HMO Blue, Inc.

000818749 55-0604-21v4 (3/21)

2021 Star Ratings

B2l0u2e1CSrotsasrBRluaetSinhigesld of Massachusetts - H2261

2B0l2u1e MCreodsiscBarleueStSahrieRldatoifngMsassachusetts - H2261

E2v0e2r1y Myeaerd,iMcaeredicSatraereRvaltuiantgess plans based on a 5-star rating system. 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:
Every year, Medicare evaluates plans based on a 5-star rating system. Medicare Star Ratings help you know how good a job our

pla1n.isAdnoOingv.erYaolluStcaarnRuasteingthtehsaet cSotmarbRinaetsinagllsotfoocuormplpaanr'sesocuorrepsl.an's performance to other plans. The two main types of Star Ratings are:

21.. SAunmOmvaeryraSlltSartaRr aRtiantginsgththaattfoccoumsboineosuarllmoefdoiucralpolarno'surscporreessc.ription drug services.

2. Summary Star Ratings that focus on our medical or our prescription drug services.
Some of the areas Medicare reviews for these ratings include:

Some HofotwheoaurremaseMmbeedriscarraetereovuirewplsanfo'srstehrevsiecersatainngdscinacrelu;de:

HHoowwwouerllmouermdboecrtsorastedeotuerctpilalnne'ssseesrvaincdeskaenedpcmaerem;bers healthy;

HHoowwwweellloouurrpdloancthoerslpdseoteucrtmilelnmesbseers aunsde rkeeceopmmmeemndbedrsahnedalsthayfe; prescription medications.

How well our plan helps our members use recommended and safe prescription medications.
For 2021, Blue Cross Blue Shield of Massachusetts received the following Overall Star Rating fromMedicare.

For 2021, Blue Cross Blue Shield of Massachusetts received the following Overall Star Rating fromMedicare.
4.5 Stars

We received the following Summary Star Ratings for Blue Cross Blu4e.S5hSietaldrsof Massachusetts's health/drug plan services:

HWeealrtehcPeliavnedStehrevifcoelslo:wing Summary Star Ratings for Blue Cross Blue Shield of Massachusetts's health/drug plan services:
4 Stars

Health Plan Services: 4 Stars
Drug Plan Services: 4.5 Stars

Drug Plan Services: 4.5 Stars
The number of stars shows how well our plan performs.

The number of stars shows how5wstealrlso-urexpclaenllepnetrforms.
4 stars - above average
35ssttaarrss-- aevxecrealgleent
24ssttaarrss-- baebloovweaavveerraaggee
13ssttaarrs- -poavoerrage
2 stars - below average

Learn more about our plan and1hsotwarw- epoaorer different from other plans at www.medicare.gov.

YLoeaurmnamyoarlesoabcountaocutrupsla7ndaanydshaowweweke farroemd8iff:0er0eant.mfr.otmo 8o:t0h0erpp.mla.nEs asttwerwnwti.mmeedatic8a0re0.-g6o7v8.-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.
You may also contact us 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

CtourMreanrtcmhe3m1b.eOrsuprlheoasuerscaolflo80p0er-a2t0io0n-4f2ro5m5 (Atopllr-iflr1eet)ooSre7p1t1em(TbTeYr 3).0 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

SCtaurrRenatimngesmabrerbsapsledasoenc5allS8ta0r0s-.2S0ta0r-4R2a5ti5ng(stoallr-efraeses)eossre7d1e1a(cThTyYea).r and may change fromone year to the next.

Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change fromone year to the next.

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.

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).

000405393 | 99-0288-21 (HMO) H2261_20218_M 1/1

1/1



02

Resources



Medicare Plan Options

JOIN US TO LEARN MORE ABOUT MEDICARE COVERAGE

When Medicare seems overwhelming or confusing, we’re here to make it easier to understand.
Register for one of our informational online webinars to find out how Medicare works, get answers
to your questions, and learn about our extensive plan options, including Medicare Advantage
plans (HMO & PPO), Medicare Supplement plans (Medigap), and Prescription Drug Plans (PDP).

Visit bluecrossma.com/seminar to see a full list of dates and times. You can also:



Register for a live online webinar Watch a pre-recorded seminar

Live Webinar Topics: Date Time
Medicare Advantage (HMO & PPO) 7/8/2021 11:00 a.m. - 12:00 p.m.
GeoBlue Travel Insurance 7/8/2021 4:00 p.m. - 4:30 p.m.
Original Medicare & Medex®' (Medicare Supplement) 7/9/2021 1:00 p.m. - 1:45 p.m.
Prescription Drug Plans (PDP) 7/9/2021 2:30 p.m. - 3:15 p.m.
Medicare Advantage (HMO & PPO) 7/12/2021 4:30 p.m. - 5:30 p.m.
Original Medicare & Medex (Medicare Supplement) 7/13/2021 11:00 a.m. - 11:45 a.m.
Prescription Drug Plans (PDP) 7/13/2021 1:30 p.m. - 2:15 p.m.
Dental Blue® 65 7/14/2021 10:00 a.m. - 10:30 a.m.
GeoBlue Travel Insurance 7/14/2021 1:30 p.m. - 2:00 p.m.
Medicare Advantage (HMO & PPO) 7/15/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 7/16/2021 1:30 p.m. - 2:15 p.m.
Prescription Drug Plans (PDP) 7/16/2021 3:00 p.m. - 3:45 p.m.
Dental Blue 65 7/19/2021 2:00 p.m - 2:30 p.m.

continued

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

Visit bluecrossma.com/seminar to see the latest list of webinar times and dates.

Live Webinar Topics: Date Time
GeoBlue Travel Insurance 7/19/2021 3:00 p.m. - 3:30 p.m.
Medicare Advantage (HMO & PPO) 7/20/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex (Medicare Supplement) 7/21/2021 4:30 p.m. - 5:15 p.m.
Prescription Drug Plans (PDP) 7/21/2021 6:00 p.m. - 6:45 p.m.
Original Medicare & Medex (Medicare Supplement) 7/22/2021 11:00 a.m. - 11:45 a.m.
Medicare Advantage (HMO & PPO) 7/22/2021 4:30 p.m. - 5:30 p.m.
Dental Blue 65 7/23/2021 10:00 a.m. - 10:30 a.m.
Prescription Drug Plans (PDP) 7/23/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 7/26/2021 9:00 a.m. - 10:00 a.m.
Original Medicare & Medex (Medicare Supplement) 7/26/2021 2:00 p.m. - 2:45 p.m.
Prescription Drug Plans (PDP) 7/27/2021 1:00 p.m. - 1:45 p.m.
Medicare Advantage (HMO & PPO) 7/27/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex (Medicare Supplement) 7/28/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 7/28/2021 12:00 p.m. - 12:45 p.m.
GeoBlue Travel Insurance 7/29/2021 4:00 p.m. - 4:30 p.m.
Dental Blue 65 7/29/2021 5:00 p.m. - 5:30 p.m.
Medicare Advantage (HMO & PPO) 7/30/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 7/30/2021 1:00 p.m. - 1:45 p.m.
Medicare Advantage (HMO & PPO) 8/2/2021 9:00 a.m. - 10:00 a.m.
Original Medicare & Medex (Medicare Supplement) 8/2/2021 1:00 p.m. - 1:45 p.m.
Medicare Advantage (HMO & PPO) 8/3/2021 2:00 p.m. - 3:00 p.m.
Prescription Drug Plans (PDP) 8/3/2021 4:30 p.m. - 5:15 p.m.
Dental Blue 65 8/4/2021 10:00 a.m. - 10:30 a.m.
GeoBlue Travel Insurance 8/4/2021 2:00 p.m. - 2:30 p.m.
Original Medicare & Medex (Medicare Supplement) 8/5/2021 11:00 a.m. - 11:45 a.m.
Prescription Drug Plans (PDP) 8/5/2021 1:30 p.m. - 2:15 p.m.

Visit bluecrossma.com/seminar to see the latest list of webinar times and dates.

Live Webinar Topics: Date Time
Medicare Advantage (HMO & PPO) 8/6/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 8/9/2021 1:00 p.m. - 1:45 p.m.
Medicare Advantage (HMO & PPO) 8/10/2021 12:00 p.m. - 1:00 p.m.
Prescription Drug Plans (PDP) 8/10/2021 3:00 p.m. - 3:45 p.m.
Original Medicare & Medex (Medicare Supplement) 8/11/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 8/11/2021 11:30 a.m. - 12:15 p.m.
Dental Blue 65 8/12/2021 1:00 p.m. - 1:30 p.m.
GeoBlue Travel Insurance 8/12/2021 3:00 p.m. - 3:30 p.m.
Medicare Advantage (HMO & PPO) 8/13/2021 11:00 a.m. - 12:00 p.m.
Prescription Drug Plans (PDP) 8/16/2021 3:00 p.m. - 3:45 p.m.
Original Medicare & Medex (Medicare Supplement) 8/17/2021 10:00 a.m. - 10:45 a.m.
Medicare Advantage (HMO & PPO) 8/17/2021 5:00 p.m. - 6:00 p.m.
Medicare Advantage (HMO & PPO) 8/18/2021 9:00 a.m. - 10:00 a.m.
Dental Blue 65 8/19/2021 5:00 p.m. - 5:30 p.m.
GeoBlue Travel Insurance 8/19/2021 6:00 p.m. - 6:30 p.m.
Original Medicare & Medex (Medicare Supplement) 8/20/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 8/20/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 8/23/2021 12:00 p.m. - 1:00 p.m.
Original Medicare & Medex (Medicare Supplement) 8/24/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 8/24/2021 6:30 p.m. - 7:15 p.m.
Medicare Advantage (HMO & PPO) 8/25/2021 10:00 a.m. - 11:00 a.m.
Dental Blue 65 8/25/2021 2:00 p.m. - 2:30 p.m.
Original Medicare & Medex (Medicare Supplement) 8/26/2021 1:00 p.m. - 1:45 p.m.
Prescription Drug Plans (PDP) 8/26/2021 2:30 p.m - 3:15 p.m.
Medicare Advantage (HMO & PPO) 8/27/2021 11:00 a.m. - 12:00 p.m.
Prescription Drug Plans (PDP) 8/30/2021 2:00 p.m. - 2:45 p.m.
Medicare Advantage (HMO & PPO) 8/31/2021 5:00 p.m. - 6:00 p.m.

Visit bluecrossma.com/seminar to see the latest list of webinar times and dates.

Register Today

Visit bluecrossma.com/seminar to see the latest list of webinar times and dates.

Can’t attend? No problem! Call us to speak to one of our
sales representatives directly at, 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

A Blue Cross Blue Shield of Massachusetts representative will present the webinar and 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 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. ®´ Registered Marks of Blue Cross and Blue Shield
of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2021 Blue Cross and Blue

Shield of Massachusetts, Inc. or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000768460 Y0014_2053_M S2893_2041_M 99-0645-21 (6/21)

Medicare Advantage Top 100 Drug List

TOP 100 DRUGS

Looking for one good reason why a Medicare Advantage plan with prescription coverage from
Blue Cross Blue Shield of Massachusetts is the right plan for you? This list is just a sample
of our Medicare Advantage plan’s drug list.
We cover these eligible medications, plus hundreds of others.

MEDICATION NAME DILTIAZEM 24HR ER (CD) LAMOTRIGINE
DONEPEZIL HCL LANTUS®´ SOLOSTAR®´
ALBUTEROL SULFATE HFA DORZOLAMIDE-TIMOLOL LATANOPROST
ALENDRONATE SODIUM DOXAZOSIN MESYLATE LEVOTHYROXINE SODIUM
ALLOPURINOL DOXYCYCLINE HYCLATE LISINOPRIL
ALPRAZOLAM DULOXETINE HCL LISINOPRIL-HYDROCHLOROTHIAZIDE
AMITRIPTYLINE HCL ELIQUIS®´ LORAZEPAM
AMLODIPINE BESYLATE ESCITALOPRAM OXALATE LOSARTAN POTASSIUM
AMOXICILLIN ESTRADIOL LOVASTATIN
AMOXICILLIN-POT CLAVULANATE EZETIMIBE MELOXICAM
ATENOLOL FAMOTIDINE METFORMIN HCL
ATORVASTATIN CALCIUM
AZITHROMYCIN FENOFIBRATE METFORMIN HCL ER

BRIMONIDINE TARTRATE FINASTERIDE METHOTREXATE
FLUOXETINE HCL METOPROLOL SUCCINATE
BUPROPION HCL SR FLUTICASONE PROPIONATE METOPROLOL TARTRATE
BUPROPION XL FUROSEMIDE MIRTAZAPINE
CARVEDILOL GABAPENTIN MONTELUKAST SODIUM
CELECOXIB GLIMEPIRIDE NIFEDIPINE ER
CEPHALEXIN GLIPIZIDE NITROFURANTOIN MONO-MACRO
CHLORTHALIDONE GLIPIZIDE ER OMEPRAZOLE
CIPROFLOXACIN HCL HYDROCHLOROTHIAZIDE ONETOUCH®´ DELICA®´ PLUS LANCET
CITALOPRAM HBR HYDROCODONE-ACETAMINOPHEN ONETOUCH ULTRA®´ BLUE TEST STRIP
CLOBETASOL PROPIONATE IBUPROFEN ONETOUCH VERIO®´ TEST STRIP
CLONAZEPAM
CLOPIDOGREL

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

MEDICATION NAME ISOSORBIDE MONONITRATE ER OXYBUTYNIN CHLORIDE ER
DICLOFENAC SODIUM ROSUVASTATIN CALCIUM TRAZODONE HCL
OXYCODONE-ACETAMINOPHEN SERTRALINE HCL TRIAMCINOLONE ACETONIDE
OXYCODONE HCL TRIAMTERENE-
SHINGRIX HYDROCHLOROTHIAZID
PANTOPRAZOLE SODIUM TRULICITY®´
SIMVASTATIN VALACYCLOVIR
PAROXETINE HCL SPIRONOLACTONE
POTASSIUM CHLORIDE SULFAMETHOXAZOLE- VENLAFAXINE HCL ER
TRIMETHOPRIM
PRAVASTATIN SODIUM SYMBICORT®´ WARFARIN SODIUM
TAMSULOSIN HCL ZOLPIDEM TARTRATE
PREDNISOLONE ACETATE TIMOLOL MALEATE
PREDNISONE TRAMADOL HCL
PROAIR®´ HFA
QUETIAPINE FUMARATE

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).

000396735 ® Registered Marks of the Blue Cross and Blue Shield Association. 50-0177-21 (9/20)
®´ Registered Marks are property of their respective owners.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc.

Y0014_2051_M

Medicare HMO Blue (HMO)

NEED TO FIND A DOCTOR?

It’s easy to find a doctor in the Medicare HMO Blue network.

In fact, your current PCP may already be part of our network. To search for
participating doctors, simply follow these steps:

Visit Enter all fields, including Select
bluecrossma.com/findadoctor. Medicare HMO Blue Search.
as your network.

 

Learn More with Our Online Directory We’re Here to Help

When you use our Find a Doctor tool, If you need help finding a doctor, or if
you can see: you don’t have Internet access, call us at
• Whether the office is handicap-accessible 1-800-678-2265 (TTY: 711). A representative
• Whether weekend or evening is available to help you:
• October 1 through March 31;
office hours are available
• What medical school a doctor attended 8:00 a.m. to 8:00 p.m. ET,
• And more seven days a week
• April 1 through September 30;
8:00 a.m. to 8:00 p.m. ET,
Monday through Friday

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.
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 and SM Service Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks
of Blue Cross Blue Shield of Massachusetts, Inc., or Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.

© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross Blue Shield of Massachusetts HMO Blue, Inc.

000405597 H2261_2085_C 50-0239-21 (9/20)

03

Disclosures



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 www.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. © 2020 Blue Cross and Blue Shield
of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000401451 55-1490A (9/20)



Translation Resources

Proficiency of Language Assistance Services

English: ATTENTION: If you don't speak English, language assistance services, free of charge,
are available to you. Call 1-800-200-4255 (TTY: 711).

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

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

Chinese/ : 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-200-4255
(TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành
cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/‫ااﻟﻌﺮﺑﯿﺔ‬:
1-800-200-4255 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻌﺮﺑﯿﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
(711 :‫)ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ‬.

Mon-Khmer, Cambodian/ :
1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont
proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza
linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

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

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

Hindi/ :
1-800-200-4255 (TTY: 711)

Gujarati/ :
1-800-200-4255 (TTY: 711)

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.

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. © 2020 Blue Cross and Blue Shield of
Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

Y0014_16110 Accepted 08302016 000744770 | 55-1490B (12/20)