BCBSMA MEDICARE PPO SalesKit Book 08/01/2021 Approved by Danielle Roy 07/16/2021 11:22 AM

Medicare Advantage Plans

MEDICARE PPO BLUE (PPO) 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.

H2230_2049_C (08/01/21)



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

Dear Prospective Member,
Thank you for your interest in our Medicare Advantage PPO 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. We also include routine dental,
vision, and hearing services in all 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
Enclosures By mail: Complete the enclosed
enrollment form and return it in the
Ready to Enroll? self-addressed envelope.

By phone: 1-800-678-2265 (TTY: 711) By fax: Complete the enclosed enrollment
October 1 through March 31: form and fax to 1-617-246-8506.
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 1-800-678-2265 (TTY: 711) for more information.

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

and Blue Shield of Massachusetts HMO Blue, Inc.

000396684 H2230_2089_M 99-000396684-21 (9/20)

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 PPO Blue SaverRx (PPO)
Medicare PPO Blue ValueRx (PPO)
Medicare PPO Blue PlusRx (PPO)

2021 SUMMARY OF BENEFITS

H2230 PLANS 017, 018, 002

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2230_2093_M

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 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

January 1, 2021 - December 31, 2021

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. It doesn’t list every service that we cover or list every limitation or exclusion.
To get a complete list of services we cover, call 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-options.

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

1 2021 Summary of Benefits

THINGS TO KNOW ABOUT

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 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 PPO Blue SaverRx (PPO),
Medicare PPO Blue ValueRx (PPO), or Medicare PPO Blue SaverRx (PPO),
Medicare PPO Blue PlusRx (PPO), you must Medicare PPO Blue ValueRx (PPO),
be entitled to Medicare Part A, be enrolled in and Medicare PPO Blue PlusRx (PPO)
Medicare Part B, and live in our service area. have a network of doctors, hospitals,
You must continue to pay your Medicare pharmacies, and other providers. If you
Part B premium. use the providers in our network, you may
Our service area includes the following pay less for your covered services. But if
counties in Massachusetts: Barnstable, you want to, you can also use providers
Bristol, Essex, Franklin, Hampden, that are not in our network.
Hampshire, Middlesex, Norfolk, Plymouth,
Suffolk, and Worcester.

bluecrossma.com/medicare-options 2

Depending on your plan, you may pay • Our plan members also get more than
more if you use providers that are not in our what is covered by Original Medicare.
network. Out-of-network/non-contracted Some of the extra benefits are outlined
providers are under no obligation to in this booklet.
treat Medicare PPO Blue SaverRx (PPO),
Medicare PPO Blue ValueRx (PPO) and • Plans may offer supplemental benefits
Medicare PPO Blue PlusRx (PPO) members, in addition to Part C benefits and
except in emergency situations. For a Part D benefits.
decision about whether we will cover
an out-of-network service, we encourage We cover Part D drugs. In addition, we cover
you or your provider to ask us for a pre- Part B drugs such as chemotherapy and
service organization determination before some drugs administered by your provider.
you receive the service. Please call our • You can see the complete plan formulary
Member Service number or see your
Evidence of Coverage for more information, (list of Part D prescription drugs) and any
including the cost sharing that applies to restrictions on our website, bluecrossma.
out-of-network services. com/medicare-options.
• You must generally use network • Or, call us and we will send you a copy
of the formulary. The formulary may
pharmacies to fill your prescriptions for change at any time. You will receive
covered Part D drugs. notice when necessary.
• You can see our plan’s provider directory
at our website (bluecrossma.com/ How will I determine
medicare-options). my drug costs?
• You can see our plan’s pharmacy
directory at our website (bluecrossma. Our plans group each medication into one of
com/pharmacyfinder). five or six “tiers.” You will need to use your
• Or, call us and we will send you a copy formulary to locate what tier your drug is
of the provider and pharmacy directories. on to determine how much it will cost you.
The pharmacy network, and/or provider The amount you pay depends on the drug’s
network may change at any time. You will tier and what stage of the benefit you have
receive notice when necessary. reached. Later in this document we discuss
the benefit stages that occur after you meet
What do we cover? your deductible: Initial Coverage, Coverage
Gap, and Catastrophic Coverage.
Like all Medicare health plans, 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.

3 2021 Summary of Benefits

SUMMARY OF BENEFITS:

January 1, 2021 - December 31, 2021

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Monthly Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol,
Plan Premium Essex, Franklin, Hampden, Essex, Franklin, Hampden, Essex, Franklin, Hampden,
Hampshire, Middlesex, Hampshire, Middlesex, Hampshire, Middlesex,
Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk
counties: $0 per month counties: $76 per month counties: $263 per month

Worcester County: Worcester County: Worcester County:
$0 per month $86 per month $263 per month

You must continue to pay your Medicare Part B premium.

Deductibles

Medical: These plans do not have a medical deductible.

Prescription Drugs: $405 per year $320 per year $200 per year
for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5

Maximum Your yearly limit(s) Your yearly limit(s) Your yearly limit(s)
Out-of-Pocket in this plan: in this plan: in this plan:
Responsibility
(does not include costs $7,550 for services $4,900 for services $3,400 for services
you receive from you receive from you receive from
related to prescription in-network providers. in-network providers. in-network providers.

drugs) $7,550 for services you $4,900 for services you $5,100 for services you
receive from any provider. receive from any provider. 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 4

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Inpatient Our plan covers an Our plan covers an Our plan covers an
Hospital Coverage unlimited number unlimited number of unlimited number of
of days for an inpatient days for an inpatient days for an inpatient
Outpatient hospital stay. hospital stay. hospital stay.
Hospital Coverage In-Network:
Ambulatory Surgery In-Network: In-Network: $150 copay per day
Center $390 copay per day $300 copay per day for days 1 through 5
Doctor’s Office Visits for days 1 through 5 for days 1 through 5 You pay nothing per day
Primary Care for days 6 through 90
Physician: You pay nothing per day You pay nothing per day You pay nothing per day
for days 6 through 90 for days 6 through 90 for days 91 and beyond
Out-of-Network:
You pay nothing per day You pay nothing per day 20% of the cost per stay
for days 91 and beyond for days 91 and beyond Per admission benefit.

Out-of-Network: Out-of-Network: In-Network:
$440 copay per day $350 copay per day $150/visit
for days 1 through 5 for days 1 through 5 Out-of-Network:
20% of the total cost
You pay nothing per day You pay nothing per day
for days 6 through 90 for days 6 through 90 In-Network:
$150/visit
You pay nothing per day You pay nothing per day Out-of-Network:
for days 91 and beyond or days 91 and beyond 20% of the total cost

Per admission benefit. Per admission benefit. In-Network:
$10 copay
Authorization rules may apply Out-of-Network:
$45 copay
In-Network: In-Network:
$325/visit $250/visit

Out-of-Network: Out-of-Network:
45% of the total cost 40% of the total cost

Authorization rules may apply

In-Network: In-Network:
$275/visit $250/visit

Out-of-Network: Out-of-Network:
45% of the total cost 40% of the total cost

Authorization rules may apply

In-Network: In-Network:
$10 copay $10 copay

Out-of-Network: Out-of-Network:
$25 copay $20 copay

5 2021 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

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

Out-of-Network: Out-of-Network: Out-of-Network:
$55 copay $50 copay $45 copay

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

In and Out-of-Network: In and Out-of-Network: In-Network:
You pay nothing You pay nothing 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 • Prostate cancer screenings (PSA)

• Alcohol misuse counseling • Sexually transmitted infections
screening and counseling
• Bone mass measurement
• Tobacco use cessation counseling
• Breast cancer screening (counseling for people with no sign
(mammogram) of tobacco-related disease)

• Cardiovascular disease • Flu shots, pneumococcal shots,
(behavioral therapy) Hepatitis B shots (limitations may apply)

• Cardiovascular screenings • “Welcome to Medicare” preventive visit
(one-time)
• Cervical and vaginal cancer screening
• Yearly “Wellness” visit
• Lung cancer screening
(low dose computed tomography (LDCT)) Any additional preventive services
approved by Medicare during the contract
• Colorectal cancer screenings year will be covered.
(Colonoscopy, Fecal occult blood test,
Flexible sigmoidoscopy)* Authorization rules may apply

• Depression screening You pay $0 for a supplemental annual
physical exam. Includes a detailed
• Diabetes screenings medical/family history and a head to toe
assessment with hands-on examination
• HIV screening of all body systems to assess overall
general health.
• Medical nutrition therapy services

• Obesity screening and counseling

*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 PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

$90 copay $90 copay $75 copay

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

Urgently Needed In-Network: $10-$45 In-Network: $10-$40 In-Network: $10-$35
Services copay copay copay

Out-of-Network: $55 copay Out-of-Network: $50 copay Out-of-Network: $45 copay

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

Diagnostic Services/Labs/Imaging

Diagnostic Radiology In-Network: In-Network: In-Network:
(such as MRIs, CT $325 copay per day $250 copay per day $150 copay per day
scans): per category per category per category

Out-of-Network: Out-of-Network: Out-of-Network:
$375 copay per day $325 copay per day 40% of the cost per day
per category per category per category

Authorization rules may apply

Diagnostic Tests In-Network: In-Network: In-Network:
and Procedures $10 copay per day $10 copay per day $10 copay per day

Out-of-Network: Out-of-Network: Out-of-Network:
45% of the cost 40% of the cost 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: In-Network: In-Network:
$10 copay per day $10 copay per day $10 copay per day

Out-of-Network: Out-of-Network: Out-of-Network:
45% of the cost 40% of the cost 20% of the cost

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

Outpatient X-rays: In-Network: In-Network: In-Network:
$10 copay per day $10 copay per day $10 copay per day

Out-of-Network: Out-of-Network: Out-of-Network:
45% of the cost 40% of the cost 20% of the cost

Authorization rules may apply

7 2021 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Therapeutic In-Network: In-Network: In-Network:
Radiology Services: $60 copay per visit You pay nothing You pay nothing

Out-of-Network: Out-of-Network: Out-of-Network:
45% of the cost 40% of the cost 20% of the cost

Authorization rules may apply

Hearing Services

Routine Exam— In-Network: In-Network: In-Network:
up to one per year: $0 copay $0 copay $0 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$45 copay $45 copay $45 copay

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

Non Routine Exam: In-Network: In-Network: In-Network:
$10-$45 copay $10-$40 copay $10-$35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$25-$55 copay $20-$50 copay $45 copay

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

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

Dental Services

Limited Medicare- In-Network: In-Network: In-Network:
Covered Dental $45 copay $40 copay $35 copay
Services:
Out-of-Network: Out-of-Network: Out-of-Network:
$55 copay $50 copay $45 copay or 20% of the
cost, depending on the
service

Routine Dental In-Network: In-Network: In-Network:
Services: Single $0 copay $0 copay $0 copay
Copay for Visit that
Includes: Cleaning Out-of-Network: Out-of-Network: Out-of-Network:
(for up to 2 per year; $60 copay $50 copay $45 copay
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.

bluecrossma.com/medicare-options 8

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Vision Services

Medicare-Covered In-Network: In-Network: In-Network:
Eye Exam: $10-$45 copay $10-$40 copay $10-$35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$25-$55 copay $20-$50 copay $45 copay

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

Routine Eye Exam: In-Network: In-Network: In-Network:
(up to 1 per year) $0 copay $0 copay $0 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$45 copay $45 copay $45 copay

You must use an EyeMed network provider for covered in-network services.

Eyewear: (For In and Out-of-Network: In and Out-of-Network: In and Out-of-Network:
Covered Eyewear, Our plan pays up to Our plan pays up to Our plan pays up to
you pay any balance
in excess of the $200 every two years $200 every two years $200 every two years
$200 limit.)
for covered eyewear for covered eyewear for covered eyewear

Mental Health Services

Inpatient Visit: In-Network: In-Network: In-Network:
$300 copay per day $275 copay per day $150 copay per day
for days 1 through 5 for days 1 through 5 for days 1 through 5

You pay nothing per day You pay nothing per day You pay nothing per day
for days 6 through 90 for days 6 through 90 for days 6 through 90

You pay nothing per day You pay nothing per day You pay nothing per day
for days 91 and beyond for days 91 and beyond for days 91 and beyond

Out-of-Network: Out-of-Network: Out-of-Network:
$400 copay per day $325 copay per day 20% of the cost per stay
for days 1 through 5 for days 1 through 5

You pay nothing per day You pay nothing per day
for days 6 through 90 for days 6 through 90

You pay nothing per day You pay nothing per day
for days 91 and beyond for days 91 and beyond

Authorization rules may apply

9 2021 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Outpatient Group In-Network: In-Network: In-Network:
Therapy Visit: $40 copay $40 copay $35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$40 copay $40 copay 20% of the cost

Authorization rules may apply

Outpatient Individual In-Network: In-Network: In-Network:
Therapy Visit: $40 copay $40 copay $35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$40 copay $40 copay 20% of the cost

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

Skilled Our plan covers up to Our plan covers up to Our plan covers up to
Nursing Facility 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.
(SNF)
In-Network: In-Network: In-Network:
You pay nothing per day for You pay nothing per day for $20 copay per day for days
days 1 through 20 days 1 through 20 1 through 20

$160 copay per day for $160 copay per day for $100 copay per day for
days 21 through 44 days 21 through 44 days 21 through 44

You pay nothing per day for You pay nothing per day for You pay nothing per day for
days 45 through 100 days 45 through 100 days 45 through 100

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

Authorization rules may apply

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

Out-of-Network: Out-of-Network: Out-of-Network:
45% of the cost 40% of the cost 20% of the cost

Ambulance In-Network: In-Network: In-Network:
$275 copay per trip $200 copay per trip $100 copay per trip

Out-of-Network: Out-of-Network: Out-of-Network:
$275 copay per trip $200 copay per trip $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 Not covered Not covered Not covered
(Including chair
vans)

bluecrossma.com/medicare-options 10

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Medicare Part B In and Out-of-Network: In and Out-of-Network: In and Out-of-Network:
Drugs (Including 20% coinsurance 20% coinsurance 10% coinsurance
chemotherapy)
Foot Care Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions.
(Podiatry services)
Foot exams and treatment Foot exams and treatment Foot exams and treatment
if you have diabetes-related if you have diabetes-related if you have diabetes-related
nerve damage and/or meet nerve damage and/or meet nerve damage and/or meet
certain conditions: certain conditions: certain conditions:

In-Network: In-Network: In-Network:
$10-$45 copay $10-$40 copay $10-$35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$25-$55 copay $20-$50 copay $45 copay

Diabetes Supplies and Services*

Diabetes In-Network: In-Network: In-Network:
Monitoring Supplies: You pay nothing You pay nothing You pay nothing

Out-of-Network: Out-of-Network: Out-of-Network:
You pay nothing You pay nothing 20% of the cost

Diabetes In-Network: In-Network: In-Network:
Self-Management You pay nothing You pay nothing You pay nothing
Training:
Out-of-Network: Out-of-Network: Out-of-Network:
You pay nothing You pay nothing 20% of the cost

Therapeutic Shoes In-Network: In-Network: In-Network:
or Inserts: You pay nothing You pay nothing You pay nothing

Out-of-Network: Out-of-Network: Out-of-Network:
You pay nothing You pay nothing 20% of the cost

Durable In-Network: In-Network: In-Network:
Medical 20% of the cost 20% of the cost 10% of the cost
Equipment
(wheelchairs, Out-of-Network: Out-of-Network: Out-of-Network:
oxygen, etc.) 20% of the cost 20% of the cost 20% of the cost

Authorization rules may apply

*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 DME 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.

11 2021 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Prosthetic Devices (braces, artificial limbs, etc.) In-Network:
10% of the cost
Prosthetic Devices: In-Network: In-Network: Out-of-Network:
20% of the cost 20% of the cost 20% of the cost
In-Network:
Out-of-Network: Out-of-Network: 10% of the cost
20% of the cost 20% of the cost Out-of-Network:
20% of the cost
Related Medical In-Network: In-Network:
Supplies: 20% of the cost 20% of the cost $150 per calendar year
$150 per calendar year
Out-of-Network: Out-of-Network:
20% of the cost 20% of the cost

Wellness Programs (See back of this booklet for more details)

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

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

bluecrossma.com/medicare-options 12

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 $150 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, 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.

13 2021 Summary of Benefits

PRESCRIPTION DRUG BENEFITS

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRX (PPO)

Deductible $405 per year for $320 per year for $200 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug
costs reach $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 5 = Specialty Tier
Tier 2 = Generic Tier 6 = Select Care
Tier 3 = Preferred Brand Note: Cost-sharing may differ relative to the
Tier 4 = Non-Preferred Brand pharmacy’s status as preferred or standard,
mail-order, Long Term Care (LTC) or home infusion,
and 30 days or 90 days supply.

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Preferred Retail Cost Sharing

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

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

Tier 2 $10 $20 $30 $6 $12 $18 $5 $10 $15
(Generic)
copay copay copay copay copay copay copay copay copay

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

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

Tier 5 25% 27% 29%
(Specialty Tier) of the N/A N/A of the N/A N/A of the N/A N/A
cost cost cost

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

bluecrossma.com/medicare-options 14

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Standard Retail Cost Sharing

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

Tier 1 $10 $20 $30 $8 $16 $24 $6 $12 $18
(Preferred Generic) copay copay copay copay copay copay copay copay copay

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

Tier 3 $47 $94 $141 $47 $94 $141 $47 $94 $141
(Preferred Brand) copay copay copay copay copay copay copay copay copay

Tier 4 $100 $200 $300 $100 $200 $300 $100 $200 $300
(Non-Preferred copay copay copay copay copay copay copay copay copay
Brand)

Tier 5 25% N/A 27% 29% N/A
(Specialty Tier) of the N/A of the N/A N/A of the N/A
cost
cost cost

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

Mail Order Cost Sharing

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

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

Tier 2 $10 $20 $20 $6 $12 $12 $5 $10 $10
(Generic)
copay copay copay copay copay copay copay copay copay

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

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

Tier 5 25% 27% 29%
(Specialty Tier) of the N/A N/A of the N/A N/A of the N/A N/A
cost cost cost

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

15 2021 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”).
Catastrophic This means that there’s a temporary change in what you will pay for your drugs.
Coverage 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.

After your yearly out-of-pocket drug costs (including drugs purchased through your
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 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.

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

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.
H2230_2095_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, or 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

Translation Resources

Proficiency of Language Assistance Services

TRANSLATION RESOURCES

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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.
ZBlaudezCwroońsspBolduenuSmhieelrd1o-f8M00a-s2s0a0c-h4u2s5et5ts(TisTaYn:In7d1e1p)e. ndent 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.

000819199 55-0605-21v4 (3/21)

2021 Star Ratings

B2l0u2e1CSrotsasrBRluaetSinhigesld of Massachusetts - H2230

2B0l2u1e MCreodsiscBarleueSStahrieRldatoifngMsassachusetts - H2230

E2v0e2r1y Myeaerd,icMaerediScatarereRvaltuiantgess 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 plan

is d1o. inAgn. YOovuercaallnSutasreRthaetisnegSthtatrcRoamtibnignsestoalclofmopuarrpelaonu'rs psclaonr'essp. erformance to other plans. The two main types of Star Ratings are:

21.. SAunmOmvaeryraSlltSartaRr aRtiantginsgththaattfoccoumsboinneosuarllmoefdoiucralpolarno'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:

HHoowwwouerllmouermdboecrtsorrastedeotuerctpillalnne'sssseesrvaincdeskaenedpcmaerem;bers healthy;

HHoowwwweellloouurrpdloancthoerslpdseoteucrtmilelnmesbseerssaunsde 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 Stars

Drug Plan Services: 4 Stars
The number of stars shows how well our plan performs.

The number of stars shows how5wstealrlso-urexpclaenllepnetrforms.
4 stars - above average
35ssttaarrss-- aevxecrealgleent
4 stars - above average
2 stars - below average
3 stars - average
1 star - poor
2 stars - below average

Learn more about our plan and1hsotwar w- epoaorer different from other plans at www.medicare.gov.

YLeoaurmnamyoarlesoabcountaocutrupsla7ndaanydshaoweweke farroemd8iff:e0r0enat.mfr.otmo 8o:t0h0erpp.mla.nsEasttwerwnwti.mmeedaitc8a0re0.-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

CtourMrenatrmchem31b.erOsuprlehaosuercsaollf8o0p0e-r2a0ti0o-n4f2r5o5m(Atopll-rfirle1e)tooSr 7ep11te(mTbTeYr)3. 0 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

SCtuarrRenattimngesmabrerbsapsledasoenc5allS8ta0r0s-.2S0t0ar-4R2a5ti5ng(stoallr-efraeses)eossre7d1e1a(cThTyYe)a.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).

000407019 | 99-0289-21 (PPO) H2230_20219_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) 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.
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.

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
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.
Original Medicare & Medex (Medicare Supplement) 9/1/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 9/1/2021 11:00 a.m. - 11:45 a.m.
Medicare Advantage (HMO & PPO) 9/2/2021 2:00 p.m. - 3:00 p.m.
GeoBlue Travel Insurance 9/2/2021 4:00 p.m. - 4:30 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) 9/3/2021 9:00 a.m. - 10:00 a.m.
Dental Blue 65 9/3/2021 11:00 a.m. - 11:30 a.m.
Medicare Advantage (HMO & PPO) 9/7/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex (Medicare Supplement) 9/8/2021 2:30 p.m. - 3:15 p.m.
Prescription Drug Plans (PDP) 9/8/2021 4:00 p.m. - 4:45 p.m.
Medicare Advantage (HMO & PPO) 9/9/2021 2:00 p.m. - 3:00 p.m.
Prescription Drug Plans (PDP) 9/9/2021 4:30 p.m. - 5:15 p.m.
Medicare Advantage (HMO & PPO) 9/10/2021 11:00 a.m. - 12:00 p.m.
Dental Blue 65 9/13/2021 2:00 p.m. - 2:30 p.m.
GeoBlue Travel Insurance 9/13/2021 3:30 p.m. - 4:00 p.m.
Prescription Drug Plans (PDP) 9/15/2021 3:00 p.m. - 3:45 p.m.
Medicare Advantage (HMO & PPO) 9/17/2021 1:30 p.m. - 2:30 p.m.
Medicare Advantage (HMO & PPO) 9/20/2021 9:00 a.m. - 10:00 a.m.
Original Medicare & Medex (Medicare Supplement) 9/20/2021 1:00 p.m. - 1:45 p.m.
Dental Blue 65 9/21/2021 10:00 a.m. - 10:30 a.m.
GeoBlue Travel Insurance 9/21/2021 11:30 a.m. - 12:00 p.m.
Medicare Advantage (HMO & PPO) in Spanish 9/22/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex (Medicare Supplement) 9/22/2021 6:30 p.m. - 7:15 p.m.
Prescription Drug Plans (PDP) 9/23/2021 1:00 p.m. - 1:45 p.m.
Original Medicare & Medex (Medicare Supplement) 9/23/2021 3:00 p.m. - 3:45 p.m.
Medicare Advantage (HMO & PPO) 9/24/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 9/27/2021 9:00 a.m. - 9:45 a.m.
Prescription Drug Plans (PDP) 9/27/2021 1:00 p.m. - 1:45 p.m.
Medicare Advantage (HMO & PPO) 9/28/2021 11:00 a.m. - 12:00 p.m.
Dental Blue 65 9/29/2021 10:00 a.m. - 10:30 a.m.
GeoBlue Travel Insurance 9/29/2021 11:30 a.m. - 12:00 p.m.
Original Medicare & Medex (Medicare Supplement) 9/30/2021 4:00 p.m. - 4:45 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 (7/21)

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 PPO Blue (PPO)

NEED TO FIND A DOCTOR?

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

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

Visit Enter all fields, including Select Search
bluecrossma.com/findadoctor Medicare PPO Blue
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,
you can see: or if you don’t have Internet access,
• Whether the office is handicap-accessible call us at 1-800-678-2265 (TTY: 711).
• Whether weekend or evening office hours A representative is available to help you:

are available • October 1 through March 31;
• 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

Search for Doctors and Hospitals Outside of Massachusetts

Go to bcbs.com, select “Find a Doctor or Hospital”, and follow the easy steps.

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

000407070 H2230_2086_C 37-1880-21 (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)