MEDICARE HMO BLUE (HMO) 2023 Get the coverage you need and the peace of mind you deserve. Medicare Advantage Plans Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. PRESCRIPTION DRUG PLANS (PDP) Blue MedicareRx Value Plus Blue MedicareRx Premier Coverage You Need From a Name You Can Trust Blue MedicareRx (PDP) 2023 Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. September 2023 (2305796)
101 Huntington Avenue Suite 1300 Boston, MA 02199-7611 bluecrossma.org Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Dear Prospective Member, Thank you for your interest in our Medicare Advantage HMO Blue plans. We want you to get the coverage you need and the peace of mind you deserve. That’s why our plans may include: Great Coverage Including prescription drug coverage and an extensive network of doctors Lower Costs Low copays for primary care visits and $0 copays on routine dental, hearing, and vision exams Enhanced Benefits Such as fitness and weight-loss reimbursements, telehealth, over-the-counter allowance, comprehensive dental, and more Why Choose Blue? Quality, service, and trust. That’s why more people in Massachusetts choose our Medicare plans over any other option.1 Please see the enclosed to learn more. If you have any questions, we’re here to help. Sincerely, Gloria A. Paradiso, Vice President, Government Sales Enclosures Ready to Enroll? By phone: 1-800-678-2265 (TTY: 711) October 1 through March 31: 8:00 a.m. to 8:00 p.m., seven days a week April 1 through September 30: 8:00 a.m. to 8:00 p.m., Monday–Friday Online: bluecrossma.com/medicare By mail: Complete the enclosed enrollment form and return it in the self-addressed envelope. By fax: Complete the enclosed enrollment form and fax to 1-617-246-8506.
1. Represents Medicare Advantage and Medicare Supplemental Individual and Group plan membership based on data from Centers for Medicare & Medicare Services (cms.gov) and the Massachusetts Department of Insurance (mass.gov). Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001612097 H2261_2276_M 55-0619-23 (8/22)
IN THIS BOOKLET 01 Plan Information • Summary of Benefits (including a Pre-Enrollment checklist) • Plan Rating Sheet 02 Resources • Seminar Information • Top 100 Drugs • How to Find a Doctor 03 Disclosures • Nondiscrimination Notice • Translation Resources • Commitment to Confidentiality 04 Enrollment • Enrollment Forms • Business Reply Envelope
Plan Information 01
2023 SUMMARY OF BENEFITS Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Medicare HMO Blue PlusRx (HMO) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. H2261_2279_M PLANS 024, 022, 023, 005
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 covered by Blue Cross Blue Shield of Massachusetts, call our Member Service department and ask for the “Evidence of Coverage.” You can also access the “Evidence of Coverage” online at our website, bluecrossma.com/medicare.
1 2023 Summary of Benefits SUMMARY OF BENEFITS January 1, 2023 - December 31, 2023 Choose How You get your Medicare benefits You can choose to: • Get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. • Get your Medicare benefits by joining a Medicare health plan (such as Medicare HMO Blue SaverRx [HMO], Medicare HMO Blue ValueRx [HMO], Medicare HMO Blue FlexRx [HMO-POS], and Medicare HMO Blue PlusRx [HMO]). Tips for comparing your Medicare choices • This Summary of Benefits booklet gives you an overview of what Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue FlexRx (HMO-POS), and Medicare HMO Blue PlusRx (HMO) cover, and what you pay. • To compare our plan with other Medicare health plans, ask the other plans’ representatives for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on medicare.gov. • To learn more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet • Things to Know About Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue FlexRx (HMO-POS), and Medicare HMO Blue PlusRx (HMO) • Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services • Covered Medical and Hospital Benefits • Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call Member Service at the number shown in the next section.
bluecrossma.com/medicare 2 THINGS TO KNOW ABOUT OUR PLANS 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 1-800-200-4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1-800-200-4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday If you call after business hours, you may leave a message that includes your name, phone number, and the time you called, and a representative will return your call no later than one business day after you leave a message. Member Service also has free language interpreter services available for non-English speakers. Non-Members October 1–March 31 1-800-678-2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1–September 30 1-800-678-2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday Our website: bluecrossma.com/medicare Who can join? To join Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue FlexRx (HMO-POS), or Medicare HMO Blue PlusRx (HMO), you must be eligible for Medicare Part A, be enrolled in Medicare Part B, and live in our service area. You must continue to pay your Medicare Part B premium. Our service area includes the following counties in Massachusetts: Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester. Which doctors, hospitals, and pharmacies can I use? Our Medicare HMO Blue plans offer access to the doctors, hospitals, pharmacies, and other providers in our HMO network. With Medicare HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), and Medicare HMO Blue PlusRx (HMO), you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. With Medicare HMO Blue FlexRx (HMO-POS), you can use providers that are not in our network for certain services.
3 2023 Summary of Benefits As a member of our Medicare HMO Blue plans, you must choose a network Primary Care Provider (PCP). Your PCP will provide most of your care and will coordinate or help you arrange the rest of the covered services you get as a member of our plan. In most situations, your network PCP must give you approval in advance before you can use other providers in the plan’s network, such as specialists, hospitals, skilled nursing facilities, or home health care agencies. This is called giving you a “referral.” Referrals from your PCP are not required for emergency care or urgently needed services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can view our plan’s provider directory and pharmacy directory at bluecrossma.com/ medicare. Or, call us and we will send you a copy of the provider and pharmacy directories. The pharmacy network, and/or provider network may change at any time. You’ll receive notice when necessary. What do we cover? We cover everything that Original Medicare covers—and more. • Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. • Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. • Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. • You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions at, bluecrossma.com/ medicare-options. • Or, call us and we’ll send you a copy of the formulary. The formulary may change at any time. You will receive notice when necessary. How will I determine my drug costs? Our plan groups each medication into one of five “tiers.” You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Later in this document, we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible. Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call us if you would like more information.
bluecrossma.com/medicare 4 SUMMARY OF BENEFITS: January 1, 2023 - December 31, 2023 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Monthly Plan Premium Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $0 per month Worcester County: $0 per month Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $35 per month Worcester County: $55 per month Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $258 per month Worcester County: $258 per month Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk counties: $95 per month Worcester County: $105 per month You must continue to pay your Medicare Part B premium. Deductibles Medical: These plans do not have a medical deductible. Prescription Drugs: $300 per year for Tiers 3, 4, 5 $320 per year for Tiers 3, 4, 5 $200 per year for Tiers 3, 4, 5 $260 per year for Tiers 3, 4, 5 Maximum Out-of-Pocket Responsibility (does not include costs related to prescription drugs) Your yearly limit(s) in this plan: $5,600 for services you receive from in-network providers. Your yearly limit(s) in this plan: $3,450 for services you receive from in-network providers. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Your yearly limit(s) in this plan: $3,900 for services you receive from in-network providers. $9,900 for services you receive from outof-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.
5 2023 Summary of Benefits Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Inpatient Hospital Coverage Our plan covers an unlimited number of days for an inpatient hospital stay. $390 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Per admission benefit. $330 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Per admission benefit. $125 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Per admission benefit. In-Network: $245 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: 20% of the cost per stay Authorization rules may apply. Outpatient Hospital Coverage $325/visit $250/visit $150/visit In-Network: $210/visit Out-of-Network: 20% of the total cost Authorization rules may apply. Ambulatory Surgery Center $280/visit $250/visit $150/visit In-Network: $200/visit Out-of-Network: 20% of the total cost Authorization rules may apply. Doctor’s Office Visits (including telehealth visits) Primary Care Provider: $10 copay $10 copay $0 copay In-Network: $10 copay Out-of-Network: $65 copay Specialist: $45 copay* $40 copay* $30 copay* In-Network: $35 copay* Out-of-Network: $65 copay *You pay nothing for Medicare-covered specialist services performed in the home furnished by a network provider. Authorization rules may apply. Referral from your doctor may be required.
bluecrossma.com/medicare 6 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Preventive Care 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: • Abdominal aortic aneurysm screening • Alcohol use counseling • Bone mass measurement • Breast cancer screening (mammogram) • Cardiovascular disease (behavioral therapy) • Cardiovascular screenings • Cervical and vaginal cancer screening • Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy)** • Depression screening • Diabetes screenings • HIV screening • Flu shots, pneumococcal shots, Hepatitis B shots (limitations may apply) • Lung cancer screening (low-dose computed tomography [LDCT]) • Medical nutrition therapy services • Obesity screening and counseling • Prostate cancer screenings (PSA) • Sexually transmitted infections screening and counseling • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) • “Welcome to Medicare” preventive visit (one-time) • Yearly “Wellness” visit • Any additional preventive services approved by Medicare during the contract year will be covered. 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.
7 2023 Summary of Benefits Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Preventive Care (continued) You pay $0 for a supplemental annual physical exam. Includes a detailed medical/family history and a head-to-toe assessment with hands-on examination of all body systems to assess overall general health. You pay $0 for a supplemental annual physical exam. Includes a detailed medical/family history and a head-to-toe assessment with hands-on examination of all body systems to assess overall general health. You pay $0 for a supplemental annual physical exam. Includes a detailed medical/family history and a head-to-toe assessment with hands-on examination of all body systems to assess overall general health. You pay $0 in-network and $65 out-of-network for a supplemental annual physical exam. Includes a detailed medical/family history and a head-to-toe assessment with hands-on examination of all body systems to assess overall general health. Emergency Care $90 copay $105 copay $75 copay $90 copay Your copay is waived if you are admitted to the hospital within 24 hours or held overnight for observation. Urgently Needed Services (including telehealth visits) $10-$45 copay per visit* $10-$40 copay per visit* $0-$30 copay per visit* In-Network: $10–$35 copay per visit* Out-of-Network: $60 copay per visit *You pay nothing for Medicare-covered specialist services performed in the home furnished by a network provider. Diagnostic Services/Labs/Imaging Diagnostic Radiology (such as MRIs, CT scans): $310 copay per day per category $250 copay per day per category $150 copay per day per category In-Network: $200 copay per day per category Out-of-Network: 40% of the cost Authorization rules may apply. Diagnostic Tests and Procedures $10 copay per day* $10 copay per day* $0 copay per day In-Network: $10 copay per day* Out-of-Network: 20% of the cost *You pay nothing for covered services performed at home by a network provider. Authorization rules may apply.
bluecrossma.com/medicare 8 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Lab Services: $10 copay per day* $10 copay per day* $0 copay per day In-Network: $10 copay per day* Out-of-Network: 20% of the cost *You pay nothing for Medicare-covered services performed at home by a network provider Authorization rules may apply. Referral from your doctor may be required. Outpatient X-rays: $10 copay per day $10 copay per day $5 copay per day In-Network: $10 copay per day Out-of-Network: 20% of the cost Authorization rules may apply. Therapeutic Radiology Services: $60 copay per visit You pay nothing You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Authorization rules may apply. Hearing Services Routine Exam— up to one per year: $0 copay $0 copay $0 copay In-Network: $0 copay Out-of-Network: Not covered You must use a TruHearing network provider for all routine hearing exams. Non-Routine Exam: $10-$45 copay $10-$40 copay $0–$30 copay In-Network: $10-$35 copay Out-of-Network: $65 copay Hearing Aids: $699-$999 copay per hearing aid per year $699-$999 copay per hearing aid per year $699-$999 copay per hearing aid per year $699-$999 copay per hearing aid per year You must use a TruHearingTM network provider for all routine hearing exams and the purchase of covered hearing aids. There is no coverage for out-of-network providers.
9 2023 Summary of Benefits Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Dental Services Limited MedicareCovered Dental Services: $45 copay $40 copay $30 copay In-Network: $35 copay Out-of-Network: $65 copay or 20% Dental Services — Non-Medicare Covered Non-Medicare Covered Dental Services: $0 copay for preventive dental. 50% co-insurance for comprehensive services. $500 maximum per calendar year for preventive and comprehensive services combined. $0 copay. Coverage for preventive services only. Maximum of two visits each calendar year. $0 copay. Coverage for preventive services only. Maximum of two visits each calendar year. In-Network: You pay $0 copay. Out-of-Network: You pay a $45 copay. Coverage for preventive services only. Maximum of two visits each calendar year. Refer to the Evidence of Coverage for complete details.
bluecrossma.com/medicare 10 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Vision Services MedicareCovered Eye Exam: $10-$45 copay $10-$40 copay $0-$30 copay In-Network: $10-$35 copay Out-of-Network: $65 copay Eyewear After Cataract Surgery: (for Medicarecovered standard eyewear) $0 copay $0 copay $0 copay In-and Out-of-Network: $0 copay Routine Eye Exam: (up to 1 every 12 months) $0 copay $0 copay $0 copay In-Network: $0 copay Out-of-Network: Not covered You must use an EyeMed®´ network provider for all routine eye exams. Eyewear: (For covered eyewear, you pay any balance in excess of the $200 limit.) Our plan pays up to $200 once every 24 months for prescription eyewear Our plan pays up to $200 once every 24 months for prescription eyewear Our plan pays up to $200 once every 24 months for prescription eyewear In-Network: Our plan pays up to $200 once every 24 months for prescription eyewear Out-of-Network: Not covered You must use an EyeMed network provider for all routine eye exams and the purchase of covered eyewear. There is no coverage for out-of-network providers. Mental Health Services Inpatient Visit: $300 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond $275 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond $125 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond In-Network: $200 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond Out-of-Network: 20% of the cost per stay Authorization rules may apply.
11 2023 Summary of Benefits Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Outpatient Group Therapy Visit: $30 copay $25 copay $10 copay In-Network: $10 copay Out-of-Network: 20% of the cost Authorization rules may apply. Outpatient Individual Therapy Visit: (including telehealth visits) $30 copay* $25 copay* $10 copay* In-Network: $10 copay* Out-of-Network: 20% of the cost *You pay nothing for Medicare-covered services performed at home by a network provider. Authorization rules may apply. Additional Services Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $160 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $160 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $100 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Our plan covers up to 100 days in a SNF. In-Network: You pay nothing per day for days 1 through 20 $140 copay per day for days 21 through 44 You pay nothing per day for days 45 through 100 Out-of-Network: 20% of the cost per stay Authorization rules may apply. Physical Therapy $40 copay $30 copay $15 copay In-Network: $15 copay Out-of-Network: 20% of the cost Authorization rules may apply. Referral from your doctor may be required.
bluecrossma.com/medicare 12 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Ambulance $275 copay per trip $150 copay per trip $50 copay per trip In-Network: $100 copay per trip 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. Transportation (Including chair vans) Not covered Not covered Not covered Not covered Medicare Part B Drugs (Including Chemotherapy) No more than 20% co-insurance No more than 20% co-insurance No more than 10% co-insurance In-and Out-of-Network: No more than 20% co-insurance Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions. Starting July 1, 2023, you will pay no more than $35 for a one-month supply of insulins covered by our plan, furnished under Part B. Foot Care (Podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $10-$45 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $10-$40 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0-$30 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-Network: $10-$35 copay Out-of-Network: $65 copay Referral from your doctor may be required Over-thecounter items (OTC) Our plan pays up to $65 per quarter (up to $260 per year) toward over-the-counter health & wellness products. Not covered Not covered Not covered CVS will manage the OTC benefit. See the OTC catalog for a list of eligible items. Be sure to use your benefit amount before the end of each quarter (March, June, September, December). Remaining benefit does not roll over. Purchase OTC items by mail, phone, or in participating CVS retail stores. You can find the catalog at cvs.com/otchs/bcbsma. If you have questions or to order by phone, please call 1-888-628-2770 (TTY:711) Monday – Friday 9 am to 8 pm ET.
13 2023 Summary of Benefits Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Diabetes Supplies and Services* Diabetes Monitoring Supplies: You pay nothing You pay nothing You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Authorization rules may apply. Diabetes SelfManagement Training: You pay nothing You pay nothing You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Therapeutic Shoes or Inserts: You pay nothing You pay nothing You pay nothing In-Network: You pay nothing Out-of-Network: 20% of the cost Durable Medical Equipment (wheelchairs, oxygen, etc.) 20% of the cost 20% of the cost 10% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Authorization rules may apply. Prosthetic Devices (braces, artificial limbs, etc.) Prosthetic Devices: 20% of the cost 20% of the cost 10% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Related Medical Supplies: 20% of the cost 20% of the cost 10% of the cost In-Network: 10% of the cost Out-of-Network: 20% of the cost Wellness Programs (See back of this booklet for more details) Fitness: $250 per calendar year $150 per calendar year $250 per calendar year $150 per calendar year Weight Loss: $150 per calendar year $150 per calendar year $150 per calendar year $150 per calendar year *There is no co-insurance or copayment for the One Touch®´ blood glucose test strips and blood glucose monitors purchased at participating retail and mail service pharmacies; otherwise you pay all costs. Test strips and blood glucose monitors are also available at DME suppliers with no co-insurance or copayment. There is no co-insurance or copayment for members eligible for covered therapeutic molded shoes and inserts, diabetes self-management training preventive benefit, or fasting plasma glucose tests.
bluecrossma.com/medicare 14 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 and HMO Blue PlusRx) per calendar year toward your club membership fees and exercise classes. What programs qualify? • Virtual/online fitness memberships, subscriptions, programs, or classes that provide cardiovascular and strength training using a digital platform. • Home Fitness Equipment like stationary bikes, weights, exercise bands, treadmills, fitness machines. • Home Fitness Equipment WILL NOT cover wearable fitness trackers or items that are considered “Recreational Equipment” or “Sports Equipment.” Examples include kayaks, inline skates, bicycles, ice skates, trampolines, fitness clothing, sneakers. • Health clubs with a variety of cardiovascular and strength-training exercise equipment, e.g., traditional health clubs, YMCAs, YWCAs, and community fitness centers or facilities that only have a pool. • Fitness classes at participating Councils on Aging (COA) facilities; fitness studios with instructor-led groups such as yoga, Pilates, Zumba®´, kickboxing, CrossFit®´, and indoor cycling/spinning and other exercise classes. • Programs that DO NOT qualify: Martial arts centers; gymnastics facilities; country clubs; tennis or aerobic facilities; social clubs; and sports teams/ leagues. You cannot receive the Fitness Benefit for personal training, lessons, coaching, or clothing. What is the Weight-Loss Benefit? Enroll in a qualified weight-loss program and receive up to $150 per calendar year toward your program fees. Employer group benefits may vary. What kinds of programs qualify? • Traditional WW, (formerly known as Weight Watchers®´) meetings, WW Online and At Work programs, 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. REWARDING YOU FOR HEALTHY CHOICES GET REIMBURSED WHEN YOU ENROLL IN QUALIFIED FITNESS AND WEIGHT-LOSS PROGRAMS. $150-250 FITNESS REIMBURSEMENT $150 WEIGHT-LOSS REIMBURSEMENT
15 2023 Summary of Benefits PRESCRIPTION DRUG BENEFITS Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Deductible $300 per year for Tiers 3, 4, 5 $320 per year for Tiers 3, 4, 5 $200 per year for Tiers 3, 4, 5 $260 per year for Tiers 3, 4, 5 Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $4,660. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail service pharmacies. Tier 1 = Preferred Generic Tier 2 = Generic Tier 3 = Preferred BrandTier Tier 4 = Non-Preferred Drug Tier 5 = Specialty Tier Note: Cost sharing may differ relative to the pharmacy’s status as preferred or standard, mail service, Long-Term Care (LTC) or home infusion, and 30 days or 90 days supply. Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO BlueFlexRx (HMO-POS) Preferred Retail Cost Sharing Drug Tier 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Tier 2 (Generic) $8 copay $16 copay $24 copay $6 copay $12 copay $18 copay $5 copay $10 copay $15 copay $5 copay $10 copay $15 copay Tier 3 (Preferred Brand) $42 copay $84 copay $126 copay $42 copay $84 copay $126 copay $42 copay $84 copay $126 copay $42 copay $84 copay $126 copay Select Insulin $35 $70 $105 $35 $70 $105 $35 $70 $105 $35 $70 $105 Tier 4 (Non-Preferred Drug) $95 copay $190 copay $285 copay $95 copay $190 copay $285 copay $95 copay $190 copay $285 copay $95 copay $190 copay $285 copay Tier 5 (Specialty Tier) 28% of the cost N/A N/A 27% of the cost N/A N/A 29% of the cost N/A N/A 28% of the cost N/A N/A Standard Retail Cost Sharing Drug Tier 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply Tier 1 (Preferred Generic) $8 copay $16 copay $24 copay $8 copay $16 copay $24 copay $6 copay $12 copay $18 copay $6 copay $12 copay $18 copay Tier 2 (Generic) $20 copay $40 copay $60 copay $12 copay $24 copay $36 copay $10 copay $20 copay $30 copay $10 copay $20 copay $30 copay
bluecrossma.com/medicare 16 Medicare HMO Blue SaverRx (HMO) Medicare HMO Blue ValueRx (HMO) Medicare HMO Blue PlusRx (HMO) Medicare HMO Blue FlexRx (HMO-POS) Tier 3 (Preferred Brand) $47 copay $94 copay $141 copay $47 copay $94 copay $141 copay $47 copay $94 copay $141 copay $47 copay $94 copay $141 copay Select Insulin $35 $70 $105 $35 $70 $105 $35 $70 $105 $35 $70 $105 Tier 4 (Non-Preferred Drug) $100 copay $200 copay $300 copay $100 copay $200 copay $300 copay $100 copay $200 copay $300 copay $100 copay $200 copay $300 copay Tier 5 (Specialty Tier) 28% of the cost N/A N/A 27% of the cost N/A N/A 29% of the cost N/A N/A 28% of the cost N/A N/A Mail Service Cost Sharing Drug Tier 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply 30- day supply 60- day supply 90- day supply Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay $0 copay Tier 2 (Generic) $8 copay $16 copay $16 copay $6 copay $12 copay $12 copay $5 copay $10 copay $10 copay $5 copay $10 copay $10 copay Tier 3 (Preferred Brand) $42 copay $84 copay $84 copay $42 copay $84 copay $84 copay $42 copay $84 copay $84 copay $42 copay $84 copay $84 copay Select Insulin $35 $70 $70 $35 $70 $70 $35 $70 $70 $35 $70 $70 Tier 4 (Non-Preferred Drug) $95 copay $190 copay $190 copay $95 copay $190 copay $190 copay $95 copay $190 copay $190 copay $95 copay $190 copay $190 copay Tier 5 (Specialty Tier) 28% of the cost N/A N/A 27% of the cost N/A N/A 29% of the cost N/A N/A 28% of the cost N/A N/A If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,660 After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand-name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $7,400, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail service) reach $7,400, you pay the greater of: 5% of the cost, or $4.15 copay for generic (including brand drugs treated as generic) and a $10.35 copayment for all other drugs.
17 2023 Summary of Benefits PRE-ENROLLMENT CHECKLIST Before making an enrollment decision, it’s important that you fully understand our benefits and rules. We’ve put together the checklist below to help you. If you have any questions, you can call and speak to a customer service representative. Understanding the Benefits The Evidence of Coverage (EOC) provides a complete list of all coverage and services. It is important to review plan coverage, costs, and benefits before you enroll. 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. Review the formulary to make sure your drugs are covered. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums, and/or copayments/co-insurance may change on January 1, 2024. 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 Medicare HMO Blue FlexRx (HMO-POS) plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will pay a higher copay for services received by non-contracted providers. Call Us: 1-800-678-2265 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. Independent Licensees of the Blue Cross and Blue Shield Association. H2261_22189_M
bluecrossma.com/medicare 18 Contact Information and Hours of Operation Members October 1 - March 31 1-800-200-4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1 - September 30 1-800-200-4255 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday - Friday If you call after business hours, you may leave a message that includes your name, phone number and the time you called, and a representative will return your call no later than one business day after you leave a message. Member Service also has free language interpreter services available for non-English speakers. Non-Members October 1 - March 31 1-800-678-2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 7 days a week April 1 - September 30 1-800-678-2265 (TTY: 711) 8:00 a.m. to 8:00 p.m., 5 days a week, Monday - Friday Our website: bluecrossma.com/medicare
19 2023 Summary of Benefits 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, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov.
bluecrossma.com/medicare 20 NOTES
You can file a complaint if you feel that you received inaccurate, misleading, or inappropriate information. Please call Member Service at 1-800-200-4255 (TTY: 711). If your complaint involves a broker or agent, be sure to include the name of the broker/agent when filing your complaint. Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM Trademarks are the property of their respective owners. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002031800 H2261_2279_M 55-0604-23 (3/23) FOR MORE INFORMATION OR HELP WITH ENROLLMENT Medicare Plan Sales 1-800-678-2265 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week. bluecrossma.com/medicare
IMPORTANT INFORMATION: 2023 Medicare Star Ratings Blue Cross Blue Shield of Massachusetts - H2261 For 2023, Blue Cross Blue Shield of Massachusetts - H2261 received the following Star Ratings from Medicare: Overall Star Rating: Health Services Rating: Drug Services Rating: Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings Are Important Medicare rates plans on their health and drug services. This lets you easily compare plans based on quality and performance. Star Ratings are based on factors that include: Feedback from members about the plan’s service and care The number of members who left or stayed with the plan The number of complaints Medicare got about the plan Data from doctors and hospitals that work with the plan More stars mean a better plan – for example, members may get better care and better, faster customer service. The number of stars show how well a plan performs. EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR Get More Information on Star Ratings Online Compare Star Ratings for this and other plans online at medicare.gov/plan-compare. Questions about this plan? Contact Blue Cross Blue Shield of Massachusetts 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 800-678- 2265 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 800-200-4255 (tollfree) or 711 (TTY). You can file a complaint if you have if you feel that you received inaccurate, misleading, or inappropriate information. Please call Blue Cross Blue Shield of Massachusetts at 1-800-200-4255 (TTY 711) If your complaint involves a broker or agent, be sure to include the name of the person when filing your complaint. H2261_2280_M 001994268_HMO | 99-0288-23 (1/23) 1/1 IMPORTANT INFORMATION: 2023 Medicare Star Ratings Blue Cross Blue Shield of Massachusetts - H2261 For 2023, Blue Cross Blue Shield of Massachusetts - H2261 received the following Star Ratings from Medicare: Overall Star Rating: Health Services Rating: Drug Services Rating: Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings Are Important Medicare rates plans on their health and drug services. This lets you easily compare plans based on quality and performance. Star Ratings are based on factors that include: Feedback from members about the plan’s service and care The number of members who left or stayed with the plan The number of complaints Medicare got about the plan Data from doctors and hospitals that work with the plan More stars mean a better plan – for example, members may get better care and better, faster customer service. The number of stars show how well a plan performs. EXCELLENT ABOVE AVERAGE AVERAGE BELOW AVERAGE POOR Get More Information on Star Ratings Online Compare Star Ratings for this and other plans online at medicare.gov/plan-compare. Questions about this plan? Contact Blue Cross Blue Shield of Massachusetts 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 800-678- 2265 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 800-200-4255 (tollfree) or 711 (TTY). You can file a complaint if you have if you feel that you received inaccurate, misleading, or inappropriate information. Please call Blue Cross Blue Shield of Massachusetts at 1-800-200-4255 (TTY 711) If your complaint involves a broker or agent, be sure to include the name of the person when filing your complaint. H2261_2280_M 001994268_HMO | 99-0288-23 (1/23) 1/1
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JOIN US AND LEARN MORE ABOUT MEDICARE The best plan is the kind you understand. Join one of our upcoming Medicare seminars to learn more about your options and get answers to your questions. Topics include: Medicare Advantage (HMO and PPO) Original Medicare and Medex®´ (Medicare Supplement) Prescription Drug Plans (PDP) Dental Blue® 65 GeoBlue® Travel Insurance UPCOMING SEMINARS To view the full list of upcoming seminars including in-person and online options and to sign up, scan the QR code, or visit bluecrossma.com/seminar. Seminar Type Date Time Location Original Medicare & Medex®´ (Medicare Supplement) Monday, September 18, 2023 2:00 p.m. - 2:45 p.m. Online Prescription Drug Plans (PDP) Monday, September 18, 2023 3:00 p.m. - 3:45 p.m. Online Medicare Plan Options* Tuesday, September 19, 2023 10:00 a.m. - 12:00 p.m. John Carver Inn & Spa 25 Summer Street, Plymouth Medicare Advantage (HMO & PPO) Wednesday, September 20, 2023 10:00 a.m. - 11:00 a.m. Online Dental Blue® 65 Wednesday, September 20, 2023 11:30 a.m. - 12:00 p.m. Online GeoBlue® Travel Insurance Wednesday, September 20, 2023 12:30 p.m. - 1:00 p.m. Online Medicare Plan Options* Thursday, September 21, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester Original Medicare & Medex (Medicare Supplement) Monday, September 25, 2023 3:00 p.m. - 3:45 p.m. Online Prescription Drug Plans (PDP) Monday, September 25, 2023 4:00 p.m. - 4:45 p.m. Online Medicare Plan Options* Tuesday, September 26, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham Dental Blue® 65 Wednesday, September 27, 2023 1:00 p.m. - 1:30 p.m. Online Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx plans. The joint enterprise is a Medicare-approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal. ® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 002313605 Y0014_22171_M 99-0645-23 (8/23) Not seeing a date that works for you? There are plenty more to choose from. Check out our full list of events at bluecrossma.com/seminar, or scan the QR Code. NEED HELP SIGNING UP? For assistance signing up for a seminar, or for accommodations for persons with special needs, call 1-800-262-BLUE (2583) (TTY: 711) 7:00 a.m. – 12:00 midnight, seven days a week (excluding holidays). Seminar Type Date Time Location GeoBlue Travel Insurance Wednesday, September 27, 2023 2:00 p.m. - 2:30 p.m. Online Medicare Advantage (HMO & PPO) Wednesday, September 27, 2023 3:00 p.m. - 4:00 p.m. Online Medicare Plan Options* Wednesday, October 18, 2023 10:00 a.m. - 12:00 p.m. Marriott One Burlington Mall Road, Burlington Medicare Plan Options* Wednesday, October 18, 2023 10:00 a.m. - 12:00 p.m. John Carver Inn & Spa 25 Summer Street, Plymouth Medicare Plan Options* Thursday, October 19, 2023 10:00 a.m. - 12:00 p.m. Holiday Inn 55 Ariadne Road, Dedham Medicare Plan Options* Friday, October 20, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester Medicare Plan Options* Tuesday, October 24, 2023 10:00 a.m. - 12:00 p.m. La Quinta Inn & Suites by Wyndham 100 Congress Street, Springfield Medicare Plan Options* Monday, October 30, 2023 10:00 a.m. - 12:00 p.m. Beechwood Hotel 363 Plantation Street, Worcester *A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits. They can answer your questions and assist with enrollment when you’re ready. Visit the website below to view the agenda. 3-346
MEDICARE ADVANTAGE TOP 100 DRUG LIST Looking for one good reason why a Medicare Advantage plan with prescription drug coverage from Blue Cross Blue Shield of Massachusetts is the right plan for you? Here are 100. And this is just a sample of our Medicare Advantage plan’s drug list. We also cover hundreds of other medications. MEDICATION NAME ADVAIR DISKUS® CLOBETASOL PROPIONATE GLIPIZIDE ALBUTEROL SULFATE HFA CLONAZEPAM GLIPIZIDE ER ALENDRONATE SODIUM CLOPIDOGREL HYDROCHLOROTHIAZIDE ALLOPURINOL DICLOFENAC SODIUM HYDROCODONE-ACETAMINOPHEN ALPRAZOLAM DILTIAZEM 24HR ER (CD) IBUPROFEN AMLODIPINE BESYLATE DONEPEZIL HCL IRBESARTAN AMOXICILLIN DORZOLAMIDE-TIMOLOL ISOSORBIDE MONONITRATE ER AMOXICILLIN-CLAVULANATE POTASS DOXYCYCLINE HYCLATE JARDIANCE® ATENOLOL DOXYCYCLINE MONOHYDRATE KETOCONAZOLE ATORVASTATIN CALCIUM DULOXETINE HCL KETOROLAC TROMETHAMINE AZITHROMYCIN ELIQUIS® LANTUS® SOLOSTAR® BUPROPION HCL SR ESCITALOPRAM OXALATE LATANOPROST BUPROPION XL ESTRADIOL LEVOTHYROXINE SODIUM CARVEDILOL EZETIMIBE LISINOPRIL CELECOXIB FAMOTIDINE LISINOPRIL-HYDROCHLOROTHIAZIDE CEPHALEXIN FENOFIBRATE LORAZEPAM CHLORHEXIDINE GLUCONATE FINASTERIDE LOSARTAN POTASSIUM CHLORTHALIDONE FLUOXETINE HCL LOVASTATIN CIPROFLOXACIN HCL FLUTICASONE PROPIONATE MELOXICAM CITALOPRAM HBR FUROSEMIDE METFORMIN HCL CLINDAMYCIN HCL GABAPENTIN METFORMIN HCL ER continued Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.Llame al 1-800-200-4255 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615494 Y0014_2277_M 50-0177-23 (9/22) MEDICATION NAME METHYLPREDNISOLONE PANTOPRAZOLE SODIUM TAMSULOSIN HCL METOPROLOL SUCCINATE PAROXETINE HCL TIMOLOL MALEATE METOPROLOL TARTRATE POTASSIUM CHLORIDE TRAMADOL HCL METRONIDAZOLE PRAVASTATIN SODIUM TRAZODONE HCL MIRTAZAPINE PREDNISOLONE ACETATE TRIAMCINOLONE ACETONIDE MONTELUKAST SODIUM PREDNISONE TRIAMTERENE-HYDROCHLOROTHIAZID MUPIROCIN ROSUVASTATIN CALCIUM TRULICITY® NITROFURANTOIN MONO-MACRO SERTRALINE HCL VALACYCLOVIR OFLOXACIN SHINGRIX VALSARTAN OMEPRAZOLE SIMVASTATIN VENLAFAXINE HCL ER OXYBUTYNIN CHLORIDE ER SPIRONOLACTONE WARFARIN SODIUM OXYCODONE HCL SULFAMETHOXAZOLE-TRIMETHOPRIM ZOLPIDEM TARTRATE OXYCODONE-ACETAMINOPHEN This list is subject to change.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Medicare HMO Blue (HMO) IS YOUR PRIMARY CARE PROVIDER (PCP) IN THE MEDICARE HMO BLUE NETWORK? To find your current PCP in the Medicare HMO Network, use our Find a Doctor & Estimate Costs tool. You can also search for other in-network doctors, hospitals, and health care professionals by following these three steps: 1. Sign in to your MyBlue account at bluecrossma.org, or open the MyBlue app. 2. Under My Care, select Find a Doctor & Estimate Costs. 3. Enter a doctor, hospital, or type of care, then click Search. To search for a doctor without signing in, go to bluecrossma.com/findadoctor, and enter Medicare HMO Blue under Select a Network. The Easy Way to Find Care Search by name, specialty, facility, or keyword, or browse by category. Plus, get cost estimates for more than 1,500 common procedures. Compare up to five doctors at once, use filters to narrow your results, and review provider quality ratings. View in-depth provider profiles, which include specialties, languages, contact information, and whether they’re accepting new patients.
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. The provider network may change at any time. You’ll receive notice when necessary. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711). ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross Blue Shield of Massachusetts HMO Blue, Inc. 001633067 H2261_2282_C 50-0239-23 (8/22) WE’RE HERE TO HELP If you need help finding a doctor, or if you don’t have Internet access, call us at 1-800-678-2265 (TTY: 711). A representative is available to help you: OCTOBER 1 THROUGH MARCH 31: 8:00 a.m. to 8:00 p.m. ET, seven days a week APRIL 1 THROUGH SEPTEMBER 30: 8:00 a.m. to 8:00 p.m. ET, Monday through Friday
Disclosures 03
NONDISCRIMINATION NOTICE Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. It does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. Blue Cross Blue Shield of Massachusetts provides: • Free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print or other formats). • Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Medicare Advantage Appeals and Grievance Manager. If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at [email protected]. You can file a grievance in person, by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711). If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD). Complaint forms are available at hhs.gov. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001615321 55-1490A (9/22)
TRANSLATION RESOURCES Form Approved OMB# 0938-1421 Proficiency of Language Assistance Services Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association 1 English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at [1-800-200-4255]. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al [1-800-200-4255]. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。如果 您需要此翻译服务，请致电 1-800-200-4255。我们的中文工作人员很乐意帮助您。 这是一项免费 服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯 服務。 如需翻譯服務，請致電 1-800-200-4255。我們講中文的人員將樂意為您提供幫助。這 是一項免費 服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa [1-800-200-4255]. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au [1-800-200- 4255]. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi [1-800- 200-4255] sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter [1-800- 200-4255]. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보 또는 약 보에 관 질문에 답 드리고자 무료 역 서비스를 제공고 있습니다. 역 서비스를 이용려면 전 [1-800-200-4255]번으로 문의 주십시오. 국어를 는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Form CMS-10802 (Expires 12/31/25)
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону [1-800-200-4255]. Вам окажет помощь сотрудник, который говорит поpусски. Данная услуга бесплатная. Arabic :لوصحلل .انیدل ةیودلأا لودج وأ ةحصلاب قلعتت ةلئسأ يأ نع ةباجلإل ةیناجملا يروفلا مجرتملا تامدخ مدقن اننإ انب لاصتلاا ىوس كیلع سیل ،يروف مجرتم ىلع [ ىلع 4255-200-800-1 . [ةیبرعلا ثدحتی ام صخش موقیس ةیناجم ةمدخ هذھ .كتدعاسمب . Hindi: हमारे 'ा( या दवा की योजना के बारे म2 आपके िकसी भी 89 के जवाब देने के िलए हमारे पास मु= दुभािषया सेवाएँ उपलA हB. एक दुभािषया 8ाD करने के िलए, बस हम2 [1-800-200-4255] पर फोन कर2. कोई JKL जो िहMी बोलता है आपकी मदद कर सकता है. यह एक मु= सेवा है. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero [1-800-200-4255]. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portuguese: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número [1-800-200-4255]. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan [1-800-200-4255]. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer [1-800-200-4255]. Ta usługa jest bezpłatna. Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無 料の通訳サービスがありますございます。通訳をご用命になるには、[1-800-200-4255]にお 電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。 Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield depends upon contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity. ® Registered Marks of the Blue Cross and Blue Shield Association. © 2023 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Form CMS-10802 (Expires 12/31/25) Y0014_2249_C 001969050 | 55-1490B (1/23) 2 Form Approved OMB# 0938-1421
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. OUR COMMITMENT TO CONFIDENTIALITY This Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. Our Commitment: We respect your right to privacy. We won’t disclose personally identifiable information about you without your permission, unless the disclosure is necessary to provide our services to you or is otherwise in accordance with the law. Collection of Information We collect only personal or medical information we need to carry out our business. • Examples of personal information are name, address, date of birth, and social security number. Most often, you and your employer supply this information to enroll you in a plan. • Examples of medical information are diagnoses, treatments, and names of providers who treat you. Most often, your providers supply this information. Use and Disclosure of Information We’re required by law to protect the confidentiality of your personal and medical information and to notify you in case of a breach affecting your personal or medical information. We’ll supply your information to you upon your request or to help you understand treatment options and other benefits available to you. We also may use and disclose your information without your written authorization for the following purposes, and as otherwise permitted or required by law: • Treatment—to help providers manage or coordinate your health care and related services. For example, to refer you to another provider or remind you of appointments. • Payment—to obtain payment for your coverage, provide you with health benefits, and assist another health plan or provider in its payment activities. For example, to manage enrollment records, make coverage determinations, administer claims, or coordinate benefits with other coverage you may have.
• Health Care Operations—to operate our business, including accreditation, credentialing, customer service, disease management, and fraud-prevention activities. For example, to do business planning, arrange for medical review, or conduct quality assessment and improvement activities. • Legal Compliance—to comply with applicable laws. For example, to respond to regulatory authorities responsible for oversight of government benefit programs or our operations; to parties or courts in the course of judicial or administrative proceedings; to law enforcement officials during an investigation; and as necessary to comply with workers’ compensation laws. • Research and Public Health—for medical research studies in accordance with laws for the protection of human research subjects, and to report to public health authorities and otherwise prevent or lessen a serious and imminent threat to health or safety. For example, for the purpose of preventing or controlling disease, injury, or disability. • To an Account (such as an employer) or Party It Designates—for administration of its health plan. For example, to a self-insured account for claim review and audits. We’ll disclose your information only to designated individuals. That, along with contract obligations, helps protect your information from unauthorized use. To carry out these purposes, we share information with entities that perform functions for us subject to contracts that limit use and disclosure to intended purposes. We use physical, electronic, and procedural safeguards to protect your privacy. Even when allowed, uses and disclosures are limited to the minimum amount reasonably necessary for the intended task. Special Notes Regarding Disclosure Special protections apply to information about certain medical conditions. For example, with very few exceptions allowed by law, we won’t disclose any information regarding HIV or AIDS to any party without your written permission. We won’t disclose mental health treatment records to you without first receiving approval from your treating provider or another equally qualified mental health professional. Also, we’re prohibited from using or disclosing genetic information for underwriting purposes. Except as provided in this notice, we won’t use or disclose your personal or medical information without your written authorization. A form for this purpose is available on our website or by calling Member Service. Specifically, we must have your written authorization to use or disclose your information for: • Marketing purposes; • The sale of PHI; • Most use and disclosures of psychotherapy notes. You may revoke your authorization at any time. Your authorization must be in writing. Your revocation won’t affect any action that we have already taken in reliance on your authorization.