BCBSMA PDP Sales Kit Book June 2022 Approved By Danielle Roy 5/19/2022 12:22 PM

Blue MedicareRx (PDP) 2022

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Blue MedicareRx Value Plus
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Blue MedicareRx Premier
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a Name You Can Trust

Blue Cross Blue Shield of Massachusetts
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aisnadnBIlnudeeSpheinedldeAntssLoicceiantsioeen.of the Blue Cross
and Blue Shield Association.
June 2022 (2203852)



Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP)

FINDING THE RIGHT PRESCRIPTION DRUG PLAN FOR YOU

Thank you for your interest in our Blue MedicareRx prescription drug plans (PDP).
They’re the right plan to deliver the comprehensive drug coverage you need.

Our Plans  Get the Coverage You Deserve

• Blue MedicareRx Value Plus (PDP) We want to make sure your plan fits your
• Blue MedicareRx Premier (PDP) needs. That’s why we’ve sent you these
enclosed materials to help you make your
Key Features for 2022 decision:
• Plan Brochure: Answers questions about
• $1 copayments on Tier 1 generic drugs
at network retail pharmacies that offer Medicare Part D, and highlights key
preferred cost sharing features of the Blue MedicareRx plans
• S ummary of Benefits: Gives you an
• Opportunity to save with lower costs overview of Blue MedicareRx plan
at more than 20,000+ preferred retail options
pharmacies* • Medicare Star Rating Sheet: Shows you
the Medicare program’s summary rating
• Save money when you get a three-month of Blue MedicareRx’s overall plan quality
supply of certain drugs delivered right to and performance
your home with the mail order pharmacy • Top 100 Drug List: Gives you a list of the
100 most commonly used brand-name
• For Blue MedicareRx Value Plus: and generic drugs we cover
$1 copayments on Tier 1 generic drugs • Network Chain Pharmacies: Gives you
at network retail pharmacies that offer a list of our extensive network of chain
preferred cost sharing, and $0 annual pharmacies
deductible on generic and preferred
generic drugs

• For Blue MedicareRx Premier:
$0 annual deductible on all drugs

Questions?

If you have any questions about how Medicare works, call our team
of Medicare experts today. See the next page for more information.

*Retail pharmacies may be added or removed throughout the year. For a current listing of
pharmacies in your area, you can search our online directory at rxmedicareplans.com.

Independent Licensees of the Blue Cross and Blue Shield Association. S2893_2116_M

Learn More Today

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

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

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 24 hours a day, 7 days a week
7 days a week;
4/1-9/30, 8:00 a.m. to 8:00 p.m. ET,
Monday through Friday
You can use our automated answering
service outside of these hours.

We look forward to providing you with convenient, high-quality prescription drug coverage.

Sincerely,
Blue MedicareRx (PDP)

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross
& Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which
have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and

are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-
approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.
Coverage is available to residents of the service area or members of an employer or union
group and separately issued by one of the following plans: Anthem Blue Cross® and
Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross
& Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

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

Every year, Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated
each year and may change from one year to the next. Star Ratings can be found at medicare.gov.

® Registered Marks of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks,
Service Marks, and Trademarks are property of their respective owners. © 2021 All Rights Reserved.

000871511 PL-22 99-0652-22 (8/21)

IN THIS BOOKLET

01 Plan Information
• Sales Brochure
• Summary of Benefits
• Pre-Enrollment Checklist
• Plan Rating Sheet

02 Resources
• Seminar Information
• Top Covered Drugs
• Network Chain Pharmacy List

03 Disclosures
• Nondiscrimination Notice and
Translation Resources Notice
• Privacy Notice

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx
Prescription Drug Plan (PDP)

PRESCRIPTION
DRUG COVERAGE
THAT FITS
YOUR NEEDS

Our 2022 Plan Information

Independent Licensee of the Blue Cross
and Blue Shield Association.
S2893_2117_M

THANK YOU
FOR YOUR INTEREST
IN OUR 2022
PRESCRIPTION
DRUG PLANS

CONTENTS

What Is Medicare Part D? . . . . . . . . . . 1
Plans That Fit Your Needs . . . . . . . . . 2
90-Day Supply for as Low as $1 . . . . . . 2
Why Choose Blue MedicareRx? . . . . . . 3
Our Pharmacy Network . . . . . . . . . . . 6
Formulary Coverage . . . . . . . . . . . . . 8
2022 Blue MedicareRx Plan
Comparison Chart . . . . . . . . . . . . 9-10
Frequently Asked Questions . . . . . . . . 11

WHAT IS MEDICARE PART D?

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

How Part D works

(Information provided below is specific to 2022)
In addition to the monthly premium, Medicare Part D plans have four different benefit stages
that affect how much you owe for your prescriptions: Annual Deductible (if applicable),
Initial Coverage, Coverage Gap, and Catastrophic Coverage.

Here's how they work:

Annual Deductible The Blue MedicareRx Value Plus plan has an annual deductible only on Tiers 3, 4, and 5.
(if applicable) The Blue MedicareRx Premier plan has no annual deductible.
Refer to the Plan Comparison Chart on pages 9-10 for more details.

Initial Coverage There is a $4,430 initial coverage limit. This includes your copayments, co-insurance,
Coverage Gap and payments made by the plan for covered prescriptions.
Catastrophic
Coverage There is a coverage gap that starts once total drug costs (member and plan payments)
reach $4,430 and ends when your out-of-pocket prescription drug costs reach $7,050.
When you're in the Coverage Gap stage, you pay 25% of the costs of generic drugs.
For brand-name drugs, you pay 25% of the negotiated price (excluding the dispensing fee).
You continue paying 25% for generic drugs and 25% of the negotiated price (excluding
the dispensing fee) for brand-name drugs until yearly out-of-pocket costs paid by you
and others on your behalf reach $7,050. The payments made on your behalf (excludes
payments made by Blue MedicareRx) count toward your out-of-pocket costs.
Refer to the Plan Comparison Chart on pages 9-10 for your costs in the Coverage Gap
for each of the Blue MedicareRx plans.

Takes effect after you and others on your behalf have paid $7,050 in annual
out-of-pocket prescription costs.

Am I eligible?

You’re eligible for Medicare prescription drug coverage
and Blue MedicareRx membership if:

• You have Medicare Part A and/or Medicare Part B
• You’re a United States citizen or are lawfully present in the United States
• You live in our geographic service area

1 Blue MedicareRx Prescription Drug Plan

PLANS THAT FIT YOUR NEEDS

Our Blue MedicareRx Value Plus (PDP) and Blue MedicareRx Premier (PDP)
plans help complete your Medicare coverage by offering the comprehensive
prescription drug benefits you need.

Blue MedicareRx Value Plus Blue MedicareRx Premier

$0 $0

ANNUAL DEDUCTIBLE ANNUAL DEDUCTIBLE

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

Cost savings through preferred cost sharing
at participating network retail pharmacies

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

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

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

rxmedicareplans.com 2

WHY CHOOSE Blue MedicareRx?

Our Blue MedicareRx plans are standalone prescription drug plans that give
you the flexibility, service, and support you need from a Medicare Part D plan.
They’re offered to residents of Connecticut, Massachusetts, Rhode Island,
and Vermont who qualify for Medicare.

 World-class Service Contact Us:
 and Support
Connecticut Residents:
We’re here for you. Our experts are 1-866-832-9702 (TTY: 711)
available to answer your questions 24 hours a day, 7 days a week
and offer suggestions, so whether
you’re new to Medicare Part D or Massachusetts Residents:
switching plans, we make it easy 1-800-678-2265 (TTY: 711)
for you to get the coverage that’s 10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
right for you. Just call us at one 4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
of the numbers listed here.
Rhode Island Residents:
More Pharmacies to 1-800-505-2583 (TTY: 711)
Choose from Nationwide 10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.;
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
With approximately 64,000+ You can use our automated answering system outside
pharmacies in our network, you of these hours.
can enjoy peace of mind knowing
you can use your coverage when Vermont Residents:
and where you need it at national 1-888-496-4178 (TTY: 711)
chains and independent pharmacies 24 hours a day, 7 days a week
throughout the United States.
Check page 5 for more details Online: rxmedicareplans.com
on our pharmacy network.

You Can Trust Blue

Over seven million Medicare
members nationwide are enrolled
in a Blue Cross Blue Shield plan.*

*Data attributed to all Blue Cross Blue Shield Association plans across the country,
CMS, Barclays Research, 2021, Quarter 2, Brand Protection Financial Services Reporting.

3 Blue MedicareRx Prescription Drug Plan

Example:

Blue MedicareRx Value Plus

Paul is healthy and only takes
medications on occasion.
He wants more for less:
• Lower monthly premium
• $0 deductible on Tier 1

and Tier 2, which contain
some of the most commonly
used generic drugs



Paul’s Choice:
Blue MedicareRx

Value Plus

rxmedicareplans.com 4

64,000+ PHARMACIES
IN OUR NETWORK1

TWO PLANS TO CHOOSE FROM

We offer you a choice of two Blue MedicareRx plans with different premiums, coverage
levels, and out-of-pocket costs: Blue MedicareRx Value Plus and Blue MedicareRx Premier.
Our Blue MedicareRx plans offer great service, access to 64,000+ network pharmacies
nationwide, and mail order savings.

Blue MedicareRx Blue MedicareRx
Value Plus Premier

Large Network of Retail Pharmacies

Network Retail Pharmacies
with Preferred Cost Sharing
Mail Order Service
Includes most Medicare Part D-eligible
generic drugs
Some of the most commonly used
generics are available at the lowest
copayment (Tier 1)
Additional Plan Coverage for Tier 1
preferred generic drugs and Tier 2
generic drugs in the Coverage Gap

1. Retail pharmacies may be added or removed throughout the year. For a current listing of pharmacies in your area,
you can search our online directory at rxmedicareplans.com.

5 Blue MedicareRx Prescription Drug Plan

OUR PHARMACY NETWORK

What pharmacies can I use?

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

What is preferred cost sharing for the Blue MedicareRx plans?

When you visit a network pharmacy that offers preferred cost sharing, you pay lower copays
for your prescriptions than you would at other pharmacies. And it’s easy for you to get these
savings. 20,000+ of the pharmacies in our network offer preferred cost sharing, including:1

Types of network pharmacies

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

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

1. Other pharmacies are available in our network.

rxmedicareplans.com 6

Example:

Blue MedicareRx Premier

Martha takes several expensive
drugs and reaches the
coverage gap.
She wants the most coverage:
• A plan with no annual deductible
• More extensive coverage of her

generic medications even after
she’s reached the coverage gap



Martha’s Choice:
Blue MedicareRx

Premier

7 Blue MedicareRx Prescription Drug Plan

FORMULARY COVERAGE

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

2022 Drug Tier Label Blue MedicareRx Blue MedicareRx
Tier 1: Preferred Generic Value Plus covers: Premier covers:
Tier 2: Generic
Certain generic drugs available at the lowest copayment.

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

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

Tier 4: Non-preferred Higher cost generic and non-preferred drugs, many of which may have lower cost
Drug options available on Tier 1, Tier 2, and Tier 3.

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

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

Convenient mail order service

You can get prescription drugs shipped to your home through our network mail order delivery
program. For refills of your mail order prescriptions, you have the option to sign up for an automatic
refill program. Typically, you should expect to receive your prescription drugs within 10 calendar
days from the time that the mail order pharmacy receives the order.
You’ll pay the same amount for a 90-day supply of a Tier 1 prescription drug ordered through mail
order as you would pay for a 30-day supply purchased from a retail preferred cost sharing pharmacy.

rxmedicareplans.com 8

2022 Blue MedicareRx PLAN COMPARISON CHART

Monthly Premium2 Blue MedicareRx Value Plus Network Retail Pharmacy
Annual Deductible with Standard Cost Sharing
Initial Coverage $51.70 30-Day Supply Retail
A copayment or co-insurance Tier 1: $6
for covered prescription $0 (Tier 1 and Tier 2) Tier 2: $20
drugs, until the annual cost of $480 (Tier 3, Tier 4, and Tier 5) Tier 3: $47
prescription drug expenses Tier 4: 37%
you pay and we pay reaches Network Retail Pharmacy Tier 5: 25%
$4,430. Any deductible, with Preferred Cost Sharing
copayments, or co-insurance 30-Day Supply Retail
you pay counts toward Tier 1: $1
the $4,430. Tier 2: $8
Tier 3: $42
Coverage Gap Tier 4: 37%
The cost for covered Tier 5: 25%
prescription drug expenses
between $4,430 in drug 90-Day Supply Mail Order
costs and $7,050 in annual Tier 1: $1
out-of-pocket costs. Tier 2: $16
Tier 3: $84
Tier 4: 37%
Tier 5: N/A3

For covered generics, you pay
25% of the costs.
For covered brand-names, you pay
25% of the negotiated price
(excluding the dispensing fee).

Catastrophic Coverage For covered generics (including drugs treated as generics), you pay
The cost for covered $3.95 or 5%, whichever is greater.
prescription drugs after you
and others on your behalf For all other covered drugs, you pay $9.85 or 5%, whichever is greater.
have paid $7,050 in annual
out-of-pocket costs. You pay
a flat-dollar amount, or 5%,
whichever is greater.

2. You must continue to pay your Medicare Part B premium. 3. Specialty Tier drugs aren’t available at an extended day supply.

9 Blue MedicareRx Prescription Drug Plan

Blue MedicareRx Premier
$136.20

$0

Network Retail Pharmacy Network Retail Pharmacy with
with Preferred Cost Sharing Standard Cost Sharing
30-Day Supply Retail 30-Day Supply Retail
Tier 1: $1 Tier 1: $6
Tier 2: $7 Tier 2: $12
Tier 3: $30 Tier 3: $40
Tier 4: 35% Tier 4: 44%
Tier 5: 33% Tier 5: 33%

90-Day Supply Mail Order
Tier 1: $1
Tier 2: $14
Tier 3: $60
Tier 4: 35%
Tier 5: N/A3

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

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

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

For covered generics (including drugs treated as generics), you pay $3.95 or 5%, whichever is greater.
For all other covered drugs, you pay $9.85 or 5%, whichever is greater.

rxmedicareplans.com 10

FREQUENTLY ASKED QUESTIONS

Enrolling in a Blue MedicareRx Plan

Q: How can I enroll? Q: When can I enroll?

A: You can enroll by: A: You can enroll in a Blue MedicareRx plan
• Filling out and mailing a paper application. only during specific times of the year
• Filling out a secure online application on our unless you’re newly 65.

website at rxmedicareplans.com. Q: Is financial assistance available?
• Completing an application by phone:
A: If you need financial assistance covering
Contact Us: your Prescription Drug Plan costs, you
may be eligible to receive Extra Help,
Connecticut Residents: including reduced premiums, deductibles,
1-866-832-9702 (TTY: 711) copayments, and co-insurance. If you
24 hours a day, 7 days a week qualify for Extra Help, Medicare will tell us
how much assistance you’ll receive when
Massachusetts Residents: you enroll in our plan, and we’ll inform you of
1-800-678-2265 (TTY: 711) the amount you’ll be responsible for paying.
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week; To see if you qualify for Extra Help, call:
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
• 1-800-MEDICARE (1-800-633-4227),
Rhode Island Residents: TTY: 1-877-486-2048, 24 hours a day,
1-800-505-2583 (TTY: 711) days a week.
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.;
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m. • The Social Security Administration at
You can use our automated answering system outside 1-800-772-1213, TTY: 1-800-325-0778
of these hours. between 7:00 a.m. and 7:00 p.m. ET,
Monday through Friday.
Vermont Residents:
1-888-496-4178 (TTY: 711) • Your state Medicaid office.
24 hours a day, 7 days a week
Q: What is the late enrollment penalty?
Online: rxmedicareplans.com
A: If you choose not to enroll in a Medicare
Call 1-800-MEDICARE (1-800-633-4227), Prescription Drug Plan during your initial
TTY: 1-877-486-2048, 24 hours a day, 7 days a week. enrollment period or had a continuous
Visit the CMS Medicare Online Enrollment Center period of 63 days or more without
located at medicare.gov. “creditable” prescription drug coverage
(“Creditable” means the drug coverage is
11 Blue MedicareRx Prescription Drug Plan expected to pay, on average, at least as
much as Medicare’s standard prescription
drug coverage), you may be subject to a
late enrollment penalty when you do enroll.
The penalty is 1% of the national average
monthly premium for each month you
were eligible, but weren’t enrolled. The
penalty will be added to your premium for
as long as you’re enrolled in a Medicare
Prescription Drug Plan.

Drug Coverage Common Terms

Q: What if I already have drug coverage? Initial Enrollment Period
The Initial Enrollment Period is the period when you
A: Eligible individuals may only enroll in one first become Medicare eligible because:
Medicare Prescription Drug Plan at a time. • You turn 65 (beginning 3 months before your birthday
If you already have a Medicare Advantage
plan or other insurance that includes and extending to 3 months after your birthday).
Part D coverage, enrolling in this plan will • You qualify due to disability or End-Stage Renal
automatically disenroll you from your
current plan. Disease (3 months before to 3 months after your
If you get your health care benefits 25th month of disability).
from TRICARE®´ or the U.S. Department
of Veterans Affairs, joining a Medicare Annual Election Period
Prescription Drug Plan might not be a The Annual Election Period occurs from October 15
cost-effective option, unless you qualify through December 7 each year. During this time, you
for Extra Help. If you get your coverage may enroll in or change Medicare Prescription Drug
through your employer or union, contact Plans. Coverage will be effective January 1 of the
your benefits administrator to compare following year.
your options.
Special Enrollment Period
Q: What drugs are covered? A Special Enrollment Period is available in certain
situations, such as:
A: For a full list of covered drugs, visit • Permanently moving into our plan’s service area,
rxmedicareplans.com, or call us at the
number on the back page. We must give losing employer group prescription drug coverage,
you at least 30 days’ advance notice of qualifying for Extra Help, or if you become eligible
a change, and a 30-day refill of the drug for both Medicare and Medicaid. If you think you
you’re taking at a network pharmacy. may be eligible for a Special Enrollment Period,
contact your current plan, or call us at the number
Q: What if I’m currently taking a drug on the back page.
that isn't on the drug list? • Medicare Advantage enrollees may disenroll from
their plan and return to Original Medicare between
A: You should first contact us and confirm January 1 and March 31. If you’re a Medicare
that your drug isn't covered. You can Advantage enrollee and you decide to leave the
ask us for a list of similar drugs that are plan to return to Original Medicare during this period,
covered by our plan. You can also ask us you may join a standalone Prescription Drug Plan
to make an exception to cover your drug. like Blue MedicareRx.
We encourage you to talk to your doctor
to determine the course of action that rxmedicareplans.com 12
best suits your needs. We may cover your
drug in certain cases during the first 90
days that you're a new member of our plan.
Visit rxmedicareplans.com, or call us at
the number on the back page for details
about how to request a prescription
drug exception and to find out about
our transition supply policy.

 Connecticut Residents:

FOR MORE 1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week
INFORMATION,
OR TO ENROLL: Massachusetts Residents:

1-800-678-2265 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents:

1-800-505-2583 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.;
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Vermont Residents:

1-888-496-4178 (TTY: 711) 24 hours a day, 7 days a week

Visit rxmedicareplans.com

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx
Value Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans

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

Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts,
Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

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

Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont
are the legal entities which have contracted as a joint enterprise with the Centers for
Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx

(PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Blue MedicareRx complies with applicable federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity.

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks
of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks, Service Marks,

and Trademarks are property of their respective owners. ©2021 All rights reserved.

000845452 BRC-22 55-0597-22 (9/21)

Connecticut | Massachusetts
Rhode Island | Vermont

PRE-ENROLLMENT CHECKLIST

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

Contact Us: Understanding the Benefits

Connecticut Residents: Review the full list of benefits found in the
1-866-832-9702 (TTY: 711) Evidence of Coverage (EOC), especially
24 hours a day, 7 days a week for those services for which you routinely
see a doctor. Visit rxmedicareplans.com
Massachusetts Residents: or call Customer Care to receive a copy
1-800-678-2265 (TTY: 711) of the EOC.
10/1 through 3/31, 8:00 a.m. to 8:00 p.m. ET,
7 days a week. Review the pharmacy directory to make sure
the pharmacy you use for any prescription
4/1 through 9/30, 8:00 a.m. to 8:00 p.m. ET, medicine is in the network. If the pharmacy
Monday through Friday. isn’t listed, you’ll likely have to select a new
pharmacy for your prescriptions.
Rhode Island Residents:
1-800-505-2583 (TTY: 711) Understanding Important Rules
10/1 through 3/31, 8:00 a.m. to 8:00 p.m. ET,
7 days a week. Benefits, premiums, and/or copayments/
coinsurance may change on January 1, 2023.
4/1 through 9/30, 8:00 a.m. to 8:00 p.m. ET,
Monday through Friday.

You can use our automated answering system
outside of these hours.

Vermont Residents:
1-888-496-4178 (TTY: 711)
24 hours a day, 7 days a week

rxmedicareplans.com

Independent Licensees of the Blue Cross and Blue Shield Association. S2893_2119_C

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross
& Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that
have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and

are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-
approved Part D sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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

® Registered Marks of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks,
Service Marks, and Trademarks are property of their respective owners. © 2021 All Rights Reserved.

000844558 PEC-22 55-2048-22 (9/21)

Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP)

2022 SUMMARY
OF BENEFITS

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

Independent Licensees of the
Blue Cross and Blue Shield Association.
S2893_2118_M

Blue MedicareRx

VALUE PLUS (PDP)

Blue MedicareRx

PREMIER (PDP)

A Medicare Prescription Drug Plan (PDP)
offered by ANTHEM INSURANCE CO. &
Blue Cross and Blue Shield of Massachusetts,
Blue Cross & Blue Shield of Rhode Island,
and Blue Cross and Blue Shield of Vermont
with a Medicare contract



SUMMARY OF BENEFITS

January 1, 2022 – December 31, 2022

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

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

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.; 24 hours a day, 7 days a week
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

rxmedicareplans.com

For More Information

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

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

1 2022 Summary of Benefits

SUMMARY OF BENEFITS: INTRODUCTION

Who can join?

To join Blue MedicareRx Value Plus or Blue MedicareRx Premier, you must:
• Be entitled to Medicare Part A and/or be enrolled in Medicare Part B
• Be a U.S. citizen or be lawfully present in the United States
• Live in our service area

Our service area includes the following: Central New England (Connecticut, Massachusetts,
Rhode Island, and Vermont).

Which Drugs Are Covered?

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

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

rxmedicareplans.com 2

SUMMARY OF BENEFITS

Stage 1: Annual Deductible Stage

How much is the Blue MedicareRx Blue MedicareRx
monthly premium? Value Plus (PDP) Premier (PDP)
$51.70 per month
$136.20 per month
How much is the $480.00 per year for Part D prescription
deductible? drugs except for drugs listed on Tier 1 This plan doesn’t have a deductible.
and Tier 2, which are excluded from
the deductible.

SUMMARY OF BENEFITS

Stage 2: Initial Coverage Stage

Blue MedicareRx Blue MedicareRx Both
Value Plus (PDP) Premier (PDP)
• You may get your drugs at
After you pay your yearly deductible, You pay the following until your total network retail pharmacies and
you pay the following until your total yearly drug costs reach $4,430. mail order pharmacies.
yearly drug costs reach $4,430. Total yearly drug costs are the total
Total yearly drug costs are the total drug costs paid by you and our • If you reside in a long-term
drug costs paid by you and our Part D plan. care facility, you pay the same
Part D plan. as at a standard retail pharmacy

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

3 2022 Summary of Benefits

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

Preferred Retail Cost Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
Tier 1 (Preferred Generic)
Tier 2 (Generic) $1 copay $3 copay $1 copay $3 copay
Tier 3 (Preferred Brand)
Tier 4 (Non-Preferred Drug) $8 copay $24 copay $7 copay $21 copay
Tier 5 (Specialty Tier)
$42 copay $126 copay $30 copay $90 copay

37% of the cost 37% of the cost 35% of the cost 35% of the cost

25% of the cost N/A 33% of the cost N/A

Standard Retail Cost Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
Tier 1 (Preferred Generic) $18 copay
Tier 2 (Generic) $6 copay $18 copay $6 copay $36 copay
Tier 3 (Preferred Brand) $120 copay
Tier 4 (Non-Preferred Drug) $20 copay $60 copay $12 copay 44% of the cost
Tier 5 (Specialty Tier) N/A
$47 copay $141 copay $40 copay

37% of the cost 37% of the cost 44% of the cost

25% of the cost N/A 33% of the cost

Mail Order Cost Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
Tier 1 (Preferred Generic) $1 copay $1 copay
Tier 2 (Generic) $1 copay $1 copay $7 copay $14 copay
Tier 3 (Preferred Brand) $30 copay $60 copay
Tier 4 (Non-Preferred Drug) $8 copay $16 copay 35% of the cost 35% of the cost
Tier 5 (Specialty Tier) 33% of the cost N/A
$42 copay $84 copay

37% of the cost 37% of the cost

25% of the cost N/A

rxmedicareplans.com 4

SUMMARY OF BENEFITS

Stage 3: Coverage Gap Stage

Most Medicare drug plans, including Blue MedicareRx Value Plus
(PDP) and Blue MedicareRx Premier (PDP), have a coverage gap
(also called the “donut hole”). This means that there’s a temporary
change in what you’ll pay for your drugs. The coverage gap begins
after the total yearly drug cost (including what our plan has paid
and what you’ve paid) reaches $4,430.

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 $7,050, which is the
end of the coverage gap. Not everyone will enter the coverage gap.
Under Blue MedicareRx Premier (PDP), you may pay even less for the brand and generic drugs
on the formulary. Your cost varies by tier. You’ll need to use your formulary to locate your drug’s tier.
See the chart below to find out your costs.

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

Preferred Retail Cost Sharing

Tier One-month Three-month One-month Three-month
Tier 1 supply supply supply supply
(Preferred Generic)
After you enter the coverage gap, you $1 copay $3 copay
Tier 2 (Generic) pay 25% of the plan’s cost for covered $7 copay $21 copay
brand-name drugs and 25% of the plan’s
cost for covered generic drugs until your
costs total $7,050, which is the end of
the coverage gap. Not everyone will enter
the coverage gap.

5 2022 Summary of Benefits

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

Standard Retail Cost Sharing

Tier One-month Three-month One-month Three-month
Tier 1 supply supply supply supply
(Preferred Generic)
Tier 2 (Generic) After you enter the coverage gap, you $6 copay $18 copay
pay 25% of the plan’s cost for covered $12 copay $36 copay
Tier brand-name drugs and 25% of the plan’s
Tier 1 cost for covered generic drugs until your
(Preferred Generic) costs total $7,050, which is the end of
Tier 2 (Generic) the coverage gap. Not everyone will enter
the coverage gap.

Mail Order Cost Sharing

One-month Three-month One-month Three-month
supply supply supply supply
$1 copay
After you enter the coverage gap, you $1 copay
pay 25% of the plan’s cost for covered $7 copay $14 copay
brand-name drugs and 25% of the plan’s
cost for covered generic drugs until your
costs total $7,050, which is the end of
the coverage gap. Not everyone will enter
the coverage gap.

rxmedicareplans.com 6

SUMMARY OF BENEFITS

Stage 4: Catastrophic Coverage Stage

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

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased
through your retail pharmacy and through mail order) reach $7,050,
you pay the greater of:

• 5% of the cost,

• or a $3.95 copay for generic drugs (including brand drugs treated as generic)
and a $9.85 copay for all other drugs.

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

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

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

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

7 2022 Summary of Benefits

If you believe that Blue MedicareRx 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:

Blue MedicareRx (PDP) You can file a grievance in person, by mail,
or fax. If you need help filing a grievance,
Grievance Department Coordinator Blue MedicareRx Grievance Department
P.O. Box 30016 is available to help you.
Pittsburgh, PA 15222-0330
Phone: 1-866-884-9478
Fax: 1-866-217-3353

You can also file a civil rights complaint with the U.S. Department of Health
and Human Services, Office for Civil Rights, electronically through the Office
for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/
lobby.jsf, or by mail or phone at:

U.S. Department of Health Complaint forms are available at
and Human Services hhs.gov/ocr/office/file/index.html.

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, TTY: 1-800-537-7697

rxmedicareplans.com 8

 Connecticut Residents:

FOR QUESTIONS, 1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week
OR TO ENROLL:
Massachusetts Residents:

1-800-678-2265 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents:

1-800-505-2583 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.;
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Vermont Residents:

1-888-496-4178 (TTY: 711) 24 hours a day, 7 days a week

rxmedicareplans.com

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx
Value Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans

available to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer
or union group and separately issued by one of the following plans: Anthem Blue Cross®

and Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross
& Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont

are the legal entities which have contracted as a joint enterprise with the Centers
for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for

Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal. This information
is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

® Independent Licensees of Blue Cross and Blue Shield Association. Registered Marks
of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks and
Trademarks are property of their respective owners. © 2021 All Rights Reserved.

000844403 99-0653-22 SB-22 (9/21)

IMPORTANT INFORMATION:

2022 Medicare Star Ratings
Blue MedicareRx - S2893

For 2022, Blue MedicareRx - S2893received the following Star Ratings from Medicare:

Overall Star Rating: Not offered

Health Services Rating:
Drug Services Rating:

Every year, Medicare evaluates plans based on a 5-star rating system.

Why Star Ratings Are Important The number of stars show how
well a plan performs.
Medicare rates plans on their health and drug services.
EXCELLENT
This lets you easily compare plans based on quality and ABOVE AVERAGE
performance. AVERAGE
BELOW AVERAGE
Star Ratings are based on factors that include: POOR

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.

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 MedicareRx 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 877-479-2227 (toll-free) or 711
(TTY). Current members please call 888-543-4917 (toll-free) or 711 (TTY).

S2893_2161_M 001130252 | 55-001130252 (10/21) 1/1



02

Resources



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 Original Medicare Prescription Dental GeoBlue®
(HMO and PPO) and Medex®´ Drug Plans Blue® 65 Travel Insurance

(Medicare Supplement) (PDP)

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

Medicare Advantage Wednesday, June 1, 2022 2:00 p.m. - 3:00 p.m. Online
(HMO & PPO)
Medicare Plan Options* Thursday, June 2, 2022 10:00 a.m. - 12:00 p.m Resort and Conference Center at Hyannis,
35 Scudder Avenue, Hyannis
Original Medicare & Medex®´ Thursday, June 2, 2022 2:00 p.m. - 2:45 p.m. Online
(Medicare Supplement) Thursday, June 2, 2022 3:00 p.m. - 3:45 p.m.
Prescription Drug Plans Friday, June 3, 2022 9:30 a.m. - 10:00 a.m. Online
(PDP)
Dental Blue® 65 Online

GeoBlue® Travel Insurance Friday, June 3, 2022 10:30 a.m. - 11:00 a.m. Online

Medicare Advantage Monday, June 6, 2022 2:00 p.m. - 3:00 p.m. Online
(HMO & PPO) Tuesday, June 7, 2022 9:30 a.m. - 10:15 a.m. Online
Tuesday, June 7, 2022 10:00 a.m - 12:00 p.m. Marriott, 8A Centennial Drive, Peabody
Original Medicare & Medex
(Medicare Supplement)

Medicare Plan Options*

Prescription Drug Plans Tuesday, June 7, 2022 10:30 a.m. - 11:15 a.m. Online
(PDP) Tuesday, June 7, 2022 3:00 p.m. - 4:00 p.m. Online

Medicare Advantage
(HMO & PPO) in Spanish

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

Seminar Type Date Time Location

Medicare Plan Options* Wednesday, June 8, 2022 10:00 a.m. - 12:00 p.m. Marriott, One Burlington Mall Road,
Burlington
Medicare Advantage Wednesday, June 8, 2022 4:00 p.m. - 5:00 p.m. Online
(HMO & PPO)
Medicare Plan Options* Thursday, June 9, 2022 10:00 a.m. - 12:00 p.m. enVision Hotel, 31 Hampshire Street,
Mansfield
Original Medicare & Medex Thursday, June 9, 2022 2:00 p.m. - 2:45 p.m. Online
(Medicare Supplement)
Prescription Drug Plans Thursday, June 9, 2022 3:00 p.m. - 3:45 p.m. Online
(PDP)
Medicare Advantage Friday, June 10, 2022 9:30 a.m. - 10:30 a.m. Online
(HMO & PPO)
Medicare Advantage Monday, June 13, 2022 2:00 p.m. - 3:00 p.m. Online
(HMO & PPO)
Original Medicare & Medex Tuesday, June 14, 2022 9:30 a.m. - 10:15 a.m. Online
(Medicare Supplement)
Medicare Plan Options* Tuesday, June 14, 2022 10:00 a.m. - 12:00 p.m. Lombardo’s, 6 Billings Street, Randolph

Prescription Drug Plans Tuesday, June 14, 2022 10:30 a.m. - 11:15 a.m. Online
(PDP)
Dental Blue® 65 Wednesday, June 15, 2022 9:30 a.m. - 10:00 a.m. Online

Medicare Plan Options* Wednesday, June 15, 2022 10:00 a.m. - 12:00 p.m. La Quinta Inn & Suites by Wyndham, 100
Congress Street, Springfield

*A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP,
and Medicare Supplement plan options and benefits. Visit the website below to view the agenda.

They can answer your questions and assist with enrollment when you’re ready.

Not seeing a date that works for you? NEED HELP SIGNING UP?

There are plenty more to choose from. For assistance signing up for a seminar,
Check out our full list of events at or for accommodations for persons with
bluecrossma.com/seminar or scan special needs, call 1-800-262-BLUE (2583)
the QR Code. (TTY: 711) 7:00 a.m. – 12:00 midnight,
seven days a week (excluding holidays).

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. © 2022 Blue Cross
and Blue Shield of Massachusetts, Inc. or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

001622800 Y0014_2220_M S2893_2202_M 99-0645-22 (5/22)

Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP)

WE’VE GOT YOU COVERED:
OUR MOST COMMONLY COVERED DRUGS

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

ADVAIR DISKUS atorvastatin calcium citalopram hydrobromide
albuterol sulfate hfa azithromycin clonazepam
alendronate sodium BASAGLAR KWIKPEN clopidogrel
allopurinol bupropion hydrochloride e diltiazem hydrochloride e
alprazolam carbidopa/levodopa donepezil hcl
amlodipine besylate carvedilol donepezil hydrochloride
amos levothyroxine sodium celecoxib doxycycline hyclate
amoxicillin cephalexin duloxetine hydrochloride
amoxicillin/clavulanate p chlorthalidone ELIQUIS
atenolol ciprofloxacin hydrochlori escitalopram oxalate

continued

Independent Licensees of the Blue Cross and Blue Shield Association. S2893_2121_C

estradiol lorazepam prednisone
ezetimibe losartan potassium quetiapine fumarate
famotidine lovastatin rosuvastatin calcium
finasteride meloxicam sertraline hcl
fluoxetine hcl memantine hydrochloride sertraline hydrochloride
fluoxetine hydrochloride metformin hydrochloride SHINGRIX
fluticasone propionate metformin hydrochloride e simvastatin
furosemide metoprolol succinate er spironolactone
gabapentin metoprolol tartrate sulfamethoxazole/trimetho
glimepiride mirtazapine SYMBICORT
glipizide montelukast sodium SYNTHROID
glipizide er mupirocin tamsulosin hydrochloride
hydrochlorothiazide MYRBETRIQ timolol maleate
hydrocodone bitartrate/ac nitrofurantoin monohydrat torsemide
ibuprofen omeprazole tramadol hcl
INCRUSE ELLIPTA omeprazole dr trazodone hydrochloride
isosorbide mononitrate er oxybutynin chloride er triamcinolone acetonide
JANUVIA oxycodone hydrochloride triamterene/hydrochloroth
ketoconazole oxycodone/acetaminophen TRULICITY
latanoprost pantoprazole sodium valsartan
levothyroxine sodium potassium chloride er warfarin sodium
lisinopril pravastatin sodium XARELTO
lisinopril/hydrochlorothi prednisolone acetate zolpidem tartrate

• Drugs listed in all CAPS identify brand-name drugs (e.g., SYNTHROID).
• Drugs listed in lowercase italics identify generic drugs (e.g., azithromycin).
• Please note this list can change per CMS requirements.

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

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

CONTACT US:

Connecticut Residents: Massachusetts Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week.

4/1-9/30, 8:00 a.m. to 8:00 p.m. ET,
Monday through Friday.

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m. 24 hours a day, 7 days a week

4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Online: rxmedicareplans.com

The formulary may change at any time. You’ll receive notice when necessary.
Effective as of January 1, 2022.

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

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

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

Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont
are the legal entities which have contracted as a joint enterprise with the Centers for
Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx

(PDP) plans. The joint enterprise is a Medicare-approved Part D sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks
of the Blue Cross and Blue Shield Association. ®´, SM, TM Registered Marks, Service Marks,

and Trademarks are property of their respective owners. © 2021 All Rights Reserved.

000873868 99-0654-22 TDL-22 (9/21)

Connecticut | Massachusetts
Rhode Island | Vermont

Blue MedicareRx (PDP)

NETWORK CHAIN PHARMACIES

We have more than 64,000+ pharmacies in our network and we also contract with many
independent pharmacies for your convenience. Below is a list of the chain pharmacies for
our Blue MedicareRX Value Plus (PDP) and Blue MedicareRx Premier (PDP) plans that may be
in your area. The network retail pharmacies highlighted in blue offer preferred cost sharing.
Plan members pay a lower copay at these pharmacies than at our other network pharmacies.
For a complete and most up-to-date list of our network pharmacies, including many independent
pharmacies, please call us at one of the numbers below.

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

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m. 24 hours a day, 7 days a week
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Online: rxmedicareplans.com

Acme Fresh Markets (Akron, Beacon Prescriptions Community Family Fare Pharmacy
OH) Bel Air Pharmacy (A Walgreens Pharmacy) Food City Pharmacy
Acme Pharmacy (Eastern Benzer Pharmacy Copps Food Center Food Lion Pharmacy
seaboard) Big Y Pharmacy Costco Pharmacy Fred Meyer Pharmacy
AHS-St John Pharmacy Bi-Mart Pharmacy Cub Foods Fresh Market Pharmacy
Albertsons Market Brookshire Brothers CVS Pharmacy Fruth Pharmacy
Albertson's Pharmacy Brookshire Pharmacy Dierbergs Family Pharmacies Fry’s Pharmacy
Aurora Pharmacy Carrs Pharmacy Dillon Pharmacy Gerbes Pharmacy
B & B Pharmacy Cashwise Pharmacy Discount Drug Mart Giant Eagle Pharmacy
Baker's Pharmacy City Market Pharmacy Duane Reade Giant Pharmacy
Bartell Drug Coborn’s Pharmacy Fairview Pharmacy Haggen Pharmacy

continued

Independent Licensees of the Blue Cross and Blue Shield Association. S2893_2122_C

Hannaford Food & Drug Klein’s ShopRite Pharmacy Patient First Pharmacy Scotts Pharmacy
Harmons Pharmacy Shaw's / Star Markets
Harps Food Stores Klingensmith’s Drug Stores Pavilion’s Pharmacy ShopRite
Harris Teeter Pharmacy Smith's Pharmacy
Hartig Drug Kmart Pharmacy Pick ‘n Save Pharmacy Stop & Shop Pharmacy
Harvard Vanguard Medical Super 1 Pharmacy
Associates Pharmacy Kroger Pharmacy Price Chopper (KS-MO) Thrifty White Pharmacy
Harveys Supermarkets Times Pharmacy
HEB Pharmacy Kroger Sav-On Price Chopper Tom Thumb
Hen House Pharmacy Kroger Specialty Pharmacy (NY-New England) Tops Markets
Homeland Pharmacy Price Cutter Pharmacy United Market Street
Hometown Pharmacy Lewis Family Drug Pharmacy
Hy-Vee Pharmacy Publix Pharmacy United Pharmacy
Ingles Markets Longs Drugs Vons Pharmacy
Jay C Plus Pharmacy QFC Pharmacy Walgreens
Kessel Pharmacy Marc’s Walmart
King Kullen Pharmacy Raley’s Drug Center Wegmans Pharmacy
King Soopers Mariano’s Pharmacy Weis Markets
Kinney Drugs Ralphs Pharmacy White Drug
Market 32 Winn-Dixie Stores
Randall’s Pharmacy
Martin’s Pharmacy
Martin’s Super Markets (IN-MI) Reasors Pharmacy
Recept Pharmacy
Medicap Pharmacy
Rite Aid Pharmacy
Medicine Shoppe
Safeway Pharmacy
Meijer Pharmacy
Sam's Club
Metro Market Pharmacy
Save Mart Pharmacy
Navarro Pharmacy
Sav-On Pharmacy
Osco Pharmacy

Pharmacy network may change on January 1, 2023. Please also note that pharmacies may have been added to
or removed from this list since its publication. This list can change at any time; you’ll receive notice when necessary.

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

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

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

of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

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

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

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

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks
of the Blue Cross and Blue Shield Association. © 2021 Blue Cross and Blue Shield Association. All rights reserved.

000874519 99-0655-22 NWCP-22 (9/21)