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BCBSMA PDP SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

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Published by it, 2019-11-15 13:24:03

BCBSMA PDP SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

BCBSMA PDP SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

Keywords: BCBSMA PDP SalesKit Book 12/01/2019

Blue MedicareRx (PDP) Plans

BLUE MEDICARERX (PDP) 2020

COVERAGE YOU NEED FROM A NAME YOU CAN TRUST

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

S2893_19134_C

(12/01/19)



Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont

Dear Medicare Beneficiary: Choosing the Plan
That’s Best for You
Thank you for your interest in the Blue MedicareRx
prescription drug plan (PDP). It’s important to understand each plan
Blue MedicareRx (PDP) delivers comprehensive before you can determine which one is
drug coverage to Medicare beneficiaries like you. right for you. That’s why we’ve enclosed
the following materials to help assist
We offer two plans to choose from: you with your decision:

• Blue MedicareRx Value Plus (PDP) • Plan Brochure: Answers questions
• Blue MedicareRx Premier (PDP) about Medicare Part D, and highlights
key features of the Blue MedicareRx
Key Features of Our 2020 Plans Include: plans

• $1-$2 copayments on Tier 1 generic drugs • Summary of Benefits: Gives you
at network retail pharmacies that offer an overview of Blue MedicareRx
preferred cost sharing plan options

• $0 annual deductible on generic and preferred • Medicare Star Rating Sheet:
generic drugs for Blue MedicareRx Value Plus Shows you the Medicare program’s
members summary rating of Blue MedicareRx’s
overall plan quality and performance
• $0 annual deductible on all drugs for
Blue MedicareRx Premier members • Top 100 Drug List: Gives you a list
of the 100 most commonly used
• Opportunity to save with lower cost sharing brand-name and generic drugs
at more than 32,000 preferred retail pharmacies we cover

• Prescription mail order service that saves you • Network Chain Pharmacies:
money and delivers your prescriptions directly Gives you a list of our extensive
to you. Get a three-month supply of your drugs network of chain pharmacies
and pay as little as one copayment.
continued

P.O. Box 30011 | Pittsburgh, PA 15222-0330 | rxmedicareplans.com S2893_1961_M
Independent licensees of the Blue Cross and Blue Shield Association.

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 10/1-12/7, 8:00 a.m. to 8:00 p.m., 7 days a week
12/8-9/30, 8:00 a.m. to 5:00 p.m., Monday through Friday
Rhode Island Residents:
1-800-505-2583 (TTY: 711) Vermont Residents:
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week 1-888-496-4178 (TTY: 711)
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday 24 hours a day, 7 days a week
You can use our automated answering service outside
of these hours.

Questions About How Medicare Works?

Call Medicare at 1-800-633-4227 (TTY: 1-877-486-2048), 24 hours a day, 7 days a week
or visit medicare.gov.
We look forward to providing you with convenient, high-quality prescription drug coverage.
If you have any questions, don’t hesitate to call us.

Sincerely,

Blue MedicareRx

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.

196013M PL-8580-20 (09/19)

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 Blue MedicareRx
Rhode Island | Vermont Prescription Drug Plan (PDP)

2020 PRESCRIPTION DRUG
PLAN INFORMATION

TOP-RATED AND AFFORDABLE COVERAGE TO FIT YOUR NEEDS

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_19103_M

Thank you for your interest in our
2020 Prescription Drug Plans.

CONTENTS

Two Plans to Choose From . . . . . . 1
90-Day Supply for as Low as $1 . . . . 1
Why Choose Blue MedicareRx? . . . . 2
Pharmacy Network . . . . . . . . . . . 5
2020 Blue MedicareRx Plan
Comparison Chart . . . . . . . . . . . 7
Formulary Coverage . . . . . . . . . . 9
What Is Medicare Part D? . . . . . . 10
Frequently Asked Questions . . . . . 11

TWO PLANS TO CHOOSE FROM

Our Blue MedicareRx Value Plus (PDP) and Blue MedicareRx
Premier (PDP) plans include the following features:

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
Cost savings through preferred cost sharing preferred generic drugs and Tier 2
at participating network retail pharmacies generic drugs 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 Value Plus Blue MedicareRx Premier
Drug Plan Copayment for
a 90-day supply $2 $1

1 Blue MedicareRx Prescription Drug Plan

WHY CHOOSE BLUE MEDICARERx?

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

 Great service and support

Through Blue MedicareRx, your prescription drug coverage is backed by the Blue Cross
and Blue Shield Association and a long-standing history of offering you high-quality service
and support. Our representatives are available to answer your questions and offer suggestions,
so whether you’re new to Medicare Part D or switching plans, we make it easy for you to get
the coverage that’s right for you. Just call us at one of the numbers below.

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 10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week

12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - 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.; 4/1- 24 hours a day, 7 days a week

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

 More pharmacies to choose from nationwide

With more than 66,000+ pharmacies in our network—including national chains and independent
pharmacies—you’ll have the freedom to travel anywhere in the United States with the confidence
that you can use your coverage when and where you need it. Check page 5 for more details on
our pharmacy network.

You’ll have the security of knowing that the Blue Cross and Blue Shield Association has been
providing peace of mind to over 7 million Medicare members like you nationwide.

rxmedicareplans.com 2

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

 66,000+
PHARMACIES
IN OUR NETWORK

Plans that fit your needs

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 more than 66,000+ 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

rxmedicareplans.com 4

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?

More than 32,000+ of the total 66,000+ pharmacies in our network offer preferred cost sharing
for both of the Blue MedicareRx plans. You pay lower copays at these pharmacies than at
network pharmacies that offer standard cost sharing.

Which pharmacies offer preferred cost sharing?1

Enjoy cost savings in the form of lower copays at network retail preferred cost sharing
pharmacies, which include:

Pharmacy

Types of network pharmacies

• Retail pharmacies • Home-infusion pharmacies

• Mail order pharmacies • Indian Health/Tribal pharmacies

• Long-term care pharmacies

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

1. Other pharmacies are available in our network.

5 Blue MedicareRx Prescription Drug Plan

Example:
Blue MedicareRx Premier

Martha takes a lot of expensive
drugs and hits 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

rxmedicareplans.com 6

2020 BLUE MEDICARERx PLAN COMPARISON CHART

Monthly Premium1 Blue MedicareRx Value Plus

Annual Deductible $42.50

Initial Coverage $0 (Tier 1 and Tier 2)
A copayment or co-insurance for covered prescription $435 (Tier 3, Tier 4, and Tier 5)
drugs, until the annual cost of prescription drug expenses
you pay and we pay reaches $4,020. Any deductible, Network Retail Pharmacy
copayments, or co-insurance you pay counts toward the with Preferred Cost Sharing
$4,020. 30-Day Supply Retail
Tier 1: $2
Tier 2: $8
Tier 3: $37
Tier 4: 40%
Tier 5: 25%

90-Day Supply Mail Order
Tier 1: $2
Tier 2: $16
Tier 3: $74
Tier 4: 40%
Tier 5: N/A2

Coverage Gap For covered generics, you pay 25% of the costs
The cost for covered prescription drug expenses
For covered brand-names, you pay 25% of the
between $4,020 in drug costs and $6,350 in annual negotiated price (excluding the dispensing fee)

out-of-pocket costs.

Catastrophic Coverage For covered generics (including drugs treated
The cost for covered prescription drugs after you as generics), you pay $3.60 or 5%, whichever is greater

and others on your behalf have paid $6,350 in annual For all other covered drugs, you pay $8.95 or
5%, whichever is greater
out-of-pocket costs. You pay a flat-dollar amount, or 5%,

whichever is greater.

1. You must continue to pay your Medicare Part B premium.
2. Specialty Tier drugs are not available at an extended day supply.

7 Blue MedicareRx Prescription Drug Plan

Blue MedicareRx Premier
$128.00

$0

Network Retail Pharmacy Network Retail Pharmacy Network Retail Pharmacy
with Standard Cost Sharing with Preferred Cost Sharing with Standard Cost Sharing
30-Day Supply Retail 30-Day Supply Retail 30-Day Supply Retail
Tier 1: $7 Tier 1: $6
Tier 2: $19 Tier 1: $1 Tier 2: $12
Tier 3: $47 Tier 3: $40
Tier 4: 50% Tier 2: $7 Tier 4: 45%
Tier 5: 25% Tier 5: 33%
Tier 3: $30

Tier 4: 35%

Tier 5: 33%

90-Day Supply Mail Order
Tier 1: $1
Tier 2: $14
Tier 3: $60
Tier 4: 35%
Tier 5: N/A2

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

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

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
$3.60 or 5%, whichever is greater

For all other covered drugs, you pay $8.95 or 5%, whichever is greater

rxmedicareplans.com 8

FORMULARY COVERAGE

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

2020 Drug Tier Label Blue MedicareRx Blue MedicareRx
Tier 1: Preferred Generic Value Plus covers: Premier covers:
Tier 2: Generic
Tier 3: Preferred Brand Certain generic drugs available at the lowest copayment.

Tier 4: Non-preferred Drug Higher cost generic drugs available at a higher copayment than
Tier 1 generic drugs.
Tier 5: Specialty Tier
Many common brand name drugs and Many common brand name drugs
some higher cost generic drugs, many and some higher cost generic drugs
of which may have lower cost options
available on Tier 1 or Tier 2

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

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 options 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.

9 Blue MedicareRx Prescription Drug Plan

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 Blue Cross and Blue Shield, that
contract with the Centers for Medicare and Medicaid Services (CMS).

How Part D works:

(Information provided below is specific to 2020)

In addition to the monthly premium, Medicare Part D plans have four different stages:
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 7-8 for more details.

Initial Coverage There is a $4,020 initial coverage limit. This includes your copayments, co-insurance,
and payments made by the plan for covered prescriptions.

Coverage Gap There is a coverage gap that starts once total drug costs (member and plan payments)
Catastrophic reach $4,020 and ends when your out-of-pocket prescription drug costs reach $6,350.
Coverage
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 $6,350. 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 7-8 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 $6,350 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 or Medicare Part B (or you have both Part A and Part B)

» and—you’re a United States citizen or are lawfully present in the United States
» and—you live in our geographic service area

rxmedicareplans.com 10

FREQUENTLY ASKED QUESTIONS

Enrolling in a Blue MedicareRx Plan

Q: How can I enroll?

A: You can enroll by:
• Filling out and mailing a paper application.
• Filling out a secure online application on our website at rxmedicareplans.com.
• Complete an application by phone:

Contact Us:

Connecticut Residents: 1-866-832-9702 (TTY: 711) Massachusetts Residents: 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week

12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - Friday

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.; 4/1- 24 hours a day, 7 days a week

9/30, Monday through Friday 8:00 a.m. to 8:00 p.m. You

can use our answering system outside of these hours

Online: rxmedicareplans.com

Calling 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day, 7 days
a week. Visiting the CMS Medicare Online Enrollment Center located at medicare.gov.

Q: When can I enroll?

A: You can enroll in a Blue MedicareRx plan only during specific times of the year unless
you’re newly 65.

Q: Is financial assistance available?

A: If you need financial assistance covering your Prescription Drug Plan costs, you may be
eligible to receive Extra Help, including reduced premiums, deductibles, copayments, and
co-insurance. If you qualify for Extra Help, Medicare will tell us how much assistance you’ll
receive when you enroll in our plan, and we’ll inform you of the amount you’ll be responsible
for paying. To see if you qualify for Extra Help, call:
• 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day, 7 days a week.
• The Social Security Administration at 1-800-772-1213, TTY: 1-800-325-0778
between 7:00 a.m. and 7:00 p.m. ET., Monday through Friday.
• Your state Medicaid office.

Q: What is the late enrollment penalty?

A: If you choose not to enroll in a Medicare Prescription Drug Plan during your initial enrollment
period or had a continuous period of 63 days or more without “creditable” prescription drug
coverage, (“Creditable” means the drug coverage is 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.

11 Blue MedicareRx Prescription Drug Plan

Drug Coverage

Q: What if I already have drug coverage?

A: Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time.
If you already have a Medicare Advantage plan or other insurance that includes Part D
coverage, enrolling in this plan will automatically disenroll you from your current plan.
If you get your health care benefits from TRICARE®´ or the U.S. Department of Veterans
Affairs, joining a Medicare Prescription Drug Plan might not be a cost-effective option,
unless you qualify for Extra Help. If you get your coverage through your employer or union,
contact your benefits administrator to compare your options.

Q: What drugs are covered?

A: For a full listing of covered drugs, visit rxmedicareplans.com, or call us at the number
on the back page. If drugs are removed from the list during the year, we'll notify affected
members of the change in writing and online at rxmedicareplans.com at least 60 days
before the change is effective.

Q: What if I’m currently taking a drug that isn't on the drug list?

A: You should first contact us and confirm that your drug isn't covered. You can ask us for a
list of similar drugs that are covered by our plan. You can also ask us to make an exception
to cover your drug. We encourage you to talk to your doctor to determine the course of
action that 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.

Common Terms Special Enrollment Period

Initial Enrollment Period A Special Enrollment Period is available in certain
The Initial Enrollment Period is the period when you situations, such as:
first become Medicare eligible because:
• Permanently moving into our plan’s service area,
• You turn 65 (beginning 3 months before your losing employer group prescription drug coverage,
birthday and extending to 3 months after your qualifying for Extra Help, or if you become eligible
birthday). for both Medicare and Medicaid. If you think you
may be eligible for a Special Enrollment Period,
• You qualify due to disability or End-Stage Renal contact your current plan, or call us at the number
Disease (3 months before to 3 months after your on the back page.
25th month of disability).
• Medicare Advantage enrollees may disenroll from
Annual Election Period their plan and return to Original Medicare between
The Annual Election Period occurs from October 15 January 1 and March 31. If you’re a Medicare
through December 7 each year. During this time, you Advantage enrollee and you decide to leave the
may enroll in or change Medicare prescription drug plan to return to Original Medicare during this
plans. Coverage will be effective January 1 period, you may join a standalone prescription
of the following year. drug plan like Blue MedicareRx.

rxmedicareplans.com 12

FOR QUESTIONS, OR TO ENROLL:

Connecticut Residents:
1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week

Massachusetts Residents:
1-800-678-2265 (TTY: 711)
10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week
12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - Friday

Rhode Island Residents:
1-800-505-2583 (TTY: 711) Monday - Friday, 8:00 a.m. to 8:00 p.m.

(Open seven days a week 8:00 a.m. to 8:00 p.m. from
October 1 – March 31.) 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 &
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.

Connecticut | Massachusetts
Rhode Island | Vermont

Independent Licensees of the 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. © 2019 All Rights Reserved.

196027M BRC CODE 8580-20 55-0597-20 (10/19)

Pre-Enrollment Checklist

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

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents: 1-866-832-9702 (TTY: 711) 12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday- Friday
24 hours a day, 7 days a week
Vermont Residents: 1-888-496-4178 (TTY: 711)
Rhode Island Residents: 1-800-505-2583 (TTY: 711) 24 hours a day, 7 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. You can use our automated answering system
outside of these hours

Online: rxmedicareplans.com

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services
for which you routinely see a doctor. Visit rxmedicareplans.com or call Customer Service to view a
copy of the EOC.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicine
is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy
for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.
This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2021

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_1928_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

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.
®´, SM, TM Registered Marks and Trademarks are property of their respective owners. © 2019 All Rights Reserved.

196692M 55-2048-20 (09/19)

Blue MedicareRx (PDP)

2020 SUMMARY OF BENEFITS i

BLUE MEDICARERx VALUE PLUS (PDP)
BLUE MEDICARERx PREMIER (PDP)

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_1983_M



BLUE MEDICARERx VALUE PLUS (PDP)
BLUE MEDICARERx PREMIER (PDP)

(a Medicare Prescription Drug Plan (PDP) offered
by ANTHEM INSURANCE CO. & BCBSMA & BCBSRI

& BCBSVT with a Medicare contract)

SUMMARY OF BENEFITS

January 1, 2020 – December 31, 2020

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

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 10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week

12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday- 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

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 http://www.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 2020 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 and 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
(www.rxmedicareplans.com). Or, call us and we will send you a copy of the formulary.

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

How will I determine my drug costs? Which pharmacies can I use?

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

rxmedicareplans.com 2

SUMMARY OF BENEFITS:

Stage 1: Annual Deductible

How much is the Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)
monthly premium? $42.50 per month $128.00 per month
How much is the
deductible? $435.00 per year for Part D This plan does not have a deductible.
prescription drugs except for drugs
listed on Tier 1 and Tier 2 which are
excluded from the deductible.

SUMMARY OF BENEFITS:

Stage 2: Initial Coverage Stage

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

Initial Coverage After you pay your yearly deductible, You pay the following until your total
you pay the following until your total yearly drug costs reach $4,020. Total
yearly drug costs reach $4,020. Total yearly drug costs are the total drug
yearly drug costs are the total drug costs paid by both you and our
costs paid by both you and our Part D plan.
Part D plan.
You may get your drugs at network
You may get your drugs at network retail pharmacies and mail order
retail pharmacies and mail order pharmacies.
pharmacies.
If you reside in a long-term care
If you reside in a long-term care facility, you pay the same as at a
facility, you pay the same as at a standard retail pharmacy.
standard retail pharmacy.
You may get drugs from an out-of-
You may get drugs from an out-of- network pharmacy, but may pay
network pharmacy, but may pay more than you pay at an in-network
more than you pay at an in-network pharmacy.
pharmacy.

3 2020 Summary of Benefits

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

Preferred Retail Cost-Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
$6 copay $1 copay $3 copay
Tier 1 (Preferred Generic) $2 copay $24 copay $7 copay $21 copay
$111 copay $30 copay $90 copay
Tier 2 (Generic) $8 copay 40% of the cost 35% of the cost 35% of the cost
N/A 33% of the cost N/A
Tier 3 (Preferred Brand) $37 copay
Three-month
Tier 4 (Non-Preferred Drug) 40% of the cost supply
$21 copay
Tier 5 (Specialty Tier) 25% of the cost $57 copay
$141 copay
Standard Retail Cost-Sharing 50% of the cost
N/A
Tier One-month One-month Three-month
supply Three-month supply supply
supply $6 copay $18 copay
Tier 1 (Preferred Generic) $7 copay $2 copay $12 copay $36 copay
$16 copay $40 copay $120 copay
Tier 2 (Generic) $19 copay $74 copay 45% of the cost 45% of the cost
40% of the cost 33% of the cost N/A
Tier 3 (Preferred Brand) $47 copay N/A

Tier 4 (Non-Preferred Drug) 50% of the cost

Tier 5 (Specialty Tier) 25% of the cost

Mail Order Cost-Sharing

Tier One-month One-month Three-month
supply supply supply
$1 copay $1 copay
Tier 1 (Preferred Generic) $2 copay $7 copay $14 copay
$30 copay $60 copay
Tier 2 (Generic) $8 copay 35% of the cost 35% of the cost
33% of the cost N/A
Tier 3 (Preferred Brand) $37 copay

Tier 4 (Non-Preferred Drug) 40% of the cost

Tier 5 (Specialty Tier) 25% of the cost

rxmedicareplans.com 4

SUMMARY OF BENEFITS: STAGE 3:

Coverage Gap Stage

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

Coverage Gap Most Medicare drug plans have a Most Medicare drug plans have a
coverage gap (also called the “donut coverage gap (also called the “donut
hole”). This means that there’s a hole”). This means that there’s a
temporary change in what you will temporary change in what you will
pay for your drugs. The coverage gap pay for your drugs. The coverage gap
begins after the total yearly drug cost begins after the total yearly drug cost
(including what our plan has paid and (including what our plan has paid and
what you have paid) reaches $4,020. what you have paid) reaches $4,020.

After you enter the coverage gap, you After you enter the coverage gap, you
pay 25% of the plan’s cost for covered pay 25% of the plan’s cost for covered
brand name drugs and 25% of the brand name drugs and 25% of the
plan’s cost for covered generic drugs plan’s cost for covered generic drugs
until your costs total $6,350, which until your costs total $6,350, which
is the end of the coverage gap. Not is the end of the coverage gap. Not
everyone will enter the coverage gap. everyone will enter the coverage gap.

Under this plan, you may pay even less
for the brand and generic drugs on
the formulary. Your cost varies by tier.
You will need to use your formulary to
locate your drug’s tier. See the chart
that follows to find out how much it
will cost you.

5 2020 Summary of Benefits

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

Preferred Retail Cost-Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
$3 copay
Tier 1 After you enter the coverage gap, you $1 copay $21 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $7 copay
Tier 2 (Generic) brand name drugs and 25% of the Three-month
plan’s cost for covered generic drugs supply
until your costs total $6,350, which $18 copay
is the end of the coverage gap. Not $36 copay
everyone will enter the coverage gap.
Three-month
Standard Retail Cost-Sharing supply
$1 copay
Tier One-month Three-month One-month $14 copay
supply supply supply

Tier 1 After you enter the coverage gap, you $6 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $12 copay
Tier 2 (Generic) brand name drugs and 25% of the
plan’s cost for covered generic drugs
until your costs total $6,350, which
is the end of the coverage gap. Not
everyone will enter the coverage gap.

Mail Order Cost-Sharing

Tier One-month Three-month One-month
supply supply supply

Tier 1 After you enter the coverage gap, you $1 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $7 copay
Tier 2 (Generic) brand name drugs and 25% of the
plan’s cost for covered generic drugs
until your costs total $6,350, 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 Value Plus (PDP) Blue MedicareRx Premier (PDP)

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased
through your retail pharmacy and through mail order) reach $6,350,
you pay the greater of:

• 5% of the cost,

• or a $3.60 copay for generic drugs (including brand drugs treated as generic)
and an $8.95 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 2020 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, or sex, 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 https://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 www.hhs.gov/ocr/office/file/index.html.

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

rxmedicareplans.com 8

Connecticut Residents: 1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week

Massachusetts Residents: 1-800-678-2265 (TTY: 711) 10/1–12/7, 8:00 a.m. to 8:00 p.m.,
7 days a week 12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - 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

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.

© 2019 All Rights Reserved.

196025M SB-8580-20 (09/19)

2020 Star Ratings

Blue MedicareRx - S2893

2020 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and perform ance. Medicare Star Ratings help you know how
good a job our plan is doing. You can use these Star Ratings to com pare our plan's perform ance to other plans. The two m ain types of Star Ratings are:

1. An O verall Star Rating that com bines all of our plan's scores.
2. Sum m ary Star Rating that focuses on our m edical or our prescription drug services.

Som e of the areas Medicare reviews for these ratings include:
How our m em bers rate our plan's services and care;
How well our doctors detect illnesses and keep m em bers healthy;
How well our plan helps our m em bers use recom m ended and safe prescription m edications.

For 2020, Blue MedicareRx received the following O verall Star Rating from Medicare.

5 Stars

W e received the following Sum m ary Star Rating for Blue MedicareRx's health/drug plan services:

Health Plan Services: Not O ffered

Drug Plan Services: 5 Stars

This plan got Medicare's highest rating (5 stars)

The num ber of stars shows how well our plan perform s.

5 stars - excellent
4 stars - above average
3 stars - average
2 stars - below average
1 star - poor

Learn m ore about our plan and how we are different from other plans at www.m edicare.gov.
You m ay also contact us 7 days a week from 8:00 a.m . to 8:00 p.m . Eastern tim e at 877-479-2227 (toll-free) or 711 (TTY).
Current m em bers please call 888-543-4917 (toll-free) or 711 (TTY).
*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and m ay change from one year to the next.

S2893_19136_M

1/1



02

Resources



Join us for a FREE informational
meeting in your neighborhood.

When Medicare seems overwhelming or confusing,
we’ll be there to make it easier.

Get answers to your questions about Medicare coverage,
and hear what other people who share your concerns are
asking us, at one of our informational meetings.

Get a detailed look at how Medicare works, and all of our extensive plan options, including
Medicare Advantage plans (HMO & PPO), Medicare Supplement plans (Medigap), and
Prescription Drug Plans (PDP).

Reserve your seat at the location nearest you.

RESERVE We’re always adding and updating seminars. Visit our website
NOW at bluecrossma.com/seminars to see the latest list.

1-800-262-BLUE (2583) bluecrossma.com/seminar

(TTY/TDD: 711) 7:00 a.m.–12:00 a.m., You can also make your reservation online
Seven days a week (excluding holidays) anytime, 24 hours a day, seven days a week

All Medicare Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works, and all the coverage options available to fit your budget and lifestyle. This seminar will review
supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Worcester 12/2/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street
Leominster 12/3/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way
Burlington 12/3/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Peabody 12/4/2019 10:30 AM - 12:30 PM Marriott 8A Centennial Drive

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

Y0014_19126_C S2893_1994_C

All Medicare Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works, and all the coverage options available to fit your budget and lifestyle. This seminar will review
supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Rockland 12/5/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 929 Hingham Street
Waltham 12/6/2019 10:30 AM - 12:30 PM
Waltham 01/07/2020 10:30 AM - 12:30 PM Embassy Suites 550 Winter Street
Plymouth 01/09/2020 10:30 AM - 12:30 PM
Peabody 01/15/2020 10:30 AM - 12:30 PM Embassy Suites 550 Winter Street
Natick 01/22/2020 10:30 AM - 12:30 PM
Chelmsford 01/29/2020 10:30 AM - 12:30 PM John Carver Inn 25 Summer Street
Burlington 01/30/2020 10:30 AM - 12:30 PM
Hyannis 02/04/2020 10:30 AM - 12:30 PM Marriott 8A Centennial Drive
Leominster 02/06/2020 10:30 AM - 12:30 PM
Brockton 02/12/2020 10:30 AM - 12:30 PM The Verve Hotel/Crowne Plaza 1360 Worcester Street
Chelmsford 02/13/2020 10:30 AM - 12:30 PM
Brookline 02/20/2020 10:30 AM - 12:30 PM Radisson 10 Independence Drive
Randolph 02/26/2020 10:30 AM - 12:30 PM
Marriott One Burlington Mall Road

Resort and Conference Center 35 Scudder Avenue

DoubleTree by Hilton 99 Erdman Way

Holiday Inn Express 405 Westgate Drive

Radisson 10 Independence Drive

Courtyard by Marriott 40 Webster Street

Lombardo’s 6 Billings Street

For accommodations of persons with special needs at meetings, please call 1-800-262-BLUE (2583)
(TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., seven days a week.
A Blue Cross Blue Shield of Massachusetts representative will be present to discuss our
Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits, answer your
questions, and explain how to enroll. Blue Cross Blue Shield of Massachusetts is an HMO and
PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts
depends on contract renewal.

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

Blue Cross Blue Shield of Massachusetts ATENCIÓN: Si habla español, tiene a su
complies with applicable federal civil rights laws disposición servicios gratuitos de asistencia
and does not discriminate on the basis of race, lingüística. Llame al 1-800-200-4255 (TTY: 711).
color, national origin, age, disability, sex, sexual ATENÇÃO: Se fala português, encontram-se
orientation, or gender identity. disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

199977M 99-0645 (11/19)

Connecticut | Massachusetts Blue MedicareRx (PDP)
Rhode Island | Vermont

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 escitalopram oxalate metformin hydrochloride e
albuterol sulfate hfa estradiol methotrexate
alendronate sodium ezetimibe metoprolol succinate er
allopurinol finasteride metoprolol tartrate
alprazolam FLOVENT HFA mirtazapine
amlodipine besylate fluoxetine hcl montelukast sodium
amos levothyroxine sodium fluticasone propionate nitrofurantoin monohydrat
amoxicillin furosemide omeprazole
amoxicillin/clavulanate p gabapentin omeprazole dr
atenolol glimepiride oxybutynin chloride er
atorvastatin calcium glipizide oxycodone hcl
azithromycin glipizide er oxycodone/acetaminophen
BASAGLAR KWIKPEN hydrochlorothiazide pantoprazole sodium
bupropion hydrochloride e hydrocodone/acetaminophen paroxetine hcl
carbidopa/levodopa ibuprofen potassium chloride er
carvedilol INCRUSE ELLIPTA pravastatin sodium
celecoxib isosorbide mononitrate er prednisolone acetate
cephalexin JANUVIA prednisone
chlorthalidone lamotrigine quetiapine fumarate
ciprofloxacin hydrochlori latanoprost ranitidine hcl
citalopram hydrobromide levothyroxine sodium rosuvastatin calcium
clonazepam lisinopril sertraline hcl
clopidogrel lisinopril/hydrochlorothi SHINGRIX
diltiazem hcl er lorazepam simvastatin
diltiazem hydrochloride e losartan potassium spironolactone
donepezil hcl losartan potassium/hydroc sulfamethoxazole/trimetho
doxazosin mesylate lovastatin SYMBICORT
doxycycline hyclate meloxicam SYNTHROID
duloxetine hcl memantine hcl tamsulosin hydrochloride
ELIQUIS metformin hydrochloride timolol maleate

continued

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_1924_C

torsemide triamterene/hydrochloroth XARELTO
tramadol hcl venlafaxine hcl er zolpidem tartrate
trazodone hydrochloride VENTOLIN HFA
triamcinolone acetonide warfarin sodium

• Drugs listed in all CAPS identify brand-name drugs (e.g. SYNTHROID).
• Drugs listed in lowercase identify generic drugs (e.g. azithromycin).

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

This is not a complete list of drugs covered by our plan. For a complete listing, please call us at one of the numbers below.
The comprehensive formulary may be amended at any time throughout the plan year. We will 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: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week
Connecticut Residents: 1-866-832-9702 (TTY: 711) 12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - Friday
24 hours a day, 7 days a week

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 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 will receive notice when necessary. Effective as of January 1, 2020

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: 1-866-832-9702; Massachusetts: 1-800-678-2265;
Rhode Island: 1-800-505-2583; Vermont: 1-888-496-4178. 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 and Trademarks are property of their respective owners.

© 2019 All Rights Reserved.

196028M 55-2397-20 TDL-8580-20 (10/19)

Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont

Network Chain Pharmacies

We have more than 66,000 pharmacies in our network and 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 pharmacies
highlighted in blue are our retail network pharmacies that 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.

Contact Us:

Connecticut Residents: 1-866-832-9702 (TTY: 711) Massachusetts Residents: 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1–12/7, 8:00 a.m. to 8:00 p.m., 7 days a week
12/8–9/30, 8:00 a.m. to 5:00 p.m., Monday - Friday

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 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 Community (A Walgreens Pharmacy) Fruth Pharmacy
Acme Pharmacy Copps Food Center Fry’s Pharmacy
AHS-St John Pharmacy Costco Pharmacy Gerbes Pharmacy
Albertson’s Pharmacy Cub Foods Giant Eagle Pharmacy
Aurora Pharmacy CVS Pharmacy Giant Pharmacy
B & B Pharmacy Dierbergs Family Pharmacies Group Health Pharmacy
Baker’s Pharmacy Dillon Pharmacy Haggen Pharmacy
Bartell Drug Discount Drug Mart Hannaford Food & Drug
Big Y Pharmacy Duane Reade Harmons Pharmacy
Bi-Lo Pharmacy Eaton Apothecary Harps Food Stores
Bi-Mart Pharmacy Fairview Pharmacy Harris Teeter Pharmacy
Brookshire Brothers Food City Pharmacy Harvard Vanguard Medical
Brookshire Pharmacy Food Lion Pharmacy Associates Pharmacy
Carrs Pharmacy Fred Meyer Pharmacy Harveys Supermarkets
Cashwise Pharmacy Fred’s Pharmacy HEB Pharmacy
City Market Pharmacy Fred’s Xpress Hen House Pharmacy
Coborn’s Pharmacy Fresh Market Pharmacy Homeland Pharmacy

S2893_1925_C continued

Hy-Vee Pharmacy Medicine Shoppe Schnucks Pharmacy
Ingles Markets Meijer Pharmacy Scotts Pharmacy
Jay C Plus Pharmacy Metro Market Pharmacy ShopRite
Kessel Pharmacy Navarro Pharmacy Smith’s Pharmacy
King Kullen Pharmacy Osco Pharmacy Stop & Shop Pharmacy
King Soopers Patient First Pharmacy Super 1 Pharmacy
Kinney Drugs Pavilion’s Pharmacy Thrifty White Pharmacy
Kleins Shoprite Pharmacy Pick N Save Pharmacy Times Pharmacy
Klingensmith’s Drug Stores Price Chopper Tom Thumb
Kmart Pharmacy Price Cutter Pharmacy Tops Markets
Kroger Pharmacy Publix Pharmacy United Market Street Pharmacy
Lewis Family Drug QFC Pharmacy United Pharmacy
Longs Drugs Ralphs Pharmacy Vons Pharmacy
Marc’s Randall’s Pharmacy Walgreens
Mariano’s Pharmacy Recept Pharmacy Walmart
Market 32 Rite Aid Pharmacy Wegmans Pharmacy
Martins Pharmacy Safeway Pharmacy Weis Markets
Martin’s Super Markets Pharmacy Sam’s Club Pharmacy White Drug
Med-Fast Pharmacy Save Mart Pharmacy Winn-Dixie Stores
Medicap Pharmacy Sav-On Pharmacy

Pharmacy network may change on January 1, 2021. Please also note that pharmacies may have been added to
or removed from this list since its publication.

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

The pharmacy network may change at any time. You will receive notice when necessary.

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: 1-866-832-9702; Massachusetts: 1-800-678-2265; Rhode Island: 1-800-505-2583;
Vermont: 1-888-496-4178. 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 and Trademarks are property of their respective owners.
© 2019 All Rights Reserved.

196029M | 99-0655-20 NWCP-8580-20 (10/19)

03

Disclosures


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