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BCBSMA HMO SalesKit Book 01/01/2020 Approved by Angela Gagnon 12/26/2019 9:54 AM

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Published by it, 2019-12-23 17:07:31

BCBSMA HMO SalesKit Book 01/01/2020 Approved by Angela Gagnon 12/26/2019 9:54 AM

BCBSMA HMO SalesKit Book 01/01/2020 Approved by Angela Gagnon 12/26/2019 9:54 AM

Keywords: BCBSMA HMO SalesKit Book 01/01/2020

Medicare Advantage Plans

MEDICARE HMO BLUE (HMO) 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.
Y0014_19137_M

(01/01/20)



Dear Prospective Member,

Thank you for your interest in one of our Medicare Advantage plans. When you’re a part of the
Blue Cross Blue Shield of Massachusetts family, you get a level of quality and coverage you
expect from a health plan. Our team of dedicated Medicare experts takes pride in delivering a
great experience to each of our members, every day.

Find out why more people in Massachusetts choose Blue Cross over any other plan.1
Our plans include coverage for Part D prescription drugs and a preferred pharmacy network.
Additionally, many of our plans include routine dental, vision, and hearing services. Plus, each
member gets up to $300 toward qualified fitness and weight-loss programs (up to $400 for
Medicare HMO Blue SaverRx members).

If you have any questions, we’re here to help.

Sincerely,

Gloria Paradiso, Online: bluecrossma.com/medicare
Executive Director, Medicare Sales By mail:Complete the enclosed enrollment
Enclosures
form and mail in the self-addressed
Ready to Enroll? envelope.
By fax: Complete the enclosed enrollment
By phone: 1-800-678-2265 (TTY: 711) form and fax to 1-617-246-8506.
10/1–12/7, 8:00 a.m. to 8:00 p.m.,
seven days a week. continued >
12/8–9/30, 8:00 a.m. to 5:00 p.m.,
Monday through Friday.

1. Represents Medicare Advantage and Medicare Supplemental Individual and Group plan membership based on data
from CMS (www.cms.gov) and Massachusetts DOI (www.mass.gov).

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross Blue Shield of Massachusetts is a HMO and PPO Plan with a Medicare contract. Enrollment in
Blue Cross Blue Shield of Massachusetts depends on contract renewal.

This information is not a complete description of benefits. Call 1-800-200-4255 (TTY: 711) for more information.

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

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com

® 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.

198806M 55-0619-20 (08/19)
Y0014_1997_M

IN THIS BOOKLET

01 Plan Information
• Summary of Benefits
(including a Pre-Enrollment
checklist)
• Plan Rating Sheet

02 Resources
• Seminar Information
• Top 100 Drugs
• How to Find a Doctor

03 Disclosures
• Nondiscrimination Notice
• Translation Resources
• Commitment to Confidentiality

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



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

2020 SUMMARY OF BENEFITS

H2261 PLANS 024, 022, 023, 005

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2261_1985_M

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

Blue FlexRx (HMO-POS) and Medicare HMO Blue
PlusRx (HMO) and what you pay.

ii 2020 Summary of Benefits

This information is not a complete description of benefits.
Call 1-800-200-4255 (TTY: 711) for more information.

To get a complete list of services we cover, call our Member
Service department and ask for the “Evidence of Coverage.”

You can also access the “Evidence of Coverage” online
at our website, www.bluecrossma.com/medicare-options.

SUMMARY OF BENEFITS • If you want to know more about the
coverage and costs of Original Medicare,
January 1, 2020 - December 31, 2020 look in your current “Medicare & You”
handbook. View it online at http://www.
You have choices about how medicare.gov or get a copy by calling
to get your Medicare benefits 1-800-MEDICARE (1-800-633-4227),
24 hours a day, 7 days a week.
• One choice is to get your Medicare benefits TTY users should call 1-877-486-2048.
through Original Medicare (fee-for-service
Medicare). Original Medicare is run directly Sections in this booklet
by the Federal government.
• Things to Know About Medicare HMO
• Another choice is to get your Medicare Blue SaverRx (HMO), Medicare HMO
benefits by joining a Medicare health plan Blue ValueRx (HMO), Medicare HMO Blue
(such as Medicare HMO Blue SaverRx FlexRx (HMO-POS) and Medicare HMO
(HMO), Medicare HMO Blue ValueRx Blue PlusRx (HMO)
(HMO), Medicare HMO Blue FlexRx
(HMO-POS) and Medicare HMO Blue • Monthly Premium, Deductible, and Limits
PlusRx (HMO)). on How Much You Pay for Covered Services

Tips for comparing your • Covered Medical and Hospital Benefits
Medicare choices • Prescription Drug Benefits
This document is available in other
This Summary of Benefits booklet gives you formats such as Braille and large print.
a summary of what Medicare HMO Blue This document may be available in a
SaverRx (HMO), Medicare HMO Blue ValueRx non-English language. For additional
(HMO), Medicare HMO Blue FlexRx (HMO- information, call member services at
POS) and Medicare HMO Blue PlusRx (HMO) the number shown in the next section.
cover and what you pay.
• If you want to compare our plan with other

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

1 2020 Summary of Benefits

THINGS TO KNOW ABOUT

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

Contact Information and Hours of Operation

Members

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

If you call after business hours, you may leave a message that includes your name, phone number and the time you
called, and a representative will return your call no later than one business day after you leave a message. Member
Services also has free language interpreter services available for non-English speakers.

Non-Members

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

Our website: www.bluecrossma.com/medicare-options

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

www.bluecrossma.com/medicare-options 2

Medicare HMO Blue FlexRx (HMO-POS) has What do we cover?
a network of doctors, hospitals, pharmacies,
and other providers. For some services you Like all Medicare health plans, we cover
can use providers that are not in our network. everything that Original Medicare covers—
As a member of our Medicare HMO Blue and more.
plans, you must choose a network Primary • Our plan members get all of the benefits
Care Physician (PCP). Your PCP will provide
most of your care and will coordinate or help covered by Original Medicare. For some
you arrange the rest of the covered services of these benefits, you may pay more in our
you get as a member of our plan. In most plan than you would in Original Medicare.
situations, your network PCP must give For others, you may pay less.
you approval in advance before you can use • Our plan members also get more than
other providers in the plan’s network, such as what is covered by Original Medicare.
specialists, hospitals, skilled nursing facilities, Some of the extra benefits are outlined
or home health care agencies. This is called in this booklet.
giving you a “referral.” Referrals from your PCP • Plans may offer supplemental benefits
are not required for emergency care or urgently in addition to Part C benefits and Part D
needed services. benefits.
You must generally use network pharmacies to We cover Part D drugs. In addition, we cover
fill your prescriptions for covered Part D drugs. Part B drugs such as chemotherapy and some
You can see our plan’s provider directory drugs administered by your provider.
at our website (www.bluecrossma.com/ • You can see the complete plan formulary
findadoctor). (list of Part D prescription drugs)
You can see our plan’s pharmacy and any restrictions on our website,
directory at our website www.bluecrossma.com/medicare-options.
(www.bluecrossma.com/medicare-options). • Or, call us and we will send you a copy
Or, call us and we will send you a copy of the formulary. The formulary may change
of the provider and pharmacy directories. at any time. You will receive notice when
The pharmacy network, and/or provider necessary.
network may change at any time.
You will receive notice when necessary. How will I determine
my drug costs?
3 2020 Summary of Benefits
Our plan groups each medication into one of
five “tiers.” You will need to use your formulary
to locate what tier your drug is on to determine
how much it will cost you. The amount you
pay depends on the drug’s tier and what stage
of the benefit you have reached. Later in this
document we discuss the benefit stages
that occur after you meet your deductible:
Initial Coverage, Coverage Gap, and
Catastrophic Coverage.

SUMMARY OF BENEFITS:

January 1, 2020 - December 31, 2020

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

Monthly Plan Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol,
Premium Essex, Franklin, Essex, Franklin, Essex, Franklin, Essex, Franklin,
Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire,
Deductibles Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk,
Medical: Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk
Prescription counties: counties: counties: counties:
Drugs: $0 per month $36 per month $266 per month $96 per month

Maximum Worcester County: Worcester County: Worcester County: Worcester County:
Out-of-Pocket $0 per month $56 per month $266 per month $106 per month
Responsibility
(does not You must continue to pay your Medicare Part B premium.
include costs
related to These plans do not have a medical deductible.
prescription
drugs) $320 per year for $320 per year for $200 per year for $260 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

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

$6,700 for services $4,900 for services $3,400 for services $3,900 for services
you receive from you receive from you receive from you receive from
in-network providers. in-network providers. in-network providers. in-network providers.

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

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical
services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your Medicare Part B premium, your plan premium,
and any cost-sharing for your Part D prescription drugs.

www.bluecrossma.com/medicare-options 4

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

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

Inpatient $350 copay per day $275 copay per day $150 copay per day In-network:
Hospital for days 1 through 5 for days 1 through 5 for days 1 through 5 $200 copay per day
Coverage for days 1 through 5
You pay nothing per You pay nothing per You pay nothing per
day for days 6 day for days 6 day for days 6 You pay nothing
through 90 through 90 through 90 per day for days 6
through 90
You pay nothing You pay nothing You pay nothing
per day for days 91 per day for days 91 per day for days 91 You pay nothing
and beyond and beyond and beyond per day for days 91
and beyond
Per admission benefit. Per admission benefit. Per admission benefit.
Out-of-Network:
20% of the cost
per stay

Authorization rules may apply

Outpatient $280/visit $250/visit $150/visit In-network:
Hospital $200/visit
Coverage
Out-of-Network:
20% of the total cost

Authorization rules may apply

Ambulatory $280/visit $250/visit $150/visit In-network:
$200/visit
Surgery Center
Out-of-Network:
20% of the total cost

Authorization rules may apply

Doctor’s Office Visits

Primary Care $15 copay $15 copay $5 copay In-network:
Physician: $15 copay

Out-of-network:
$65 copay

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

Out-of-network:
$65 copay

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

5 2020 Summary of Benefits

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

You pay nothing You pay nothing You pay nothing In-network:
You pay nothing

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

Our plans cover many preventive services, including:

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

• Yearly “Wellness” visit

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

Authorization rules may apply

*If any other medical condition including polyp or other tissue is found and removed during the procedure this
would be considered minimally invasive surgery. Refer to the Outpatient Surgery category for appropriate member
cost-share.

www.bluecrossma.com/medicare-options 6

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

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

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

Urgently $15-$45 copay $15–$40 copay $5–$35 copay In network:
Needed per visit per visit per visit $15–$35 copay
Services per visit

Out-of-network:
$65 copay per visit

Diagnostic Services/Labs/Imaging

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

Authorization rules may apply

$10 copay per day $10 copay per day $0 copay per day In network:
$10 copay per day
Diagnostic
tests and Out-of-network:
procedures 20% of the cost

Authorization rules may apply

7 2020 Summary of Benefits

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

$10 copay per day $10 copay per day $0 copay per day In network:
Lab services: $10 copay per day

Out-of-network:
20% of the cost

Authorization rules may apply

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

Authorization rules may apply

Therapeutic $60 copay per visit You pay nothing You pay nothing In network:
radiology You pay nothing
services:
Out-of-network:
20% of the cost

Hearing Services

Routine $15-$45 copay $15–$40 copay $5–$35 copay In network:
Exam— $15–$35 copay
up to one per
year: Out-of-network:
$45 copay

$15-$45 copay $15–$40 copay $5–$35 copay In network:
$15–$35 copay
Non Routine
Exam: Out-of-network:
$65 copay

Hearing Aids: Our plan pays up to Our plan pays up to Our plan pays up to Our plan pays up to

$400 every 36 months $400 every 36 months $400 every 36 months $400 every 36 months

for hearing aids for hearing aids for hearing aids for hearing aids

Dental Services

Limited $45 copay $40 copay $35 copay In network:
Medicare- $35 copay
covered dental
services: Out-of-network:
$65 copay or 20%

www.bluecrossma.com/medicare-options 8

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
$40 copay $35 copay
Routine dental $60 copay In network:
services: $35 copay
Single copay Out-of-network:
for visit that $45 copay
includes:
Cleaning (for
up to 1 every
six months);
prophylaxis
only - does
not include
periodontal
cleaning
Dental x-ray(s)*
(for up to
1 every six
months)
Oral exam (for
up to 1 every
six months)

*Dental x-ray(s) coverage is limited to one set of bitewings every 6 months.

9 2020 Summary of Benefits

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

Medicare- $15-$45 copay $15-$40 copay $5-$35 copay In-network:
Covered Eye $15-$35 copay
Exam:
Out-of-Network:
$65 copay

Eyewear $0 copay $0 copay $0 copay In and
after cataract Out-of-Network:
surgery: (for $0 copay
Medicare-
covered
standard
eyewear)

Routine eye $15 copay $15 copay $35 copay In-network:
exam: (up to $15 copay
1 per year)
Out-of-Network:
Not covered

Eyewear: Our plan pays up to Our plan pays up to Our plan pays up to In and Out-of-
(For covered $150 once every 24 $150 once every 24 $150 once every 24 Network:
eyewear, months for prescription months for prescription months for prescription Our plan pays up to
you pay any eyewear eyewear eyewear
balance in $150 once every 24
excess of the
$150 limit.) months for prescription

eyewear

Mental Health Services

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

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

Authorization rules may apply

www.bluecrossma.com/medicare-options 10

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
$40 copay $40 copay $35 copay
In-network:
Outpatient $40 copay Authorization rules may apply $35 copay
group therapy Out-of-Network:
visit: Our plan covers up to $40 copay $35 copay 20% of the cost
Outpatient 100 days in a SNF.
individual You pay nothing Authorization rules may apply In-network:
therapy visit: per day for days 1 $35 copay
Skilled through 20 Our plan covers up to Our plan covers up to Out-of-Network:
Nursing $160 copay per day for 100 days in a SNF. 100 days in a SNF. 20% of the cost
Facility days 21 through 44
(SNF) You pay nothing You pay nothing $20 copay per day for Our plan covers up to
per day for days 45 per day for days 1 days 1 through 20 100 days in a SNF.
Physical through 100 through 20 In-network:
Therapy $100 copay per day for You pay nothing per
$160 copay per day for days 21 through 44 day for days 1
days 21 through 44 through 20
You pay nothing $140 copay per day for
You pay nothing per day for days 45 days 21 through 44
per day for days 45 through 100 You pay nothing
through 100 per day for days 45
through 100
Out-of-Network:
20% of the cost per
stay

Authorization rules may apply

$40 copay $20 copay $15 copay In-network:
$15 copay

Out-of-Network:
20% of the cost

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

$250 copay per trip $100 copay per trip $100 copay per trip In-network:
$100 copay per trip
Ambulance
Out-of-Network:
$100 copay per trip

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

11 2020 Summary of Benefits

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

Medicare 20% coinsurance 15% coinsurance 10% coinsurance In and
Part B Drugs Out-of-network:
(Including 10% coinsurance
Chemotherapy)
Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions.

Foot Care Foot exams and Foot exams and Foot exams and Foot exams and
(Podiatry treatment if you have treatment if you have treatment if you have treatment if you have
services) diabetes-related nerve diabetes-related nerve diabetes-related nerve diabetes-related nerve
damage and/or meet damage and/or meet damage and/or meet damage and/or meet
certain conditions: certain conditions: certain conditions: certain conditions:
$15-$45 copay $15–$40 copay $5–$35 copay
In-network:
$15–$35 copay

Out-of-Network:
$65 copay

Referral from your doctor may be required

Diabetes Supplies and Services*

Diabetes You pay nothing You pay nothing You pay nothing In-network:
monitoring You pay nothing You pay nothing You pay nothing
supplies: You pay nothing You pay nothing Out-of-Network:
20% of the cost
Diabetes self- You pay nothing
management In-network:
training: You pay nothing
Out-of-Network:
Therapeutic You pay nothing 20% of the cost
shoes or
inserts: In-network:
You pay nothing
Out-of-Network:
20% of the cost

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

blood glucose monitors are also available at DME suppliers with no coinsurance or copayment. There is no coinsurance

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

preventive benefit, or fasting plasma glucose tests.

www.bluecrossma.com/medicare-options 12

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

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

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

13 2020 Summary of Benefits

WELLNESS PROGRAMS

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

Take control of your health with our Fitness and Weight Loss Benefits

What is the Fitness Benefit?

Enroll in a qualified health club or fitness facility and receive up to $150 ($250 for HMO Blue
SaverRx) per calendar year toward your club membership fees and exercise classes.

What programs qualify?

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

• Fitness classes at participating Councils on Aging (COA) facilities; fitness studios with
instructor-led groups such as yoga, pilates, zumba, kickboxing, cross-fit, and indoor cycling/
spinning and other exercise classes.

• Programs that DO NOT qualify: Martial arts centers; gymnastics facilities; country clubs; tennis,
aerobic, or pool-only facilities; social clubs; and sports teams/ leagues. You cannot receive the
Fitness Benefit for personal training, lessons, coaching, exercise equipment, or clothing.

What is the Weight Loss Benefit?

Enroll in a qualified weight loss program and receive up to $150 per calendar year toward your
program fees. Employer group benefits may vary.

What kinds of programs qualify?

• Traditional Weight Watchers meetings, Weight Watchers Online and At Work program,
and hospital-based and other non-hospital based weight loss programs that combine healthy
eating, exercise, and coaching sessions.

Programs that DO NOT qualify: Individual nutrition counseling sessions, pre-packaged
meals, books, videos, scales, or other items and supplies.

www.bluecrossma.com/medicare-options 14

PRESCRIPTION DRUG BENEFITS

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

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

After you pay your yearly deductible, you pay the following until your total yearly drug costs reach
Initial Coverage $4,020 Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

You may get your drugs at network retail pharmacies and mail order pharmacies.

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

Tier 4 = Non-Preferred Brand Tier 5 = Specialty Tier

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

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

Preferred Retail Cost Sharing

Drug Tier 30 60 90 30 60 90 30 60 90 30 60 90
day day day day day day day day day day day day
Tier 1 supply supply supply supply supply supply supply supply supply supply supply supply
(Preferred
Generic) $2 $4 $6 $2 $4 $6 $1 $2 $3 $1 $2 $3
Tier 2 copay copay copay copay copay copay copay copay copay copay copay copay
(Generic)
Tier 3 $8 $16 $24 $6 $12 $18 $5 $10 $15 $5 $10 $15
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)
Tier 4 $42 $84 $126 $42 $84 $126 $42 $84 $126 $42 $84 $126
(Non-Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)
$95 $190 $285 $95 $190 $285 $95 $190 $285 $95 $190 $285
Tier 5 copay copay copay copay copay copay copay copay copay copay copay copay
(Specialty Tier)
26% 26% 26% 26% 26% 26% 25% 25% 25% 26% 26% 26%
of the of the of the of the of the of the of the of the of the of the of the of the
cost cost cost cost cost cost cost cost cost cost cost cost

Standard Retail Cost-Sharing

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

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

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

15 2020 Summary of Benefits

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

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

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

Tier 5 26% 26% 26% 26% 26% 26% 25% 25% 25% 26% 26% 26%
(Specialty Tier) of the of the of the of the of the of the of the of the of the of the of the of the
cost cost cost cost cost cost cost cost cost cost cost cost

Mail Order Cost-Sharing

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

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

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

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

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

Tier 5 26% 26% 26% 26% 26% 26% 25% 25% 25% 26% 26% 26%
(Specialty Tier) of the of the of the of the of the of the of the of the of the of the of the of the
cost cost cost cost cost cost cost cost cost cost cost cost

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

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

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

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

• 5% of the cost, or

• $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment
for all other drugs.

www.bluecrossma.com/medicare-options 16

Pre-Enrollment Checklist

Before making an enrollment decision, it is important that you fully
understand our benefits and rules. If you have any questions, you can call
and speak to a customer service representative.

Contact Us: 1-800-678-2265 (TTY: 711)

December 8 through September 30, 8:00 a.m. to 5:00 p.m. ET, Monday through Friday.
October 1 through December 7, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services
for which you routinely see a doctor. Visit bluecrossma.com/medicare or call 1-800-678-2265 (TTY: 711)
December 8 through September 30, 8:00 a.m. to 5:00 p.m. ET, Monday through Friday. October 1 through
December 7, 8:00 a.m. to 8:00 p.m. ET, seven days a week. to view a copy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network.
If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the
network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

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

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

For our HMO Plans: Except in emergency or urgent situations, we do not cover services by out-of-network
providers (doctors who are not listed in the provider directory).
Our plan allows you to see providers outside of our network (non-contracted providers). However, while we
will pay for covered services provided by a non-contracted provider, the provider must agree to treat you.
Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will
pay a higher co-pay for services received by non-contracted providers.

Independent Licensees of the Blue Cross and Blue Shield Association.
H2261_1990_C

17 2020 Summary of Benefits

Contact Information and Hours of Operation

Members

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

Monday - Friday

If you call after business hours, you may leave a message that includes your name, phone number and the time you
called, and a representative will return your call no later than one business day after you leave a message. Member
Services also has free language interpreter services available for non-English speakers.

Non-Members

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

Monday - Friday

Our website: www.bluecrossma.com/medicare-options

www.bluecrossma.com/medicare-options 18

NONDISCRIMINATION NOTICE

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color, national
origin, age, disability, or sex. It does not exclude people or treat them differently
because of race, color, national origin, age, disability, sex, sexual orientation or
gender identity.

Blue Cross Blue Shield of Massachusetts provides:

• Free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters and written information in other formats
(large print or other formats).

• Free language services to people whose primary language is not English, such
as qualified interpreters and information written in other languages.

If you need these services, contact the Medicare Advantage Appeals and Grievance Manager.
If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services
or discriminated in another way on the basis of race, color, national origin, age, disability, or
sex, you can file a grievance with the Medicare Advantage Appeals and Grievance Manager
by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255 (TTY: 711) from
April 1 through September 30, 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1
through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506; or email at
[email protected] You can file a grievance in person, by mail, fax,
email, or you can call 1-800-200-4255 (TTY: 711).
If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager
is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human
Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201;
by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).
Complaint forms are available at www.hhs.gov.

19 2020 Summary of Benefits

Translation Resources

Proficiency of Language Assistance Services

TRANSLATION RESOURCES

Proficiency of Language Assistance Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available
to you. Call 1-800-200-4255 (TTY: 711).

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

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

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

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

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

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

Arabic/‫ﺍﺍﻟﻌﺮﺑﻴﺔ‬:
1-800-200-4255 ‫ ﺍﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈﻥ ﺧﺪﻣﺎﺕ ﺍﻟﻤﺴﺎﻋﺪﺓ ﺍﻟﻠﻐﻮﻳﺔ ﺗﺘﻮﺍﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎﻥ‬،‫ ﺇﺫﺍ ﻛﻨﺖ ﺗﺘﺤﺪﺙ ﺍﻟﻌﺮﺑﻴﺔ‬:‫ﻣﻠﺤﻮﻅﺔ‬
(711 :‫)ﻫﺎﺗﻒ ﺍﻟﺼﻢ ﻭﺍﻟﺒﻜﻢ‬.

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

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

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

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

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

PolishB/lPueolCsrkosis: BUluWe AShGielAd :ofJMeażseslaicmhuóswettisszispaon pInodlespkeund, emntoLżiceesnzsesekoofrzthyesBtalućezCrboeszspałnadtnBelujepSohmielodcAyssociation
językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

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

Gujarati/ :
1-800-200-4255 (TTY: 711)
www.bluecrossma.com/medicare-options 20

FOR MORE INFORMATION
OR HELP WITH ENROLLMENT

bluecrossma.com/Medicare | Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
December 8 through September 30, 8:00 a.m. to 5:00 p.m. ET, Monday through Friday

October 1 through December 7, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with an Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

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

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

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

®, SM Registered and Service 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.

198467M 55-0604-20 (09/19)

2020 Star Ratings

Blue Cross Blue Shield of Massachusetts - H2261

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:

2020 Star Ratings1. An Overall Star Rating that combines all of our plan's scores.

2. Sum m ary Star Rating that focuses on our m edical or our prescription drug services.

Blue Cross Blue Shield of Massachusetts - H2261
Som e of the areas Medicare reviews for these ratings include:

H2o0w2o0uMr emdeicmarbeerSstarartReaotuinrgpsl*an's services and care;

HTohwewMelel doiucar rdeoPctrorgsradmeteracteilslnaelsl sheesalathndankdeeppremscermiptbioenrs dhreuagltphlya;ns 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:

How well our plan helps our m em bers use recom m ended and safe prescription m edications.
1. An O verall Star Rating that com bines all of our plan's scores.

For 2020, Blu2e. CSruomssmBalruyeSStahrieRldatoinf gMtahsastafcohcuusseetstsornecoeuivremd etdhiecafloollor woiunrgpOrevsecrraiplltiSotnardRruagtinsgerfvriocems.Medicare.

Som e of the areas Medicare reviews for these ratings include: 4 Stars

W e received theHfoowlloowuirngm Seummbmeras rryaStetaoruRraptlianng'sfosreBrvluiceesCraonsds cBaluree; Shield of Massachusetts's health/drug plan services:

How well our doctors detect illnesses and keep m em bers healthy;

He a lth Plan Se rvice s : recom m ended3.a5ndStsaarsfe
How well
our plan helps our m em bers use p re s crip tio n m edications.

Drug PlaFnorSe2r0v2ic0e,sB:lue Cross Blue Shield of Massachusetts received the f5olSlotawrisng O verall Star Rating from Medicare.

The nu m ber of stars shows how well our plan perform s. 4 Stars

W e received the following Sum m ary Star R5atsitnagrsfo-reBxluceellCenrotss Blue Shield of Massachusetts's health/drug plan services:

Health Plan Services: 4 stars - above average 3.5 Stars
3 stars - average

2 stars - below average

Drug Plan Services: 1 star - poor 5 Stars

Learn m ore about our plan and how we are different from other plans at www.m edicare.gov.
The num ber of stars shows how well our plan perform s.

You m ay also contact us 7 days a week from 8:00 a.m . to 8:00 p.m . Eastern tim e at 800-678-2265 (toll-free) or 711 (TTY), from O ctober 1 to March 31. O ur hours
of ope ration from April 1 to Septem ber 30 are Monday thro5ugstharFsrid- aeyxcfreollmen8t :00 a.m . to 8:00 p.m . Eastern tim e.

Current m em bers please call 800-200-4255 (toll-free) or 7411st(aTrTs Y-).above average
*Star Ratings are based on 5 Stars. Star Ratings are asses3sesdtaersac-hayveearargaend m ay change from one year to the next.

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 800-678-2265 (toll-free) or 711 (TTY), from O ctober 1 to March 31. O ur hours
of operation from April 1 to Septem ber 30 are Monday through Friday from 8:00 a.m . to 8:00 p.m . Eastern tim e.

Current m em bers please call 800 -200-4255 (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.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare Contract.
Enrollment in Blue Cross and Blue Shield depends upon contract renewal. Blue Cross Blue Shield of Massachusetts
complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin,
age, disability, sex, sexual orientation or gender identity.

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

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

198478 | 99-0288-20 (HMO) 1/1

H2261_19228_M



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:

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 John Carver Inn 25 Summer Street
Natick 01/22/2020 10:30 AM - 12:30 PM
Marriott 8A Centennial Drive

The Verve Hotel/Crowne Plaza 1360 Worcester Street

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:

Chelmsford 01/29/2020 10:30 AM - 12:30 PM Radisson 10 Independence Drive
Burlington 01/30/2020 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Hyannis 02/04/2020 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue
Leominster 02/06/2020 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way
Brockton 02/12/2020 10:30 AM - 12:30 PM Holiday Inn Express 405 Westgate Drive
Chelmsford 02/13/2020 10:30 AM - 12:30 PM Radisson 10 Independence Drive
Brookline 02/20/2020 10:30 AM - 12:30 PM Courtyard by Marriott 40 Webster Street
Randolph 02/26/2020 10:30 AM - 12:30 PM Lombardo’s 6 Billings Street
Lynnfield 03/03/2020 10:30 AM - 12:30 PM Spinelli’s Function Facility Route One South
Taunton 03/04/2020 10:30 AM - 12:30 PM Holiday Inn 700 Myles Standish Blvd
Natick 03/10/2020 10:30 AM - 12:30 PM The Verve Hotel/Crowne Plaza 1360 Worcester Street
Peabody 03/12/2020 10:30 AM - 12:30 PM Marriott 8A Centennial Drive
Burlington 03/24/2020 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Dartmouth 03/26/2020 10:30 AM - 12:30 PM Rachel’s Lakeside 950 State Road

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.

000259875M 99-0645 (12/19)

Medicare Advantage Top 100 Drug List

TOP 100 DRUGS

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

MEDICATION NAME CLOBETASOL PROPIONATE GLIMEPIRIDE
ALENDRONATE SODIUM CLONAZEPAM GLIPIZIDE
ALLOPURINOL CLOPIDOGREL GLIPIZIDE ER
ALPRAZOLAM DICLOFENAC SODIUM HYDROCHLOROTHIAZIDE
AMITRIPTYLINE HCL DILTIAZEM 24HR ER (CD) HYDROCODONE-ACETAMINOPHEN
AMLODIPINE BESYLATE DONEPEZIL HCL IBUPROFEN
AMOXICILLIN
AMOXICILLIN-CLAVULANATE DOXAZOSIN MESYLATE IRBESARTAN
POTASSIUM
ATENOLOL DOXYCYCLINE HYCLATE ISOSORBIDE MONONITRATE ER
ATORVASTATIN CALCIUM DULOXETINE HCL LAMOTRIGINE
AZITHROMYCIN ELIQUIS®´ LANTUS®´ SOLOSTAR®´
BRIMONIDINE TARTRATE ESCITALOPRAM OXALATE LATANOPROST

BUPROPION HCL SR ESTRADIOL LEVOTHYROXINE SODIUM

BUPROPION XL EZETIMIBE LISINOPRIL
CARVEDILOL FENOFIBRATE LISINOPRIL HYDROCHLOROTHIAZIDE
CELECOXIB FINASTERIDE LORAZEPAM
CEPHALEXIN FLUOXETINE HCL LOSARTAN POTASSIUM
CHLORTHALIDONE FLUTICASONE PROPIONATE LOSARTAN-HYDROCHLOROTHIAZIDE
CIPROFLOXACIN HCL FUROSEMIDE LOVASTATIN
CITALOPRAM HBR GABAPENTIN MELOXICAM

continued

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

MEDICATION NAME OXYCODONE HCL SPIRONOLACTONE
METFORMIN HCL SULFAMETHOXAZOLE-
OXYCODONE-ACETAMINOPHEN TRIMETHOPRIM
METFORMIN HCL ER SYMBICORT®´
PANTOPRAZOLE SODIUM TAMSULOSIN HCL
METHOTREXATE PAROXETINE HCL TIMOLOL MALEATE
METOPROLOL SUCCINATE POTASSIUM CHLORIDE TRAMADOL HCL
METOPROLOL TARTRATE PRAVASTATIN SODIUM TRAZODONE HCL
METRONIDAZOLE PREDNISOLONE ACETATE TRIAMCINOLONE ACETONIDE
MIRTAZAPINE PREDNISONE TRIAMTERENE-
MONTELUKAST SODIUM HYDROCHLOROTHIAZIDE
PROAIR®´ HFA VALACYCLOVIR
NIFEDIPINE ER VENLAFAXINE HCL ER
QUETIAPINE FUMARATE
NITROFURANTOIN MONO-MACRO RANITIDINE HCL WARFARIN SODIUM
OMEPRAZOLE ROSUVASTATIN CALCIUM
ONETOUCH®´ DELICA®´ ZOLPIDEM TARTRATE
ONETOUCH®´ ULTRA®´ SERTRALINE HCL
BLUE TEST STRIPS
ONETOUCH® VERIO® SHINGRIX
OXYBUTYNIN CHLORIDE ER SIMVASTATIN

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-258-2226 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-258-2226 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association.

®´, TM Registered Marks and Trademarks are property of their respective owners.

© 2019 Blue Cross and Blue Shield of Massachusetts, Inc.
Printed at Blue Cross and Blue Shield of Massachusetts, Inc.

198480M Y0014_1984_M 50-0177-20 (09/19)

Medicare HMO BlueSM (HMO)

HOW TO FIND A DOCTOR

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

In fact, your current physician may already be part of our network. To locate a
participating physician, visit our website at www.bluecrossma.com/findadoctor
and follow the few easy steps to find a participating provider in your area.

 

Learn More with our Online Directory Questions? We are here to help

When you use our online provider search If you need help finding a doctor, or if you
tool, you can find out more about a particular don’t have Internet access, just call us at
physician or office, such as: 1-800-678-2265 (TTY: 711). A representative
• What medical school a physician attended is available to help you:
• Whether the office is handicap-accessible • October 1 through December 7,
• Whether weekend or evening office hours
8:00 a.m. to 8:00 p.m. ET,
are available and more seven days a week.
• December 8 through September 30,
8:00 a.m. to 5:00 p.m. ET,
Monday through Friday

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

Blue Cross Blue Shield of Massachusetts is a HMO and PPO Plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.
The provider network may change at any time. You will receive notice when necessary.

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-678-2265 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-678-2265 (TTY: 711).

®, SM Registered Marks and Service 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.

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

198482M Y0014_1999_C 50-0239-20 (09/19)

03

Disclosures



NONDISCRIMINATION NOTICE

Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender
identity. It does not exclude people or treat them differently because of race, color, national origin, age,
disability, sex, sexual orientation or gender identity.

Blue Cross Blue Shield of Massachusetts provides:

• Free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters and written information in other formats
(large print or other formats).

• Free language services to people whose primary language is not English, such as qualified
interpreters and information written in other languages.

If you need these services, contact the Medicare Advantage Appeals and Grievance Manager.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services
or discriminated in another way on the basis of race, color, national origin, age, disability, or sex,
sexual orientation or gender identity, you can file a grievance with the Medicare Advantage Appeals
and Grievance Manager by mail at P.O. Box 55007, Boston, MA 02205; phone at 1-800-200-4255
(TTY: 711) from April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday,
or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week; fax at 617-246-8506;
or email at [email protected] You can file a grievance in person,
by mail, fax, email, or you can call 1-800-200-4255 (TTY: 711).

If you need help filing a grievance, the Medicare Advantage Appeals and Grievance Manager
is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and
Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC
20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).

Complaint forms are available at www.hhs.gov.

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

199084M 55-1490A (10/19)



Translation Resources

Proficiency of Language Assistance Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available
to you. Call 1-800-200-4255 (TTY: 711).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare Contract. Enrollment in Blue Cross and
Blue Shield depends upon contract renewal.

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. © 2019 Blue Cross and Blue Shield of

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

Y0014_16110 Accepted 08302016 199085M | 55-1490B (8/19)

Our Commitment to Confidentiality

This Notice describes how medical information about you
may be used and disclosed and how you can get access to
this information. Please review it carefully.

Our Commitment: We respect your right to privacy. We will not disclose personally
identifiable information about you without your permission, unless the disclosure is
necessary to provide our services to you or is otherwise in accordance with the law.

Collection of Information

We collect only personal or medical information we need to carry out our business.
• Examples of personal information are name, address, date of birth, and social security

number. Most often, you and your employer supply this information to enroll you in a plan.
• Examples of medical information are diagnoses, treatments, and names of providers who

treat you. Most often, your providers supply this information.

Use and Disclosure of Information

We are required by law to protect the confidentiality of your personal and medical information and
to notify you in case of a breach affecting your personal or medical information. We will supply
your information to you upon your request or to help you understand treatment options and other
benefits available to you.

We also may use and disclose your information without your written authorization for the
following purposes, and as otherwise permitted or required by law:
• Treatment—to help providers manage or coordinate your health care and related services.

For example, to refer you to another provider or remind you of appointments.
• Payment—to obtain payment for your coverage, provide you with health benefits, and assist

another health plan or provider in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or coordinate benefits with other
coverage you may have.
• Health Care Operations—to operate our business, including accreditation, credentialing, customer
service, disease management, and fraud-prevention activities. For example, to do business
planning, arrange for medical review, or conduct quality assessment and improvement activities.

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

• Legal Compliance—to comply with applicable laws. For example, to respond to regulatory
authorities responsible for oversight of government benefit programs or our operations; to
parties or courts in the course of judicial or administrative proceedings; to law enforcement
officials duringan investigation; and as necessary to comply with workers’ compensation laws.

• Research and Public Health—for medical research studies in accordance with laws for the
protection of human research subjects, and to report to public health authorities and otherwise
prevent or lessen a serious and imminent threat to health or safety. For example, for the purpose
of preventing or controlling disease, injury, or disability.

• To an Account (such as an employer) or Party It Designates—for administration of its
health plan. For example, to a self-insured account for claim review and audits. We will disclose
your information only to designated individuals. That, along with contract obligations, helps
protect your information from unauthorized use.

To carry out these purposes, we share information with entities that perform functions for us
subject to contracts that limit use and disclosure to intended purposes. We use physical,
electronic, and procedural safeguards to protect your privacy. Even when allowed, uses and
disclosures are limited to the minimum amount reasonably necessary for the intended task.

Special Notes Regarding Disclosure

Special protections apply to information about certain medical conditions. For example, with
very few exceptions allowed by law, we will not disclose any information regarding HIV or AIDS to
any party without your written permission. We will not disclose mental health treatment records
to you without first receiving approval from your treating provider or another equally qualified
mental health professional. Also, we are prohibited from using or disclosing genetic information
for underwriting purposes.

Except as provided in this notice, we will not use or disclose your personal or medical information
without your written authorization. A form for this purpose is available on our website or by calling
Member Service. Specifically, we must have your written authorization to use or disclose your
information for:

• Marketing purposes;
• The sale of PHI;
• Most use and disclosures of psychotherapy notes.
You may revoke your authorization at any time. Your authorization must be in writing.
Your revocation will not affect any action that we have already taken in reliance on your authorization.


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