BCBSMA MEDICARE PPO SalesBook 2022 (V3_121421_9685) Approved by Angela Gagnon 12/14/2021 3:37 PM

Medicare Advantage Plans

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Coverage You Need From
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a Name You Can Trust

Blue Cross Blue Shield of Massachusetts
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HBl2u2e3C0r_o2s1s8a3n_dMBlue Shield Association.
2H022223(0V_22_118031_82M1_6567T2)



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

Dear Prospective Member,

Thank you for your interest in our Medicare Advantage PPO Blue plans. We want you to get
the coverage you need and the peace of mind you deserve. That’s why our plans include:

 

Great Coverage Lower Costs Enhanced Benefits
Including prescription Low copays for primary Such as fitness and weight-loss
drug coverage and the care visits and $0 copays
on routine dental, hearing, reimbursements, telehealth,
freedom to see any over-the-counter allowance,
doctor or hospital that and vision exams
participates with Medicare comprehensive dental,
and more

WHY CHOOSE BLUE?

Quality, service, and trust. That’s why more people in Massachusetts choose our
Medicare plans over any other option.1

Please see the enclosed to learn more. If you have any questions, we’re here to help.

Sincerely,

Gloria A. Paradiso, Online: bluecrossma.com/medicare
Executive Director, Medicare Sales
By mail: Complete the enclosed enrollment form
Enclosures and return it in the self-addressed envelope.

Ready to Enroll? By fax: Complete the enclosed enrollment form and fax
to 1-617-246-8506.
By phone: 1-800-678-2265 (TTY: 711)
October 1 through March 31:
8:00 a.m. to 8:00 p.m., seven days a week
April 1 through September 30:
8:00 a.m. to 8:00 p.m., Monday-Friday

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

1. Represents Medicare Advantage and Medicare Supplemental Individual
and Group plan membership based on data from CMS (cms.gov)
and the Massachusetts Department of Insurance (mass.gov).

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

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

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

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

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

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

000887761 H2230_2175_M 99-000396684-22 (9/21)

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



2022 SUMMARY
OF BENEFITS

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

H2230_2184_M Plans 017, 018, 002
Blue Cross Blue Shield of Massachusetts
is an Independent Licensee of the Blue Cross
and Blue Shield Association.



This booklet gives you a summary of drug and health services
covered by Medicare PPO Blue SaverRx (PPO), Medicare PPO
Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO),
and what you pay.

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

To get a complete list of services covered by Blue Cross
Blue Shield of Massachusetts, call our Member Service
department and ask for the “Evidence of Coverage.”
You can also access the “Evidence of Coverage”
online at our website, bluecrossma.com/medicare.

SUMMARY OF BENEFITS

January 1, 2022 - December 31, 2022

Choose How You get your Medicare benefits

You can choose to: • Get your Medicare benefits by joining
• Get your Medicare benefits through a Medicare health plan (such as Medicare
PPO Blue SaverRx (PPO), Medicare PPO
Original Medicare (fee-for-service Medicare). Blue ValueRx (PPO), or Medicare PPO
Original Medicare is run directly by the Blue PlusRx (PPO)).
Federal government.

Tips for comparing your Medicare choices

• This Summary of Benefits booklet gives you • To learn more about the coverage and costs
an overview of what Medicare PPO Blue of Original Medicare, look in your current
SaverRx (PPO), Medicare PPO Blue ValueRx Medicare & You handbook. View it online
(PPO), and Medicare PPO Blue PlusRx (PPO) at medicare.gov or get a copy by calling
cover, and what you pay. 1-800-MEDICARE (1-800-633-4227),
24 hours a day, 7 days a week. TTY users
• To compare our plan with other Medicare should call 1-877-486-2048.
health plans’ representatives, ask the
other plans for their Summary of Benefits
booklets. Or, use the Medicare Plan Finder
on medicare.gov.

Sections in this booklet • Covered Medical and Hospital Benefits
• Prescription Drug Benefits
• Things to Know About Medicare PPO Blue
SaverRx (PPO), Medicare PPO Blue ValueRx
(PPO), and Medicare PPO Blue PlusRx (PPO)

• Monthly Premium, Deductible, and Limits on
How Much You Pay for Covered Services

This document is available in other formats such as Braille and large print. This document may be available in a non-English
language. For additional information, call Member Service at the number shown in the next section.

1 2022 Summary of Benefits

THINGS TO KNOW ABOUT OUR PLANS

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

Contact Information and Hours of Operation
Members

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

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

Non-Members

October 1–March 31 April 1–September 30
1–800–678–2265 (TTY: 711) 1–800–678–2265 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 8:00 a.m. to 8:00 p.m., 5 days a week, Monday–Friday

Our website: bluecrossma.com/medicare

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

bluecrossma.com/medicare-options 2

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

We cover everything that Original Medicare
covers—and more.
• Our plan members get all of the benefits

covered by Original Medicare. For some of
these benefits, you may pay more in our
plan than you would in Original Medicare.
For others, you may pay less.
• Our plan members also get more than
what is covered by Original Medicare.
Some of the extra benefits are outlined
in this booklet.

3 2022 Summary of Benefits

SUMMARY OF BENEFITS:

January 1, 2022 - December 31, 2022

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

Monthly Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol,
Plan Premium Essex, Franklin, Hampden, Essex, Franklin, Hampden, Essex, Franklin, Hampden,
Hampshire, Middlesex, Hampshire, Middlesex, Hampshire, Middlesex,
Deductibles Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk
Medical: counties: $0 per month counties: $76 per month counties: $264 per month
Prescription Drugs:
Worcester County: Worcester County: Worcester County:
Maximum $0 per month $86 per month $264 per month
Out-of-Pocket
Responsibility You must continue to pay your Medicare Part B premium.
(does not include costs
related to prescription These plans do not have a medical deductible.
drugs)
$175 per year $290 per year $200 per year
for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5

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

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

$10,000 for services you $4,900 for services you $5,100 for services you
receive from any provider. receive from any provider. receive from any provider.

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

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

bluecrossma.com/medicare-options 4

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)
Our plan covers an
Inpatient Our plan covers an Our plan covers an unlimited number of
Hospital Coverage unlimited number unlimited number of days for an inpatient
(Per Admission Benefit) of days for an inpatient days for an inpatient hospital stay.
hospital stay. hospital stay. In-Network:
$150 copay per day
In-Network: In-Network: for days 1 through 5
$390 copay per day $325 copay per day You pay nothing per day
for days 1 through 5 for days 1 through 5 for days 6 through 90
You pay nothing per day
You pay nothing per day You pay nothing per day for days 91 and beyond
for days 6 through 90 for days 6 through 90 Out-of-Network:
20% of the cost per stay
You pay nothing per day You pay nothing per day
for days 91 and beyond for days 91 and beyond In-Network:
$150/visit
Out-of-Network: Out-of-Network: Out-of-Network:
$440 copay per day $350 copay per day 20% of the total cost
for days 1 through 5 for days 1 through 5
In-Network:
You pay nothing per day You pay nothing per day $150/visit
for days 6 through 90 for days 6 through 90 Out-of-Network:
20% of the total cost
You pay nothing per day You pay nothing per day
for days 91 and beyond or days 91 and beyond In-Network:
$5 copay
Authorization rules may apply. Out-of-Network:
$45 copay
Outpatient In-Network: In-Network:
Hospital Coverage $325/visit $250/visit

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

Authorization rules may apply.

Ambulatory Surgery Center In-Network: In-Network:
$275/visit $250/visit

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

Authorization rules may apply.

Doctor’s Office Visits: (including telehealth visits)

Primary Care Physician: In-Network: In-Network:
$0 copay $0 copay

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

5 2022 Summary of Benefits

Specialist: Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
Preventive Care SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

In-Network: In-Network: In-Network:
$45 copay* $40 copay* $35 copay*
Out-of-Network: Out-of-Network: Out-of-Network:
$55 copay $50 copay $45 copay

*You pay nothing for Medicare-covered specialist services performed in the home
furnished by a network provider.

You pay nothing You pay nothing In-Network:
You pay nothing

Out-of-Network:
$45 copay or 20% of the
cost, depending on the
service

Our plans cover many preventive services, including:

• Abdominal aortic aneurysm screening • Prostate cancer screenings (PSA)
• Alcohol use counseling
• Bone mass measurement • Sexually transmitted infections
• Breast cancer screening screening and counseling

(mammogram) • Tobacco use cessation counseling
• Cardiovascular disease (counseling for people with no sign
of tobacco-related disease)
(behavioral therapy)
• Cardiovascular screenings • Flu shots, pneumococcal shots, Hepatitis
• Cervical and vaginal cancer screening B shots (limitations may apply)
• Lung cancer screening
• “Welcome to Medicare” preventive visit
(low-dose computed tomography (LDCT)) (one-time)
• Colorectal cancer screenings
• Yearly “Wellness” visit
(Colonoscopy, Fecal occult blood test,
Flexible sigmoidoscopy)* • Any additional preventive services
• Depression screening approved by Medicare during the contract
• Diabetes screenings year will be covered.
• HIV screening
• Medical nutrition therapy services • Authorization rules may apply
• Obesity screening and counseling
• You pay $0 for a supplemental annual
physical exam. Includes a detailed
medical/family history and a head to toe
assessment with hands-on examination
of all body systems to assess overall
general health.

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

bluecrossma.com/medicare-options 6

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

$90 copay $90 copay $75 copay

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

Urgently Needed Services In-Network: $0-$45 copay* In-Network: $0-$40 copay* In-Network: $5-$35 copay*
(including telehealth visits) Out-of-Network: $55 copay Out-of-Network: $50 copay Out-of-Network: $45 copay

*You pay nothing for Medicare-covered specialist services performed in the home
furnished by a network provider.

Diagnostic Services/Labs/Imaging

Diagnostic Radiology In-Network: In-Network: In-Network:
(such as MRIs, CT scans): $365 copay per day $250 copay per day $150 copay per day
per category per category per category

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

Authorization rules may apply.

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

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

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

Lab Services: In-Network: In-Network: In-Network:
$10 copay per day* $10 copay per day* $10 copay per day*

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

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

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

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

Authorization rules may apply.

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

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

Authorization rules may apply.

7 2022 Summary of Benefits

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

Hearing Services

Routine Exam: In-Network: In-Network: In-Network:
(up to 1 every $0 copay $0 copay $0 copay
12 months)
Non-Routine Exam: Out-of-Network: Out-of-Network: Out-of-Network:
$45 copay $45 copay $45 copay
Hearing Aids:
Dental Services In-Network: In-Network: In-Network:
$0-$45 copay $0-$40 copay $5-$35 copay

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

$699-$999 copay $699-$999 copay $699-$999 copay
per hearing aid per year per hearing aid per year per hearing aid per year

You must use a TruHearing™ network provider for all routine hearing exams and the
purchase of covered hearing aids. There is no coverage for out-of-network providers.

Limited Medicare-Covered In-Network: In-Network: In-Network:
Dental Services: $45 copay. You pay $40 copay. $35 copay

Out-of-Network: Out-of-Network: Out-of-Network:
$55 copay. You pay a $50 copay. $45 copay or 20% of the
cost, depending on the
service

Non-Medicare Covered Dental Services:

Dental services—Non- In-Network: In-Network: In-Network:
Medicare Covered $0 copay for covered $0 copay for covered You pay $0 copay.
preventive services preventive services
Out-of-network:
50% coinsurance for 50% coinsurance for You pay a $45 copay.
covered comprehensive covered comprehensive
services services Coverage for preventive
services only. Maximum of
Out-of-Network: Out-of-Network: two visits each calendar
$60 copay for covered $50 copay for covered year. See Evidence of
preventive services preventive services Coverage for more details.

50% coinsurance for 50% coinsurance for
covered comprehensive covered comprehensive
services services

$500 maximum per calendar year for preventive and
comprehensive services combined. See Evidence of
Coverage for more details.

bluecrossma.com/medicare-options 8

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

Vision Services In-Network: In-Network:
$0-$40 copay $5-$35 copay
Medicare-Covered Eye In-Network: Out-of-Network: Out-of-Network:
Exam: $0-$45 copay $20-$50 copay $45 copay
In and Out-of-Network: In and Out-of-Network:
Out-of-Network: $0 copay $0 copay
$25-$55 copay

Eyewear After Cataract In and Out-of-Network:

Surgery: (for Medicare- $0 copay

covered standard eyewear)

Routine Eye Exam: In-Network: In-Network: In-Network:
(up to 1 per 12 months) $0 copay $0 copay $0 copay
Eyewear: (For Covered
Eyewear, you pay any Out-of-Network: Out-of-Network: Out-of-Network:
balance in excess of the $45 copay $45 copay $45 copay
$200 limit.)
Mental Health Services You must use an EyeMed network provider for covered in-network services.

Inpatient Visit: In and Out-of-Network: In and Out-of-Network: In and Out-of-Network:
(Per Admission) Our plan pays up to Our plan pays up to Our plan pays up to

$200 every 24 months $200 every 24 months $200 every 24 months

for eyewear for eyewear for eyewear

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

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

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

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

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

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

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

Authorization rules may apply Per Admission.

9 2022 Summary of Benefits

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

Outpatient Group In-Network: In-Network: In-Network:
Therapy Visit: $30 copay $30 copay $30 copay

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

Authorization rules may apply.

Outpatient Individual In-Network: In-Network: In-Network:
Therapy Visit: $30 copay* $30 copay* $30 copay*
(including telehealth visits)
Additional Services Out-of-Network: Out-of-Network: Out-of-Network:
$40 copay $40 copay 20% of the cost

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

Skilled Our plan covers up to Our plan covers up to Our plan covers up to
Nursing Facility 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.
(SNF)
In-Network: In-Network: In-Network:
Physical Therapy You pay nothing per day for You pay nothing per day for $20 copay per day for days
Ambulance days 1 through 20 days 1 through 20 1 through 20
Transportation
(Including chair vans) $170 copay per day for $160 copay per day for $100 copay per day for
days 21 through 44 days 21 through 44 days 21 through 44

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

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

Authorization rules may apply.

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

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

In-Network: In-Network: In-Network:
$275 copay per trip $225 copay per trip $100 copay per trip

Out-of-Network: Out-of-Network: Out-of-Network:
$275 copay per trip $225 copay per trip $100 copay per trip

If you are admitted to the hospital, you do not have to pay for the ambulance services.
Authorization rules may apply.

Not covered Not covered Not covered

bluecrossma.com/medicare-options 10

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

Medicare Part B Drugs In and Out-of-Network: In and Out-of-Network: In and Out-of-Network:
(Including chemotherapy) 20% co-insurance 20% co-insurance 10% co-insurance

Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions.

Foot Care Foot exams and treatment Foot exams and treatment Foot exams and treatment
(Podiatry services) if you have diabetes-related if you have diabetes-related if you have diabetes-related
nerve damage and/or meet nerve damage and/or meet nerve damage and/or meet
certain conditions: certain conditions: certain conditions:

In-Network: In-Network: In-Network:
$0-$45 copay $0-$40 copay $5-$35 copay

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

Diabetes Supplies and Services*

Diabetes In-Network: In-Network: In-Network:
Monitoring Supplies: You pay nothing You pay nothing You pay nothing
Diabetes Out-of-Network:
Self-Management Out-of-Network: Out-of-Network: 20% of the cost
Training: You pay nothing You pay nothing
Therapeutic Shoes In-Network:
or Inserts: Authorization rules may apply. You pay nothing
Out-of-Network:
In-Network: In-Network: 20% of the cost
You pay nothing You pay nothing
In-Network:
Out-of-Network: Out-of-Network: You pay nothing
You pay nothing You pay nothing Out-of-Network:
20% of the cost
In-Network: In-Network:
You pay nothing You pay nothing

Out-of-Network: Out-of-Network:
You pay nothing You pay nothing

*There is no co-insurance or copayment for the One Touch®´ blood glucose test strips and blood glucose monitors purchased
at participating retail and mail order pharmacies; otherwise you pay all costs. Test strips and blood glucose monitors are also
available at DME suppliers with no co-insurance or copayment. There is no co-insurance or copayment for members eligible
for covered therapeutic molded shoes and inserts,diabetes self-management training preventive benefit,
or fasting plasma glucose tests.

11 2022 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)
In-Network:
Durable In-Network: In-Network: 10% of the cost
Medical 20% of the cost 20% of the cost Out-of-Network:
Equipment 20% of the cost
(wheelchairs, Out-of-Network: Out-of-Network:
oxygen, etc.) 20% of the cost 20% of the cost In-Network:
10% of the cost
Authorization rules may apply. Out-of-Network:
20% of the cost
Prosthetic Devices (braces, artificial limbs, etc.) In-Network:
10% of the cost
Prosthetic Devices: In-Network: In-Network: Out-of-Network:
20% of the cost 20% of the cost 20% of the cost
Not covered.
Out-of-Network: Out-of-Network:
20% of the cost 20% of the cost $150 per calendar year
$150 per calendar year
Related Medical Supplies: In-Network: In-Network:
20% of the cost 20% of the cost

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

Over-the-counter items In-network: Not covered.
(OTC) Our plan pays up to $150
per calendar year toward
CVS will manage the over-the-counter health
OTC benefit. See the & wellness products.
OTC catalog for a list of
eligible items. Purchase Out-of-network:
OTC items by mail, phone, The in-network provider
or in participating CVS must be used for the OTC
retail stores. You can find items benefit.
the catalog at cvs.com/
otchs/bcbsma. If you have
questions or to order
by phone please call
1-888-628-2770 (TTY:711)
Monday – Friday 9 am
to 8 pm ET.

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

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

bluecrossma.com/medicare-options 12

WELLNESS PROGRAMS

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

Take Control of Your Health With Our Fitness and Weight-Loss Benefits

What is the Fitness Benefit? What is the Weight-Loss Benefit?

Enroll in a qualified health club or fitness Enroll in a qualified weight-loss program and
facility and receive up to $150 per calendar receive up to $150 per calendar year toward
year toward your club membership fees your program fees. Employer group benefits
and exercise classes. may vary.

What programs qualify? What kinds of programs qualify?

• Virtual/online fitness memberships, • Traditional WW, (formerly known as Weight
subscriptions, programs, or classes that Watchers®´) meetings, WW Online and At
provide cardiovascular and strength Work programs, hospital-based and other
training using a digital platform non-hospital-based weight-loss programs
that combine healthy eating, exercise, and
• Home Fitness Equipment like stationary coaching sessions.
bikes, weights, exercise bands, treadmills,
fitness machines. • Programs that DO NOT qualify: Individual
nutrition counseling sessions, pre-packaged
• Home Fitness Equipment WILL NOT meals, books, videos, scales, or other items
cover wearable fitness trackers or and supplies.
items that are considered “Recreational
Equipment” or “Sports Equipment” REWARDING YOU FOR
examples include-kayaks, inline skates, HEALTHY CHOICES
bicycles, ice skates, trampolines, fitness
clothing, sneakers GET REIMBURSED UP TO $300
PER YEAR WHEN YOU ENROLL
• Health clubs with a variety of cardiovascular
and strength-training exercise equipment, IN QUALIFIED FITNESS AND
e.g., traditional health clubs, YMCAs, YWCAs, WEIGHT-LOSS PROGRAMS.
and community fitness centers
$150
• Fitness classes at participating Councils on
Aging (COA) facilities; fitness studios with FITNESS REIMBURSEMENT
instructor-led groups such as yoga, Pilates,
Zumba®´, kickboxing, CrossFit®´, and indoor $150
cycling/spinning and other exercise classes.
WEIGHT-LOSS REIMBURSEMENT
• 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, or clothing.

13 2022 Summary of Benefits

PRESCRIPTION DRUG BENEFITS

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

Deductible $175 per year for $290 per year for $200 per year for
Initial Coverage Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

After you pay your yearly deductible, you pay the following until your total yearly drug
costs reach $4,430. Total yearly drug costs are the total drug costs paid by both you
and our Part D plan.

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

Tier 1 = Preferred Generic Tier 5 = Specialty Tier
Tier 2 = Generic Note: Cost sharing may differ relative to the
Tier 3 = Preferred Brand pharmacy’s status as preferred or standard,
Tier 4 = Non-Preferred Brand mail-order, Long-Term Care (LTC) or home infusion,
and 30-day or 90-day supply.

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)
Preferred Retail Cost Sharing

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

Tier 1 $0 $0 $0 $0 $0 $0 $0 $0 $0
(Preferred Generic) copay copay copay copay copay copay copay copay copay

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

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

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

Tier 5 30% N/A N/A 28% N/A N/A 29% N/A N/A
(Specialty Tier)
of the of the of the

cost cost cost

bluecrossma.com/medicare-options 14

Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)
Standard Retail Cost Sharing

Drug Tier 30-day 60-day 90-day 30-day 60-day 90-day 30-day 60-day 90-day
supply supply supply supply supply supply supply supply supply
Tier 1
(Preferred Generic) $10 $20 $30 $8 $16 $24 $6 $12 $18
Tier 2
(Generic) copay copay copay copay copay copay copay copay copay
Tier 3
(Preferred Brand) $20 $40 $60 $12 $24 $36 $10 $20 $30
Tier 4 copay copay copay copay copay copay copay copay copay
(Non-Preferred Brand)
$47 $94 $141 $47 $94 $141 $47 $94 $141
copay copay copay copay copay copay copay copay copay

$100 $200 $300 $100 $200 $300 $100 $200 $300
copay copay copay copay copay copay copay copay copay

Tier 5 30% N/A N/A 28% N/A N/A 29% N/A N/A
(Specialty Tier) of the of the of the
Mail Order Cost Sharing cost cost cost

Drug Tier 30-day 60-day 90-day 30-day 60-day 90-day 30-day 60-day 90-day
supply supply supply supply supply supply supply supply supply
Tier 1
(Preferred Generic) $0 $0 $0 $0 $0 $0 $0 $0 $0
Tier 2 copay copay copay copay copay copay copay copay copay
(Generic)
Tier 3 $10 $20 $20 $6 $12 $12 $5 $10 $10
(Preferred Brand)
Tier 4 copay copay copay copay copay copay copay copay copay
(Non-Preferred Brand)
$42 $84 $84 $42 $84 $84 $42 $84 $84
Tier 5 copay copay copay copay copay copay copay copay copay
(Specialty Tier)
$95 $190 $190 $95 $190 $190 $95 $190 $190
copay copay copay copay copay copay copay copay copay

30% N/A N/A 28% N/A N/A 29% N/A N/A

of the of the of the

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.

15 2022 Summary of Benefits

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

Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”).
Catastrophic Coverage 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 $4,430.

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

After your yearly out-of-pocket drug costs (including drugs purchased through
your retail pharmacy and through mail order) reach $7,050, you pay the greater of:
5% of the cost, or $3.95 copay for generic (including brand drugs treated as generic)
and a $9.85 copayment for all other drugs.

bluecrossma.com/medicare-options 16

PRE-ENROLLMENT CHECKLIST

Before making an enrollment decision, it’s important that you fully
understand our benefits and rules. We’ve put together the checklist
below to help you. If you have any questions, you can call and speak
to a customer service representative.

Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services
for which you routinely see a doctor. Visit bluecrossma.com/medicare or call 1-800-678-2265
(TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday.
October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week to view a copy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are
in the network. If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines
is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for
your prescriptions.

Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.
This premium is normally taken out of your Social Security check each month.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2023.
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
copay for services received by non-contracted providers.

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

April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday.
October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

Independent Licensees of the Blue Cross and Blue Shield Association.
H2230_2095_C
17 2022 Summary of Benefits

Contact Information and Hours of Operation
Members

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

Monday–Friday

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

Non-Members

October 1–March 31 April 1–September 30
1–800–678–2265 (TTY: 711) 1–800–678–2265 (TTY: 711)
8:00 a.m. to 8:00 p.m., 7 days a week 8:00 a.m. to 8:00 p.m., 5 days a week,

Monday–Friday

Our website: bluecrossma.com/medicare

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, sex, sexual orientation, or gender identity. It does not exclude
people or treat them differently because of race, color, national origin, age,
disability, sex, sexual orientation or gender identity.

Blue Cross Blue Shield of Massachusetts provides:

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

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

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

19 2022 Summary of Benefits

Translation Resources

TRANSLATION RESOPUrRofiCciEenScy of Language Assistance Services

Proficiency of Language Assistance Services

English: ATTENTION: If you don't speak English, language assistance services, free of charge,
are available to you. Call 1-800-200-4255 (TTY: 711).

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

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

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

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

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

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

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

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

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

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

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

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

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
ZBlaudezCwrońsspBolduenuSmhierld1o-8f 0M0a-s2s0a0c-h4u2s5e5tts(TisTaYn: I7n1d1e)p.endent Licensee of the Blue Cross and Blue Shield Association.

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

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

bluecrossma.com/medicare-options 20

 Medicare Plan Sales

FOR MORE 1-800-678-2265 (TTY: 711)
INFORMATION
OR HELP WITH April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET,
ENROLLMENT Monday through Friday.

October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET,
seven days a week.

bluecrossma.com/medicare

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

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color, national origin, age,

disability, sex, sexual orientation, or gender identity.

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

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

®Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and
TM Trademarks are the property of their respective owners. 2021 Blue Cross and Blue Shield

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

000987491 H2230_2184_M 55-0605-22 (9/21)

IMPORTANT INFORMATION:

2022 Medicare Star Ratings

Blue Cross Blue Shield of Massachusetts - H2230

For 2022, Blue Cross Blue Shield of Massachusetts - H2230 received the following Star
Ratings from Medicare:

Overall Star Rating:

Health Services Rating:
Drug Services Rating:

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

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

Feedback from members about the plan’s service and care
The number of members who left or stayed with the plan
The number of complaints Medicare got about the plan
Data from doctors and hospitals that work with the plan

More stars mean a better plan – for example, members may
get better care and better, faster customer service.

Get More Information on Star Ratings Online

Compare Star Ratings for this and other plans online at medicare.gov/plan-compare.

Questions about this plan?

Contact Blue Cross Blue Shield of Massachusetts 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time at 800-678-
2265 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are
Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 800-200-4255 (toll-
free) or 711 (TTY).

H2230_21228_M 000987954_PPO | 99-0289-22 (10/21) 1/1



02

Resources



JOIN US AND LEARN MORE ABOUT MEDICARE

Find out how Medicare works, get answers to your questions, and learn about
our extensive plan options, including Medicare Advantage plans (HMO and PPO),
Medicare Supplement plans (Medigap), and Prescription Drug Plans (PDP).

topics We Cover

We offer different plan seminars several days a week. Topics include:

    

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

See the Full List Can’t Attend? No Problem!
of Upcoming Seminars
Call us to speak to one of our sales
Visit bluecrossma.com/seminar representatives directly at
for the latest list of dates and times, 1-800-678-2265 (TTY: 711 ),
and to register for a seminar or watch
April 1 through September 30,
a pre-recorded webinar. 8:00 a.m. to 8:00 p.m. ET,
For assistance with registering, call Monday through Friday, or

1-800-262-BLUE (2583) (TTY: 711) October 1 through March 31,
7:00 a.m.–12:00 midnight, seven days a week 8:00 a.m. to 8:00 p.m. ET,
seven days a week.
(excluding holidays).

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

A Blue Cross Blue Shield of Massachusetts representative will present the webinar
and discuss our Medicare HMO, PPO, PDP, and Medicare Supplement plan options

and benefits, answer your questions, and explain how to enroll.

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont
are the legal entities which have contracted as a joint enterprise with the Centers
for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for
Blue MedicareRx plans. The joint enterprise is a Medicare-approved Part D sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.
Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, sex, sexual orientation, or gender identity.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços
linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).
® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks
of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield

of Massachusetts HMO Blue, Inc. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc.
or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000887105 99-0645-22 (9/21)

MEDICARE ADVANTAGE

TOP 100 DRUG LIST

Looking for one good reason why a Medicare Advantage plan with prescription
drug coverage from Blue Cross Blue Shield of Massachusetts is the right plan
for you? Here are 100. And this is just a sample of our Medicare Advantage plan’s
drug list. We also cover hundreds of other medications.

MEDICATION NAME ASPIRIN-DIPYRIDAMOLE ER BRILINTA®´
ATENOLOL BRIMONIDINE TARTRATE
ABIRATERONE ACETATE ATENOLOL-CHLORTHALIDONE BROMFENAC SODIUM
ACYCLOVIR ATORVASTATIN CALCIUM BUDESONIDE
ADVAIR DISKUS®´ ATROPINE SULFATE BUDESONIDE EC
AIMOVIG AUTOINJECTOR®´ AZATHIOPRINE BUMETANIDE
ALBUTEROL SULFATE AZELAIC ACID BUPRENORPHINE-NALOXONE
ALBUTEROL SULFATE HFA AZELASTINE HCL BUPROPION HCL
ALENDRONATE SODIUM AZITHROMYCIN BUPROPION HCL SR
ALFUZOSIN HCL ER BALSALAZIDE DISODIUM BUPROPION XL
ALLOPURINOL BENAZEPRIL HCL BYDUREON BCISE®´
AMANTADINE CALCIPOTRIENE
AMIODARONE HCL BENZTROPINE MESYLATE
AMLODIPINE BESYLATE CALCITONIN-SALMON
BETAMETHASONE DIPROP
AMLODIPINE BESYLATE-BENAZEPRIL AUGMENTED CALCITRIOL
BETAMETHASONE DIPROPIONATE CARBAMAZEPINE
AMMONIUM LACTATE BETAMETHASONE VALERATE CARBIDOPA-LEVODOPA
AMOXICILLIN BICALUTAMIDE CARBIDOPA-LEVODOPA ER
AMOXICILLIN-CLAVULANATE POTASS BIMATOPROST CARTIA XT
ANASTROZOLE BISOPROLOL FUMARATE CARVEDILOL
ANORO ELLIPTA®´ BOOSTRIX TDAP®´ CEFADROXIL
ARIPIPRAZOLE BREO ELLIPTA®´
ARNUITY ELLIPTA®´

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

MEDICATION NAME CLINDAMYCIN HCL DESONIDE
CLINDAMYCIN PHOSPHATE DESVENLAFAXINE SUCCINATE ER
CEFDINIR CLOBETASOL PROPIONATE DEXAMETHASONE
CEFPODOXIME PROXETIL CLONIDINE HCL DEXCOM G6®´
CEFUROXIME CLOPIDOGREL DICLOFENAC SODIUM
CELECOXIB CLOTRIMAZOLE DICYCLOMINE HCL
CEPHALEXIN CLOTRIMAZOLE-BETAMETHASONE DIGOXIN
CEVIMELINE HCL CLOZAPINE DILT-XR
CHLORHEXIDINE GLUCONATE COLCHICINE DILTIAZEM 24HR ER
CHLORTHALIDONE COLESTIPOL HCL DILTIAZEM 24HR ER (CD)
CHOLESTYRAMINE COMBIVENT RESPIMAT®´ DILTIAZEM HCL
CICLOPIROX DALIRESP®´ ONE TOUCH VERIO TEST STRIP®´
CILOSTAZOL DENTA 5000 PLUS
CIPROFLOXACIN HCL DENTAGEL
CIPROFLOXACIN-DEXAMETHASONE
CITALOPRAM HBR

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

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

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

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

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc.

000887914 Y0014_2143_M 50-0177-22 (9/21)

Medicare PPO Blue (PPO)

IS YOUR PROVIDER OF CHOICE (POC)
IN THE MEDICARE PPO BLUE NETWORK?

Use our Find a Doctor & Estimate Costs tool to see if your current POC is in
the Medicare PPO Blue network. You can also search for other in-network
doctors, hospitals, and health care professionals by simply following
these three steps:

1. 2. 3.

Sign in to your MyBlue Under My Care, select Enter a doctor, hospital,
account at bluecrossma.org, Find a Doctor & Estimate Costs. or type of care,

or open the MyBlue app. then click Search.

To search for a doctor without signing in, go to bluecrossma.com/findadoctor,
and enter Medicare PPO Blue under Select a Network.

The Easy Way to Find Care  

 Compare up to five View in-depth provider
doctors at once, use filters profiles, which include
Search by name, specialty, specialties, languages,
facility, OR keyword, to narrow your results, contact information,
and review provider
or browse by category. quality ratings. and whether they’re
Plus, get cost estimates accepting new patients.

for more than 1,500
common procedures.

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

WE’RE HERE TO HELP

If you need help finding a doctor, or if you don’t have
Internet access, call us at 1-800-678-2265 (TTY: 711).

A representative is available to help you:

 

OCTOBER 1 THROUGH MARCH 31: APRIL 1 THROUGH SEPTEMBER 30:
8:00 a.m. to 8:00 p.m. ET, 8:00 a.m. to 8:00 p.m. ET,
seven days a week Monday through Friday



Did You Know?

Your PPO plan gives you access to our nationwide network.
To search outside of Massachusetts, go to bcbs.com,

select Find a Doctor or Hospital, and follow the easy steps.

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

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

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

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

® Registered Marks of the Blue Cross
and Blue Shield Association. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc.,

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

000988061 H2230_2186_M 37-1880-22 (9/21)

03

Disclosures



NONDISCRIMINATION NOTICE

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

Blue Cross Blue Shield of Massachusetts provides:

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

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

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

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

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

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

Complaint forms are available at 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. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc.,
or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
000892700 55-1490A (9/21)



TRANSLATION RESOURCES

Translation Resources

Proficiency of Language Assistance Services

Proficiency of Language Assistance Services

English: ATTENTION: If you don't speak English, language assistance services, free of charge,
are available to you. Call 1-800-200-4255 (TTY: 711).

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

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

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

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

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

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

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

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

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

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

Blue Cross Blue Shield of Massachusetts is an Independent Licensee
of the Blue Cross and Blue Shield Association
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/Eλληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες
γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

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

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

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

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

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

Y0014_16110 Accepted 08302016 000892752 | 55-1490B (9/21)

OUR COMMITMENT TO CONFIDENTIALITY

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

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

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

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

Use and Disclosure of Information

We’re required by law to protect the confidentiality of your personal and medical information
and to notify you in case of a breach affecting your personal or medical information. We’ll supply
your information to you upon your request or to help you understand treatment options and
other benefits available to you.
We also may use and disclose your information without your written authorization for the
following purposes, and as otherwise permitted or required by law:
• Treatment—to help providers manage or coordinate your health care and related services.

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

another health plan or provider in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or coordinate benefits with other
coverage you may have.

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

• Health Care Operations—to operate our business, including accreditation, credentialing,
customer service, disease management, and fraud-prevention activities. For example,
to do business planning, arrange for medical review, or conduct quality assessment and
improvement activities.

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

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

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

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

Special Notes Regarding Disclosure

Special protections apply to information about certain medical conditions. For example,
with very few exceptions allowed by law, we won’t disclose any information regarding HIV
or AIDS to any party without your written permission. We won’t disclose mental health
treatment records to you without first receiving approval from your treating provider
or another equally qualified mental health professional. Also, we’re prohibited from using
or disclosing genetic information for underwriting purposes.
Except as provided in this notice, we won’t use or disclose your personal or medical information
without your written authorization. A form for this purpose is available on our website or by
calling Member Service. Specifically, we must have your written authorization to use or disclose
your information for:
• Marketing purposes;
• The sale of PHI;
• Most use and disclosures of psychotherapy notes.

You may revoke your authorization at any time. Your authorization must be in writing.
Your revocation won’t affect any action that we have already taken in reliance on
your authorization.