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BCBSMA 2020 PPO SalesKit Book 10/01/2019 Approved by Angela Gagnon 09/18/2019 1:45 PM

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Published by it, 2019-09-16 10:59:09

BCBSMA 2020 PPO SalesKit Book 10/01/2019 Approved by Angela Gagnon 09/18/2019 1:45 PM

BCBSMA 2020 PPO SalesKit Book 10/01/2019 Approved by Angela Gagnon 09/18/2019 1:45 PM

Keywords: BCBSMA 2020 PPO SalesKit Book 10/01/2019 Approved by Angela Gagnon 09/18/2019 1:45 PM

Medicare Advantage Plans

MEDICARE PPO BLUE (PPO) 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_19138_M

(10/01/19)



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 PPO BlueSM SaverRx (PPO)
Medicare PPO BlueSM ValueRx (PPO)
Medicare PPO BlueSM PlusRx (PPO)

2020 SUMMARY OF BENEFITS

H2230 PLANS 017, 018, 002

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2230_1986_M

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.

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

January 1, 2020 - December 31, 2020

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. It doesn’t list every service that we cover or list every limitation or exclusion.
To get a complete list of services we cover, call 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.

You have choices about • If you want to know more about the
how to get your Medicare benefits coverage and costs of Original Medicare,
look in your current “Medicare & You”
• One choice is to get your Medicare handbook. View it online at http://www.
benefits through Original Medicare (fee- medicare.gov or get a copy by calling
for-service Medicare). Original Medicare 1-800-MEDICARE (1-800-633-4227),
is run directly by the Federal government. 24 hours a day, 7 days a week.
TTY users should call 1-877-486-2048.
• Another choice is to get your Medicare
benefits by joining a Medicare health Sections in this booklet
plan (such as Medicare PPO Blue
SaverRx (PPO), Medicare PPO Blue • Things to Know About Medicare PPO
ValueRx (PPO),or Medicare PPO Blue SaverRx (PPO), Medicare PPO
Blue PlusRx (PPO). Blue ValueRx (PPO), and Medicare PPO
Blue PlusRx (PPO)
Tips for comparing your
Medicare choices • Monthly Premium, Deductible, and Limits
on How Much You Pay for Covered
This Summary of Benefits booklet gives Services
you a summary of what Medicare PPO Blue
SaverRx (PPO), Medicare PPO Blue ValueRx • Covered Medical and Hospital Benefits
(PPO), and Medicare PPO Blue PlusRx (PPO) • Prescription Drug Benefits
cover and what you pay.
• If you want to compare our plan with This document is available in other formats
such as Braille and large print.
other Medicare health plans, ask the This document may be available in a non-
other plans for their Summary of Benefits English language. For additional information,
booklets. Or, use the Medicare Plan call member services at the number shown
Finder on http://www.medicare.gov. in the next section.

1 2020 Summary of Benefits

THINGS TO KNOW ABOUT

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

www.bluecrossma.com/medicare-options 2

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

3 2020 Summary of Benefits

SUMMARY OF BENEFITS:

January 1, 2020 - December 31, 2020

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,
Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk
counties: $0 per month counties: $76 per month counties: $262 per month

Worcester County: Worcester County: Worcester County:
$0 per month $86 per month $262 per month

You must continue to pay your Medicare Part B premium.

Deductibles

Medical: These plans do not have a medical deductible.

Prescription Drugs: $405 per year $320 per year $200 per year
for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5

Maximum Your yearly limit(s) Your yearly limit(s) Your yearly limit(s)
Out-of-Pocket in this plan: in this plan: in this plan:
Responsibility
(does not include costs $6,700 for services you $4,900 for services you $3,400 for services you
receive from receive from receive from
related to prescription in-network providers. in-network providers. in-network providers.

drugs) $6,700 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.

www.bluecrossma.com/medicare-options 4







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

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

Authorization rules may apply

Hearing Services

Routine Exam: Not covered In-network: In-network:
$20-$40 copay $15-$35 copay
Non Routine Exam: In-network:
$25-$45 copay Out-of-network: Out-of-network:
$20-$40 copay $45 copay
Out-of-network:
$25-$45 copay In-network: In-network:
$20-$40 copay $15-$35 copay
Hearing Aids: Not covered
Out-of-network: Out-of-network:
$20-$40 copay $45 copay

Our plan pays up to $400 Our plan pays up to
every 36 months for $400 every 36 months for
hearing aids hearing aids

Dental Services

Limited Medicare- In-network: In-network: In-network:
covered dental $45 copay $40 copay $35 copay
services:
Out-of-network: Out-of-network: Out-of-network:
$45 copay $40 copay $45 copay or 20% of the
cost, depending on the
service

Routine dental In-network: In-network: In-network:
services: Single $60 copay $40 copay $35 copay
copay for visit that
includes: Cleaning Out-of-network: Out-of-network: Out-of-network:
(for up to 1 every six $60 copay $40 copay $45 copay
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.

www.bluecrossma.com/medicare-options 8

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

Vision Services

Medicare-Covered In-network: In-network: In-network:
Eye Exam: $25-$45 copay $20-$40 copay $15-$35 copay

Out-of-network: Out-of-network: Out-of-network:
$25-$45 copay $20-$40 copay $45 copay

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

Routine eye exam: Not covered In and Out-of-Network: In-network: $35 copay
(up to 1 per year) $20 copay Out-of-network: $45 copay

Eyewear: (For Not covered Our plan pays up to Our plan pays up to
covered eyewear, $150 every two years $150 every two years
you pay any balance for eyewear for eyewear
in excess of the
$150 limit.)

Mental Health Services

Inpatient Visit: In-network: In-network: In-network:
$300 copay per day $250 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:
$300 copay per day $250 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

9 2020 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: $40 copay $40 copay $35 copay

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

Authorization rules may apply

Outpatient individual Out-of-network: Out-of-network: Out-of-network:
therapy visit: $40 copay $40 copay $35 copay

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

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:
You pay nothing per day for You pay nothing per day for $20 copay per day for days
days 1 through 20 days 1 through 20 1 through 20

$160 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

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

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

Ambulance In-network: In-network: In-network:
$250 copay per trip $100 copay per trip $100 copay per trip

Out-of-network: Out-of-network: Out-of-network:
$250 copay per trip $100 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.

Transportation Not covered Not covered Not covered
(Including chair
vans)

www.bluecrossma.com/medicare-options 10

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

Medicare Part B In and out-of-network: In and out-of-network: In and out-of-network:
Drugs (Including 20% coinsurance 15% coinsurance 10% coinsurance
chemotherapy)
Foot Care Authorization rules may apply. Select Part B drugs are subject to step therapy restrictions.
(Podiatry services)
Foot exams and treatment Foot exams and treatment Foot exams and treatment
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:
$25-$45 copay $20-$40 copay $15-$35 copay

Out-of-network: Out-of-network: Out-of-network:
$25-$45 copay $20-$40 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

Out-of-network: Out-of-network: Out-of-network:
You pay nothing You pay nothing 20% of the cost

Diabetes In-network: In-network: In-network:
self-management You pay nothing You pay nothing You pay nothing
training:
Out-of-network: Out-of-network: Out-of-network:
You pay nothing You pay nothing 20% of the cost

Therapeutic shoes In-network: In-network: In-network:
or inserts: You pay nothing You pay nothing You pay nothing

Out-of-network: Out-of-network: Out-of-network:
You pay nothing You pay nothing 20% of the cost

Durable In-network: In-network: In-network:
Medical 20% of the cost 20% of the cost 10% of the cost
Equipment
(wheelchairs, Out-of-network: Out-of-network: Out-of-network:
oxygen, etc.) 20% of the cost 20% of the cost 20% of the cost

Authorization rules may apply

*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.

11 2020 Summary of Benefits

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

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
In-network:
Out-of-network: Out-of-network: 10% of the cost
20% of the cost 20% of the cost Out-of-network:
20% of the cost
Related medical In-network: In-network:
supplies: 20% of the cost 20% of the cost $150 per calendar year
$150 per calendar year
Out-of-network: Out-of-network:
20% of the cost 20% of the cost

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

www.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?

Enroll in a qualified health club or fitness facility and receive up to $150 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,
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.

13 2020 Summary of Benefits

PRESCRIPTION DRUG BENEFITS

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

Deductible $405 per year for $320 per year for $200 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug
costs reach $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 PPO Blue Medicare PPO Blue Medicare PPO BluePlusRx
SaverRx (PPO) ValueRx (PPO) (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 $4 $8 $12 $2 $4 $6 $1 $2 $3
(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 copay copay copay copay copay copay copay copay copay
Brand)

Tier 5 25% 25% 25% 26% 26% 26% 25% 25% 25%
(Specialty Tier) 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

www.bluecrossma.com/medicare-options 14

Medicare PPO Blue Medicare PPO Blue Medicare PPO BluePlusRx
SaverRx (PPO) ValueRx (PPO) (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 $10 $20 $30 $8 $16 $24 $6 $12 $18
(Preferred Generic) copay copay copay copay copay copay copay copay copay

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

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

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

Tier 5 25% 25% 25% 26% 26% 26% 25% 25% 25%
(Specialty Tier) 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

Mail Order 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 $4 $4 $4 $2 $2 $2 $1 $1 $1
(Preferred Generic) copay copay copay copay copay copay copay copay copay

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

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

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

Tier 5 25% 25% 25% 26% 26% 26% 25% 25% 25%
(Specialty Tier) 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

15 2020 Summary of Benefits

Medicare PPO Blue Medicare PPO Blue Medicare PPO BluePlusRx
SaverRx (PPO) ValueRx (PPO) (PPO)

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.

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 This means that there’s a temporary change in what you will pay for your drugs.
Coverage 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.

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

5% of the cost, or

$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

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.
H2230_1991_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.

198468M 55-0605-20 (09/19)









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

Y0014_19126_C
S2893_1994_C

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

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.

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:

Milford 10/14/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 11 Beaver Street

Hadley 10/14/2019 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street

Hyannis 10/15/2019 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue

Dartmouth 10/16/2019 10:30 AM - 12:30 PM Rachel's Lakeside 950 State Road

Dedham 10/16/2019 10:30 AM - 12:30 PM Holiday Inn 55 Ariadne Road

Natick 10/17/2019 10:30 AM - 12:30 PM Crowne Plaza 1360 Worcester Street

Worcester 10/17/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Leominster 10/18/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Randolph 10/18/2019 10:30 AM - 12:30 PM Lombardo's 6 Billings Street

Peabody 10/21/2019 10:30 AM - 12:30 PM Marriott 8A Centennial Drive

Westborough 10/21/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 5400 Computer Drive

Newton 10/22/2019 10:30 AM - 12:30 PM Marriott 2345 Commonwealth Avenue

Plymouth 10/23/2019 10:30 AM - 12:30 PM John Carver Inn 25 Summer Street

Springfield 10/24/2019 10:30 AM - 12:30 PM La Quinta Inn & Suites 100 Congress Street

Lynnfield 10/25/2019 10:30 AM - 12:30 PM Spinelli's Function Facility Route One South

Worcester 10/28/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Brockton 10/28/2019 10:30 AM - 12:30 PM Holiday Inn Express 405 Westgate Drive

Burlington 10/29/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road

Randolph 10/30/2019 10:30 AM - 12:30 PM Lombardo's 6 Billings Street

Waltham 10/30/2019 10:30 AM - 12:30 PM Embassy Suites 550 Winter Street

Mansfield 10/31/2019 10:30 AM - 12:30 PM Holiday Inn 31 Hampshire Street

Brookline 10/31/2019 10:30 AM - 12:30 PM Courtyard by Marriott 40 Webster Street

continued

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 11/1/2019 10:30 AM - 12:30 PM Radisson 10 Independence Drive

Milford 11/4/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 11 Beaver Street

Hyannis 11/4/2019 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue
Peabody 11/5/2019 10:30 AM - 12:30 PM
Marriott 8A Centennial Drive

Middleboro 11/6/2019 10:30 AM - 12:30 PM Lorenzo's Italian Restaurant 500 West Grove Street

Worcester 11/7/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street
Fall River 11/7/2019 10:30 AM - 12:30 PM
McGovern's Family Restaurant 310 Shove Street

Taunton 11/8/2019 10:30 AM - 12:30 PM Holiday Inn 700 Myles Standish Blvd

Burlington 11/9/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Springfield 11/11/2019 10:30 AM - 12:30 PM La Quinta Inn & Suites 100 Congress Street

Leominster 11/11/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way
Salem 11/12/2019 10:30 AM - 12:30 PM Hawthorne Hotel 18 Washington Square West

Natick 11/13/2019 10:30 AM - 12:30 PM Crowne Plaza 1360 Worcester Street

Westborough 11/13/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 5400 Computer Drive
Worcester 11/14/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Hadley 11/15/2019 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street
New Bedford 11/18/2019 10:30 AM - 12:30 PM Fairfield Inn & Suites 185 MacArthur Drive
Milford 11/19/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 11 Beaver Street

Lynnfield 11/20/2019 10:30 AM - 12:30 PM Spinelli's Function Facility Route One South
Leominster 11/20/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Tewksbury 11/21/2019 10:30 AM - 12:30 PM Holiday Inn 4 Highwood Drive

Worcester 11/22/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street
Hyannis 11/22/2019 10:30 AM - 12:30 PM
Resort and Conference Center 35 Scudder Avenue

Hadley 11/25/2019 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street
Natick 11/26/2019 10:30 AM - 12:30 PM
Crowne Plaza 1360 Worcester Street

Gardner 11/27/2019 10:30 AM - 12:30 PM Colonial Hotel 625 Betty Spring Road

continued

All Medicare Plan Options

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

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

Worcester 12/2/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Leominster 12/3/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Burlington 12/3/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Peabody 12/4/2019 10:30 AM - 12:30 PM Marriott 8A Centennial Drive

Rockland 12/5/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 929 Hingham Street

Waltham 12/6/2019 10:30 AM - 12:30 PM Embassy Suites 550 Winter Street

For accommodations of persons with special needs at meetings, please call 1-800-262-BLUE
(2583) (TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., seven days a week.
A Blue Cross Blue Shield of Massachusetts representative will be present to discuss our
Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits, answer your
questions, and explain how to enroll. Blue Cross Blue Shield of Massachusetts is an HMO and
PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts
depends on contract renewal.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are
the legal entities which have contracted as a joint enterprise with the Centers for Medicare
& Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx plans.
The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx
(PDP) depends on contract renewal.

Blue Cross Blue Shield of Massachusetts 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. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

198614M 99-0645 (09/19)

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 PPO BlueSM (PPO)

NEED TO FIND A DOCTOR?

It’s easy to find a doctor in the Medicare PPO 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

Search for doctors and hospitals outside of Massachusetts

Go to www.bcbs.com and click on Find a Doctor or Hospital and follow
the easy steps to locate a provider outside of Massachusetts.

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.

198633M Y0014_19100_C 37-1880-20 (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, 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, 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 (08/19)



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)


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