BCBSMA PPO_Sales Kit Booklet 11/01/2018 approved by Jazmin 10/26/2018 9:43 AM

Medicare Advantage Plans

Coverage you need
From a name you can trust

Medicare PPO Blue (PPO) 2019

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

H2230_18223_M
(11/01/18)



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
Senior Director, Medicare Sales
Enclosures By mail:Complete the enclosed enrollment
form and mail in the self-addressed
Ready to Enroll? envelope.

By phone: 1-800-678-2265 (TTY: 711) By fax: Complete the enclosed enrollment
10/1–3/31, 8:00 a.m. to 8:00 p.m., form and fax to 1-617-246-8506.
seven days a week.
4/1–9/30, 8:00 a.m. to 8:00 p.m., continued >
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

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
189001M 55-0619-19 (08/18)

Y0014_18192_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)

2019 Summary of Benefits

H2230 PLANS 017, 018, 002

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Crossand Blue Shield Association.
H2230_1881_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.

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.

4

Summary Of Benefits

January 1, 2019 - December 31, 2019

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.

You have choices about how to get your Medicare benefits

• One choice is to get your Medicare benefits through Original Medicare
(fee-for-service Medicare). Original Medicare is run directly by the Federal government.

• Another choice is to get your Medicare benefits by joining a Medicare health plan
(such as Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO),
or Medicare PPO Blue PlusRx (PPO).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Medicare PPO Blue SaverRx (PPO),
Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue PlusRx (PPO) cover and
what you pay.

• If you want to compare our plan with other Medicare health plans, ask the other plans for their
Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

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

Sections in this booklet

• 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
• Covered Medical and Hospital Benefits
• Prescription Drug Benefits

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 services at the number shown in the next section.

1

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

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

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

Our website: www.bluecrossma.com/medicare

Who can join?

To join Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), or Medicare PPO
Blue PlusRx (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B,
and live in our service area You must continue to pay your Medicare Part B premium.

Our service area includes the following counties in Massachusetts: Barnstable, Bristol, Essex,
Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester.

Which doctors, hospitals, and pharmacies can I use?

Medicare PPO Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO), and Medicare PPO Blue
PlusRx (PPO) have a network of doctors, hospitals, pharmacies, and other providers.
If you use the providers in our network, you may pay less for your covered services. But if you
want to, you can also use providers that are not in our network.

2

Depending on your plan, you may pay more if you use providers that are not in our network.
Out-of-network/non-contracted providers are under no obligation to treat Medicare PPO
Blue SaverRx (PPO), Medicare PPO Blue ValueRx (PPO) and Medicare PPO Blue PlusRx
(PPO) members, except in emergency situations. For a decision about whether we will cover
an out-of-network service, we encourage you or your provider to ask us for a pre-service organization
determination before you receive the service. Please call our member service number or see your
Evidence of Coverage for more information, including the cost sharing
that applies to out-of-network services.

• You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.
• You can see our plan’s provider directory at our website (www.bcbsma.com).
• You can see our plan’s pharmacy directory at our website (www.bluecrossma.com/pharmacyfinder).
• Or, call us and we will send you a copy of the provider and pharmacy directories. The pharmacy

network, and/or provider network may change at any time. You will receive notice when necessary.

What do we cover?

Like all Medicare health plans, 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.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some
drugs administered by your provider.

• You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions
on our website, www.bluecrossma.com/formularies/medicare.

• Or, call us and we will send you a copy of the formulary.
The formulary may change at any time. You will receive notice when necessary.

How will I determine my drug costs?

Our plan groups each medication into one of five “tiers.” You will need to use your formulary
to locate what tier your drug is on to determine how much it will cost you. The amount you
pay depends on the drug’s tier and what stage of the benefit you have reached. Later in this
document we discuss the benefit stages that occur after you meet your deductible:
Initial Coverage, Coverage Gap, and Catastrophic Coverage.

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.

3

Summary of Benefits: January 1, 2019 - December 31, 2019

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

Monthly Plan Premium Barnstable, Bristol, Essex, Barnstable, Bristol, Essex, Barnstable, Bristol, Essex,
Franklin, Hampden, Franklin, Hampden, Franklin, Hampden,
Hampshire, Middlesex, Hampshire, Middlesex, Hampshire, Middlesex,
Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk Norfolk, Plymouth, Suffolk
counties: counties: counties:
$0 per month $76 per month $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 for $320 per year for $200 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

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

Inpatient Hospital Our plan covers an Our plan covers an unlimited Our plan covers an unlimited
Coverage
unlimited number of days for number of days for an number of days for an

an inpatient hospital stay. inpatient hospital stay. inpatient hospital stay.

In-network: In-network: In-network:
• $350 copay per day for • $250 copay per day for • $150 copay per day

days 1 through 5 days 1 through 5 for days 1 through 5
• You pay nothing per day for
• You pay nothing per day for • You pay nothing per day for
days 6 through 90 days 6 through 90 days 6 through 90
• You pay nothing per day for
• You pay nothing per day for • You pay nothing per day for
days 91 and beyond days 91 and beyond days 91 and beyond
Out-of-network:
Out-of-network: Out-of-network: • 20% of the cost per stay
• $350 copay per day for • $250 copay per day for Per admission benefit.

days 1 through 5 days 1 through 5 Authorization rules
may apply.
• You pay nothing per day for • You pay nothing per day for
days 6 through 90 days 6 through 90

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

Per admission benefit. Per admission benefit.

Authorization rules Authorization rules

may apply. may apply.

4

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

Outpatient Hospital In-network: In-network: In-Network:
Coverage $300/visit $225/visit $150/visit

Doctor’s Office Visits Out-of-network: Out-of-network: Out-of-Network:
Primary Care $300/visit $225/visit 20% of the total cost
Physician:
Specialist: Authorization rules may apply Authorization rules may apply Authorization rules may apply

Preventive Care In-network: In-network: In-network:
$25 copay $20 copay $15 copay

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

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

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

Authorization rules may apply Authorization rules may apply Authorization rules may apply

In-network:
You pay nothing

You pay nothing 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
• Alcohol misuse counseling
• Bone mass measurement
• Breast cancer screening (mammogram)
• Cardiovascular disease (behavioral therapy)
• Cardiovascular screenings
• Cervical and vaginal cancer screening
• Lung cancer screening (low dose computed tomography (LDCT)
• Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)*
• Depression screening
• Diabetes screenings
• HIV screening
• Medical nutrition therapy services
• Obesity screening and counseling
• Prostate cancer screenings (PSA)
• Sexually transmitted infections screening and counseling
• Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
• Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots
• “Welcome to Medicare” preventive visit (one-time)
• Yearly “Wellness” visit
Any additional preventive services approved by Medicare during the contract year will be covered.
• 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.
Authorization rules may apply

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

5

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

$90 copay $90 copay $75 copay

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

Urgently Needed $25-$45 copay $20-$40 copay In-network: $15-$35 copay
Services Out-of-network: $45 copay

Diagnostic Services/Labs/Imaging

Diagnostic radiology In-network: In-network: In-network:
(such as MRIs, CT $325 copay per day $250 copay per day $150 copay per day
scans):
per category per category per category

Diagnostic tests and Out-of-network: Out-of-network: Out-of-network:
procedures $325 copay per day $250 copay per day 40% of the cost per day
per category per category per category

Authorization rules may apply Authorization rules may apply Authorization rules may apply

In-network: In-network: In-network:
$10 copay per day $10 copay per day $10 copay per day

Lab services: Out-of-network: Out-of-network: Out-of-network:
$10 copay per day $10 copay per day 20% of the cost
Authorization rules may apply Authorization rules may apply
Authorization rules may apply
In-network: In-network:
$10 copay per day $10 copay per day In-network:
$10 copay per day

Out-of-network: Out-of-network: Out-of-network:
$10 copay per day $10 copay per day 20% of the cost

Authorization rules may apply Authorization rules may apply 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:
$10 copay per day $10 copay per day 20% of the cost

Authorization rules may apply Authorization rules may apply Authorization rules may apply

Therapeutic radiology In-network: In-network: In-network:
You pay nothing You pay nothing
services: $60 copay per visit

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

Authorization rules may apply Authorization rules may apply Authorization rules may apply

6

Hearing Services Medicare PPO Blue Medicare PPO Blue Medicare PPO Blue
Routine Exam: SaverRx (PPO) ValueRx (PPO) PlusRx (PPO)

Not covered In-network: In-network:
$20-$40 copay $15-$35 copay
Non Routine Exam: In-network: Out-of-network:
Hearing Aids: $25-$45 copay $20-$40 copay Out-of-network:
In-network: $45 copay
Out-of-network: $20-$40 copay In-network:
$25-$45 copay Out-of-network: $15-$35 copay
$20-$40 copay
Not covered Not covered Out-of-network:
$45 copay
Dental Services In-network: Our plan pays up to
$40 copay $400 every three years for
Limited Medicare- In-network: Out-of-network: hearing aids
covered dental $45 copay $40 copay
services: In-network: In-network:
Out-of-network: $40 copay $35 copay
$45 copay Out-of-network: Out-of-network:
$40 copay $45 copay
Routine dental services: In-network: In-network:
Single copay for visit $60 copay $35 copay
that includes: Cleaning Out-of-network:
(for up to 1 every six $60 copay Out-of-network:
months; prophylaxis $45 copay
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)

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:
$45 copay $40 copay $45 copay

Eyewear after In and Out-of-Network: In and Out-of-Network: In and Out-of-Network:
cataract surgery: (for $0 copay $0 copay $0 copay
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 covered Not covered Our plan pays up to $150
eyewear, you pay any every two years for eyewear Our plan pays up to $150 every
balance in excess of two years for eyewear
the $150 limit.)

7

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

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 Authorization rules may apply

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

Authorization rules may apply Authorization rules may apply

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

Outpatient individual In-network: In-network: In-network:
therapy visit: $40 copay $35 copay
$40 copay

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

Skilled Our plan covers up to 100 days Our plan covers up to 100 days Our plan covers up to 100 days
Nursing Facility
(SNF) in a SNF. in a SNF. in a 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 1

days 1 through 20 days 1 through 20 through 20

• $160 copay per day for days • $160 copay per day for days • $100 copay per day for days
21 through 44 21 through 44 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. Authorization rules may apply. 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

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

8

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

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)

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)
Authorization rules may apply Authorization rules may apply Authorization rules may apply

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:
$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 monitoring In-network: In-network: In-network:
You pay nothing You pay nothing
supplies: You pay nothing
Out-of-network: Out-of-network:
Diabetes Out-of-network: You pay nothing 20% of the cost
self-management You pay nothing
training: In-network: In-network:
In-network: You pay nothing You pay nothing
You pay nothing
Out-of-network: Out-of-network:
Out-of-network: You pay nothing 20% of the cost
You pay nothing
In-network: In-network:
Therapeutic shoes In-network: You pay nothing You pay nothing
or inserts: You pay nothing
Out-of-network: Out-of-network:
Durable Out-of-network: You pay nothing 20% of the cost
Medical You pay nothing
Equipment In-network: In-network:
(wheelchairs, In-network: 20% of the cost 10% of the cost
oxygen, etc.) 20% of the cost
Out-of-network: Out-of-network:
Out-of-network: 20% of the cost 20% of the cost
20% of the cost
Authorization rules may apply. Authorization rules may apply.
Authorization rules may apply.

9

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

Prosthetic Devices (braces, artificial limbs, etc.) In-network: In-network:
20% of the cost 10% of the cost
Prosthetic devices: In-network: Out-of-network: Out-of-network:
20% of the cost 20% of the cost 20% of the cost
Related medical Out-of-network: In-network: In-network:
supplies: 20% of the cost 20% of the cost 10% of the cost
In-network: Out-of-network: Out-of-network:
Wellness Programs 20% of the cost 20% of the cost 20% of the cost
Fitness: Out-of-network:
20% of the cost $150 per calendar year $150 per calendar year
$150 per calendar year $150 per calendar year
$150 per calendar year

Weight Loss: $150 per calendar year

See back of this
booklet for more
details

*There is no coinsurance or copayment for the Johnson and Johnson® (One Touch®) or Roche Diagnostics®
(Accu-Check®) 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.

10

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 available at participating Councils on Aging (COA) facilities
• 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
FitnessBenefit for any aerobic/fitness activity fees paid to a non-qualified health club or fitness
center, or for personal training, lessons, coaching, exercise equipment, or clothing.

What is the Weight Loss Benefit?

Enroll in a qualified Weight Watchers®´ or a hospital-based 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 At Work program, and hospital-based
weight loss programs.

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

11

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
$3,820. 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 $5 $10 $15 $3 $6 $9 $1 $2 $3
(Preferred Generic) copay copay copay copay copay copay copay copay copay

Tier 2 $11 $22 $33 $7 $14 $21 $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 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

12

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 Brand) copay copay copay copay copay copay copay copay copay

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

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

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 $5 $5 $5 $3 $3 $3 $1 $1 $1
(Preferred Generic) copay copay copay copay copay copay copay copay copay

Tier 2 $11 $22 $22 $7 $14 $14 $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 Brand) copay copay copay copay copay copay copay copay copay

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

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.

13

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”). This means that
Catastrophic there’s a temporary change in what you will pay for your drugs. The coverage gap begins after
Coverage the total yearly drug cost (including what our plan has paid and what you have paid) reaches
$3,820.

After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs
and 37% of the plan’s cost for covered generic drugs until your costs total $5,100, 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 $5,100, you pay the greater of:

• 5% of the cost, or
• $3.40 copay for generic (including brand drugs treated as generic) and a $8.50 copayment for

all other drugs.

14

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) 

• 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.

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, 2020

■ 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_18182_C
15

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., 8:00 a.m. to 8:00 p.m.,
7 days a week 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 - 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., 8:00 a.m. to 8:00 p.m.,
7 days a week 5 days a week, Monday - Friday

Our website: www.bluecrossma.com/medicare

16

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 Laureen Corey, 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 Laureen Corey, 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.

17

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/ :
18 1-800-200-4255 (TTY: 711)



For more information
or help with enrollment

www.bluecrossma.com/Medicare
Medicare Plan Sales: 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.

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.

®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and

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

188128M 55-0605-18 (08/18)

Blue Cross Blue Shield of Massachusetts - H2230
2019 Medicare Star Ratings*

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and
performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star
Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are:
1. An Overall Star Rating that combines all of our plan’s scores.
2. Summary Star Rating that focuses on our medical or our prescription drug services.
Some of the areas Medicare reviews for these ratings include:
• How our members rate our plan’s services and care;
• How well our doctors detect illnesses and keep members healthy;
• How well our plan helps our members use recommended and safe prescription medications.
For 2019, Blue Cross Blue Shield of Massachusetts received the following Overall Star Rating from Medicare.

4.5 Stars

We received the following Summary Star Rating for Blue Cross Blue Shield of Massachusetts’s
health/drug plan services:

Health Plan Services: 4 Stars

Drug Plan Services:

5 Stars

The number of stars shows how well our plan performs.
5 stars - excellent

4 stars - above average

3 stars - average

2 stars - below average

1 star - poor

Learn more about our plan and how we are different from other plans at www.medicare.gov.

You may also contact us 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 Mon-
day 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).

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year
to the next.

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

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

175302 | 99-0289-18 (PPO) H2230_18240_M



02

Resources



Join us for a FREE informational
meeting in your neighborhood.

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

Get answers to your questions about Call 1-800-262-BLUE (2583)
Medicare and supplemental insurance
coverage, and hear what other people (TTY/TDD 711) 7:00 a.m.–12:00 a.m.,
who are in your shoes are asking us at 7 days a week (Excluding holidays).
one of our informational meetings.
You can also make your reservation online anytime,
24 hours a day, seven days a week by visiting
www.bluecrossma.com/seminar.

Reserve your seat at the location nearest you.

RESERVE We are always adding and updating seminars on an ongoing basis.
NOW
Visit our website at bluecrossma.com/seminars to see the most
up-to-date list.

Comprehensive 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:

Hyannis 11/05/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Cambridge 11/05/2018 10:30 AM-12:30 PM Courtyard by Marriott 777 Memorial Drive
Watertown 11/06/2018 10:30 AM-12:30 PM Residence Inn 570 Arsenal Street
Peabody 11/06/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Middleboro 11/07/2018 10:30 AM-12:30 PM Lorenzo's Italian Restaurant 500 West Grove Street
Braintree 11/07/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Fall River 11/08/2018 10:30 AM-12:30 PM McGovern's Family Restaurant 310 Shove Street
Westborough 11/08/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive

Blue Cross Blue Shield of Massachusetts is an Independent Continued
Licensee of the Blue Cross and Blue Shield Association.
Y0014_18211_M
S2893_18136_M

Comprehensive 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:

Hadley 11/09/2018 10:30 AM-12:30 PM Hadley Farms Meeting House 41 Russell Street
Taunton 11/09/2018 10:30 AM-12:30 PM Holiday Inn 700 Myles Standish Blvd
Springfield 11/12/2018 10:30 AM-12:30 PM La Quinta Inn & Suites 100 Congress Street
Leominster 11/12/2018 10:30 AM-12:30 PM DoubleTree by Hilton 99 Erdman Way
Dedham 11/13/2018 10:30 AM-12:30 PM Holiday Inn 55 Ariadne Road
Salem 11/13/2018 10:30 AM-12:30 PM Hawthorne Hotel 18 Washington Square West
Natick 11/14/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Concord 11/14/2018 10:30 AM-12:30 PM Residence Inn 320 Baker Avenue
Worcester 11/15/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Boston 11/15/2018 10:30 AM-12:30 PM Sheraton Boston Hotel 39 Dalton Street
Newton 11/16/2018 10:30 AM-12:30 PM Marriott 2345 Commonwealth Avenue
Andover 11/17/2018 10:30 AM-12:30 PM Courtyard by Marriott 10 Campanelli Drive
Plymouth 11/19/2018 10:30 AM-12:30 PM John Carver Inn 25 Summer Street
New Bedford 11/19/2018 10:30 AM-12:30 PM Fairfield Inn & Suites 185 MacArthur Drive
Milford 11/20/2018 10:30 AM-12:30 PM DoubleTree by Hilton 11 Beaver Street
Gardner 11/21/2018 10:30 AM-12:30 PM Colonial Hotel 625 Betty Spring Road
Westborough 11/21/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive
Tewksbury 11/27/2018 10:30 AM-12:30 PM Holiday Inn 4 Highwood Drive
Hyannis 11/28/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Braintree 11/29/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Natick 11/29/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Lynnfield 11/30/2018 10:30 AM-12:30 PM Spinelli's Function Facility Route One South
Burlington 12/04/2018 10:30 AM-12:30 PM Marriott One Burlington Mall Road
Worcester 12/04/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Peabody 12/05/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Rockland 12/06/2018 10:30 AM-12:30 PM DoubleTree by Hilton 929 Hingham Street
Waltham 12/07/2018 10:30 AM-12:30 PM Embassy Suites 550 Winter Street

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

A salesperson will be present with information and applications. For accommodations for persons with special needs,
please call 1-800-262-BLUE (2583) (TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., 7 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. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
188947-2M 55-1758 (10/18)



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*.

From 1/1/2018 - 5/31/2018

MEDICATION NAME

ALENDRONATE SODIUM CIPROFLOXACIN HCL FLUOXETINE HCL

ALLOPURINOL CITALOPRAM HBR FLUTICASONE PROPIONATE

ALPRAZOLAM CLONAZEPAM FUROSEMIDE

AMITRIPTYLINE HCL CLOPIDOGREL GABAPENTIN

AMLODIPINE BESYLATE DICLOFENAC SODIUM GLIMEPIRIDE

AMOXICILLIN DILTIAZEM 24HR ER GLIPIZIDE

AMOXICILLIN-CLAVULANATE DONEPEZIL HCL GLIPIZIDE ER
POTASSIUM

ATENOLOL DORZOLAMIDE-TIMOLOL HYDROCHLOROTHIAZIDE

ATORVASTATIN CALCIUM DOXAZOSIN MESYLATE HYDROCODONE-ACETAMINOPHEN

AZITHROMYCIN DOXYCYCLINE HYCLATE IBUPROFEN

BRIMONIDINE TARTRATE DULOXETINE HCL ISOSORBIDE MONONITRATE ER

BUPROPION HCL SR ELIQUIS®' LAMOTRIGINE

BUPROPION XL ESCITALOPRAM OXALATE LANTUS®' SOLOSTAR®'

CARVEDILOL ESTRADIOL LATANOPROST

CELECOXIB EZETIMIBE LEVOTHYROXINE SODIUM

CEPHALEXIN FENOFIBRATE LISINOPRIL

CHLORTHALIDONE FINASTERIDE LISINOPRIL-HYDROCHLOROTHIAZIDE

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

MEDICATION NAME ONETOUCH®' ULTRA®’ BLUE SPIRIVA®'
TEST STRIPS
LORAZEPAM OSELTAMIVIR PHOSPHATE SPIRONOLACTONE
OXYBUTYNIN CHLORIDE ER SULFAMETHOXAZOLE-TRIMETHOPRIM
LOSARTAN POTASSIUM OXYCODONE HCL SYMBICORT®'
LOSARTAN-HYDROCHLOROTHIAZIDE OXYCODONE-ACETAMINOPHEN TAMSULOSIN HCL
LOVASTATIN PANTOPRAZOLE SODIUM TIMOLOL MALEATE
MELOXICAM PAROXETINE HCL TRAMADOL HCL
METFORMIN HCL POTASSIUM CHLORIDE TRAZODONE HCL
METFORMIN HCL ER PRAVASTATIN SODIUM TRIAMCINOLONE ACETONIDE
METHOTREXATE PREDNISOLONE ACETATE TRIAMTERENE-HYDROCHLOROTHIAZIDE
METOPROLOL SUCCINATE PREDNISONE VALACYCLOVIR
METOPROLOL TARTRATE PROAIR®' HFA VALSARTAN
MIRTAZAPINE QUETIAPINE FUMARATE VENLAFAXINE HCL ER
MONTELUKAST SODIUM RANITIDINE HCL WARFARIN SODIUM
NAPROXEN ROSUVASTATIN CALCIUM ZOLPIDEM TARTRATE
NIFEDIPINE ER SERTRALINE HCL
OMEPRAZOLE SIMVASTATIN
ONETOUCH® VERIO®
ONETOUCH®’ DELICA®’

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. Contact the plan for more information. Limitations,
copayments, and restrictions may apply. Benefits, premiums and/or copayments/co-insurance may change on
January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network,
and/or 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, or sex.

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. ®´, TM Registered Marks
and Trademarks are property of their respective owners. © 2018 Blue Cross and Blue Shield
of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc.

188950M Y0014_18183_M (09/18)

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/medicare and
click on the Find a Doctor link. Then follow the few easy steps to find a participating
provider in your area.

Learn More with Questions?
our Online Directory 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 don’t have Internet access, just call us at
particular physician or office, such as: 1-800-678-2265 (TTY: 711). A representative
is available to help you:
• What medical school a physician attended
• April 1 through September 30,
• Whether the office is handicap-accessible 8:00 a.m. to 8:00 p.m. ET,
Monday through Friday
• Whether weekend or evening office hours
are available and more • October 1 through March 31,
8:00 a.m. to 8:00 p.m. ET,
seven days a week.

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.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and
Blue Shield of Massachusetts, In., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

187887M 7-1880-19 (08/18)
H2230_18143_C

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 Laureen Corey, 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 Laureen Corey, 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. © 2018 Blue Cross and
Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

188999M 55-1490A (08/18)



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 assisten-
za 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. © 2018 Blue Cross and Blue Shield of

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

Y0014_16110 Accepted 08302016 187153M | 55-1490B (REV 06/18)