BCBSMA MEDICARE HMO Sales Kit Book April 2022 Approved By Danielle Roy 3/23/2022 10:37 AM

Medicare Advantage Plans

MEDICARE HMO
BLUE (HMO)
2022

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.
April 2022 (2202051)



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

Dear Prospective Member,

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

 

Great Coverage Lower Costs Enhanced Benefits
Including prescription Low copays for primary Such as fitness and weight-loss
drug coverage and an care visits and $0 copays
on routine dental, hearing, reimbursements, telehealth,
extensive network over-the-counter allowance,
of doctors and vision exams
comprehensive dental,
and more

Why Choose Blue?

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

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

Sincerely,

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

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

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

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

Massachusetts Department of Insurance (mass.gov).

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

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

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

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

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

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

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

and Blue Shield of Massachusetts HMO Blue, Inc.

000892964 H2261_2161_M 55-0619-22 (10/21)

IN THIS BOOKLET

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

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

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

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



2022 SUMMARY
OF BENEFITS

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

H2261_2178_M PLANS 024, 022, 023, 005
Blue Cross Blue Shield of Massachusetts
is an Independent Licensee of the Blue Cross
and Blue Shield Association.



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

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

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

SUMMARY OF BENEFITS

January 1, 2022 - December 31, 2022

Choose How You get your Medicare benefits

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

Tips for comparing your Medicare choices

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

Sections in this booklet

• Things to Know About Medicare • Monthly Premium, Deductible, and Limits
HMO Blue SaverRx (HMO), Medicare on How Much You Pay for Covered Services
HMO Blue ValueRx (HMO), Medicare
HMO Blue FlexRx (HMO-POS), and • Covered Medical and Hospital Benefits
Medicare HMO Blue PlusRx (HMO) • 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 Service at the number shown in the next section.

1 2022 Summary of Benefits

THINGS TO KNOW ABOUT OUR PLANS

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

Contact Information and Hours of Operation

Members

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

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

Non-Members

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

Our website: bluecrossma.com/medicare

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

bluecrossma.com/medicare 2

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

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

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

3 2022 Summary of Benefits

SUMMARY OF BENEFITS:

January 1, 2022 - December 31, 2022

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

Monthly Plan Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol, Barnstable, Bristol,
Premium Essex, Franklin, Essex, Franklin, Essex, Franklin, Essex, Franklin,
Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire, Hampden, Hampshire,
Deductibles Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk, Middlesex, Norfolk,
Medical: Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk Plymouth, Suffolk
Prescription counties: counties: counties: counties:
Drugs: $0 per month $36 per month $268 per month $96 per month

Maximum Worcester County: Worcester County: Worcester County: Worcester County:
Out-of-Pocket $0 per month $56 per month $268 per month $106 per month
Responsibility
(does not You must continue to pay your Medicare Part B premium.
include costs
related to These plans do not have a medical deductible.
prescription
drugs) $300 per year for $320 per year for $200 per year for $260 per year for
Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5

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

$7,550 for services $3,450 for services $3,400 for services $3,900 for services
you receive from you receive from you receive from you receive from
in-network providers. in-network providers. in-network providers. in-network providers.

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

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

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

bluecrossma.com/medicare 4

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

Our plan covers an unlimited number of days for an inpatient hospital stay. In-Network:
$245 copay per day
Inpatient $390 copay per day $330 copay per day $150 copay per day for days 1 through 5
Hospital for days 1 through 5 for days 1 through 5 for days 1 through 5 You pay nothing
Coverage per day for days 6
Outpatient You pay nothing per You pay nothing per You pay nothing per through 90
Hospital day for days 6 day for days 6 day for days 6 You pay nothing
Coverage through 90 through 90 through 90 per day for days 91 and
beyond
You pay nothing You pay nothing You pay nothing Out-of-Network:
per day for days 91 per day for days 91 per day for days 91 20% of the cost
and beyond and beyond and beyond per stay

Per admission benefit. Per admission benefit. Per admission benefit. In-Network:
$210/visit
Authorization rules may apply. Out-of-Network:
20% of the total cost
$325/visit $250/visit $150/visit

Authorization rules may apply.

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

Authorization rules may apply.

Doctor’s Office Visits (including telehealth visits)

Primary Care $10 copay $10 copay $0 copay In-Network:
Physician: $10 copay

Out-of-Network:
$65 copay

Specialist: $45 copay* $40 copay* $30 copay* In-Network:
$35 copay*

Out-of-Network:
$65 copay

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

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

5 2022 Summary of Benefits

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

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

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

Our plans cover many preventive services, including:

Preventive • Abdominal aortic aneurysm screening • Prostate cancer screenings (PSA)
Care • Alcohol misuse counseling • Sexually transmitted infections screening
• Bone mass measurement
• Breast cancer screening (mammogram) and counseling
• Cardiovascular disease (behavioral therapy)
• Cardiovascular screenings • Lung cancer screening (low-dose computed
• Cervical and vaginal cancer screening tomography [LDCT])
• Colorectal cancer screenings
• Tobacco use cessation counseling
(Colonoscopy, Fecal occult blood test, (counseling for people with no sign
Flexible sigmoidoscopy)* of tobacco-related disease)

• Depression screening • Flu shots, pneumococcal shots, Hepatitis B
• Diabetes screenings shots (limitations may apply)
• HIV screening
• Medical nutrition therapy services • “Welcome to Medicare” preventive visit
• Obesity screening and counseling (one-time)

• Yearly “Wellness” visit
• Any additional preventive services

approved by Medicare during the contract
year will be covered.

• Authorization rules may apply

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

bluecrossma.com/medicare 6

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

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

Emergency $90 copay $105 copay $75 copay $90 copay
Care
Your copay is waived if you are admitted to the hospital within 24 hours or held overnight
for observation.

In-Network:

Urgently $10-$45 copay $10-$40 copay $0-$30 copay $10–$35 copay
Needed per visit* per visit* per visit* per visit*
Services
(including Out-of-Network:
telehealth
visits) $65 copay per visit

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

Diagnostic Services/Labs/Imaging

Diagnostic $310 copay per day $250 copay per day $150 copay per day In-Network:
Radiology per category per category per category
(such as MRIs, $200 copay per day
CT scans): per category

Out-of-Network:

40% of the cost

Authorization rules may apply.

In-Network:

Diagnostic $10 copay per day* $10 copay per day* $0 copay per day* $10 copay per day*
Tests and Out-of-Network:
Procedures
20% of the cost

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

7 2022 Summary of Benefits

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

$10 copay per day* $10 copay per day* $0 copay per day* In-Network:
$10 copay per day*
Lab Services: Out-of-Network:
Outpatient 20% of the cost
X-rays:
Therapeutic *You pay nothing for Medicare-covered services performed at home by a network provider
Radiology Authorization rules may apply. Referral from your doctor may be required.
Services:
$10 copay per day $10 copay per day $5 copay per day In-Network:
$10 copay per day
Authorization rules may apply. Out-of-Network:
20% of the cost
$60 copay per visit You pay nothing You pay nothing
In-Network:
You pay nothing
Out-of-Network:
20% of the cost

Authorization rules may apply.

Hearing Services

Routine $0 copay $0 copay $0 copay In-Network:
Exam— $0 copay
up to one per You must use a TruHearing network provider for all routine hearing exams. Out-of-Network:
year: Not covered
Non-Routine $10-$45 copay $10-$40 copay $0–$30 copay
Exam: In-Network:
$10-$35 copay
Out-of-Network:
$65 copay

Hearing Aids: $699-$999 copay per $699-$999 copay per $699-$999 copay per $699-$999 copay per
hearing aid per year hearing aid per year hearing aid per year hearing aid per year

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

bluecrossma.com/medicare 8

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

Limited $45 copay $40 copay $30 copay In-Network:
Medicare- $35 copay
Covered Dental
Services: Out-of-Network:
$65 copay or 20%

Non-Medicare Covered Dental Services:

Dental $0 copay for preventive $0 copay. Coverage $0 copay. Coverage In-Network:
Services — dental. for preventive services for preventive services You pay $0 copay.
Non-Medicare only. Maximum of two only. Maximum of two
Covered 50% coinsurance visits each calendar visits each calendar Out-of-Network:
for comprehensive year. year. You pay a $45 copay.
services.
Coverage for preventive
$500 maximum services only.
per calendar year Maximum of two visits
for preventive and each calendar year.
comprehensive
services combined.

Refer to the Evidence of Coverage for complete details.

9 Medex Sales: 1-800-678-2265

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

Medicare- $10-$45 copay $10-$40 copay $0-$30 copay In-Network:
Covered Eye $10-$35 copay
Exam:
Out-of-Network:
$65 copay

Eyewear After $0 copay $0 copay $0 copay In-and
Cataract Out-of-Network:
Surgery: (for $0 copay
Medicare-
covered $0 copay $0 copay $0 copay In-Network:
standard $0 copay
eyewear)
Routine Eye Out-of-Network:
Exam: (up to Not covered
1 every 12
months) You must use an EyeMed®´ network provider for all routine eye exams.

Eyewear: Our plan pays up to Our plan pays up to Our plan pays up to In-Network:
(For covered $200 once every 24 $200 once every 24 $200 once every 24 Our plan pays up to
eyewear, months for prescription months for prescription months for prescription $200 once every 24
you pay any eyewear eyewear eyewear months for prescription
balance in eyewear
excess of the
$200 limit.) Out-of-Network:
Not covered

You must use an EyeMed network provider for all routine eye exams and the purchase of covered
eyewear. There is no coverage for out-of-network providers.

Mental Health Services

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

You pay nothing You pay nothing You pay nothing You pay nothing per day
per day for days 91 per day for days 91 per day for days 91 and for days 91 and beyond
and beyond and beyond beyond
Out-of-Network:
20% of the cost
per stay

Authorization rules may apply.

bluecrossma.com/medicare 10

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

Outpatient $30 copay $25 copay $10 copay In-Network:
Group Therapy $10 copay
Visit:
Outpatient Out-of-Network:
Individual 20% of the cost
Therapy Visit:
(including Authorization rules may apply.
telehealth
visits) $30 copay* $25 copay* $10 copay* In-Network:
$10 copay*

Out-of-Network:
20% of the cost

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

Additional Services

Skilled Our plan covers up to Our plan covers up to Our plan covers up to Our plan covers up to
Nursing 100 days in a SNF. 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.
Facility $20 copay per day for
(SNF) You pay nothing You pay nothing days 1 through 20 In-Network:
Physical per day for days 1 per day for days 1 $100 copay per day for You pay nothing per day
Therapy through 20 through 20 days 21 through 44 for days 1 through 20
You pay nothing
$160 copay per day for $160 copay per day for per day for days 45 $140 copay per day for
days 21 through 44 days 21 through 44 through 100 days 21 through 44

You pay nothing You pay nothing $15 copay You pay nothing per
per day for days 45 per day for days 45 day for days 45 through
through 100 through 100 100

Authorization rules may apply. Out-of-Network:
20% of the cost per stay
$40 copay $30 copay
In-Network:
$15 copay

Out-of-Network:
20% of the cost

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

11 2022 Summary of Benefits

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

$275 copay per trip $150 copay per trip $50 copay per trip In-Network:
$100 copay per trip
Ambulance
Out-of-Network:
$100 copay per trip

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

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

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

Foot Care Foot exams and Foot exams and Foot exams and Foot exams and
(Podiatry treatment if you have treatment if you have treatment if you have treatment if you have
services) diabetes-related nerve diabetes-related nerve diabetes-related nerve diabetes-related nerve
damage and/or meet damage and/or meet damage and/or meet damage and/or meet
certain conditions: certain conditions: certain conditions: certain conditions:
$10-$45 copay $10-$40 copay $0-$30 copay
In-Network:
$10-$35 copay

Out-of-Network:
$65 copay

Referral from your doctor may be required

Over-the- Our plan pays up to Not covered Not covered Not covered
counter items $150 per calendar
(OTC) year toward over-
the-counter health &
wellness products.

CVS will manage the OTC benefit. See the OTC catalog for a list of eligible items.
Purchase OTC items by mail, phone, or in participating CVS retail stores.
You can find the catalog at cvs.com/otchs/bcbsma. If you have questions or to order by phone
please call 1-888-628-2770 (TTY:711) Monday – Friday 9 am to 8 pm ET.

bluecrossma.com/medicare 12

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Diabetes Supplies and Services*
You pay nothing In-Network:
Diabetes You pay nothing You pay nothing You pay nothing
Monitoring You pay nothing Out-of-Network:
Supplies: You pay nothing 20% of the cost

Authorization rules may apply. 10% of the cost In-Network:
You pay nothing
Diabetes Self- You pay nothing You pay nothing 10% of the cost Out-of-Network:
Management 10% of the cost 20% of the cost
Training: In-Network:
$250 You pay nothing
Therapeutic You pay nothing You pay nothing per calendar year Out-of-Network:
Shoes or $150 20% of the cost
Inserts: per calendar year In-Network:
10% of the cost
Durable 20% of the cost 20% of the cost Out-of-Network:
Medical 20% of the cost
Equipment Authorization rules may apply.
(wheelchairs, In-Network:
oxygen, etc.) 10% of the cost
Out-of-Network:
Prosthetic Devices (braces, artificial limbs, etc.) 20% of the cost
In-Network:
Prosthetic 20% of the cost 20% of the cost 10% of the cost
Devices: Out-of-Network:
20% of the cost
Related 20% of the cost 20% of the cost
Medical $150
Supplies: per calendar year

Wellness Programs (See back of this booklet for more details) $150
per calendar year
Fitness: $250 $150
per calendar year per calendar year

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

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

13 2022 Summary of Benefits

WELLNESS PROGRAMS

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

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

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

Enroll in a qualified health club or fitness facility Enroll in a qualified weight-loss program and
and receive up to $150 ($250 for HMO Blue receive up to $150 per calendar year toward
SaverRx and HMO Blue PlusRx) per calendar your program fees. Employer group benefits
year toward your club membership fees and may vary.
exercise classes.
What kinds of programs qualify?
What programs qualify?
• Traditional WW, (formerly known as Weight
• Virtual/online fitness memberships, Watchers®´) meetings, WW Online and At
subscriptions, programs, or classes that Work programs, and hospital-based and
provide cardiovascular and strength training other non-hospital based weight-loss
using a digital platform. programs that combine healthy eating,
exercise, and coaching sessions.
• Home Fitness Equipment like stationary
bikes, weights, exercise bands, treadmills, • Programs that DO NOT qualify: Individual
fitness machines. nutrition counseling sessions, pre-packaged
meals, books, videos, scales, or other items
• Home Fitness Equipment WILL NOT cover and supplies.
wearable fitness trackers or items that are
considered “Recreational Equipment” or REIMBURSING YOU FOR
“Sports Equipment.” Examples include HEALTHY CHOICES
kayaks, inline skates, bicycles, ice skates,
trampolines, fitness clothing, sneakers. GET REIMBURSED UP TO $300
PER YEAR WHEN YOU ENROLL
• Health clubs with a variety of cardiovascular
and strength-training exercise equipment, IN QUALIFIED FITNESS AND
e.g., traditional health clubs, YMCAs, WEIGHT-LOSS PROGRAMS.
YWCAs, and community fitness centers.
$150-250
• Fitness classes at participating Councils on
Aging (COA) facilities; fitness studios with FITNESS REIMBURSEMENT
instructor-led groups such as yoga, Pilates,
Zumba®´, kickboxing, CrossFit®´, and indoor $150
cycling/spinning and other exercise classes.
WEIGHT-LOSS REIMBURSEMENT
• Programs that DO NOT qualify: Martial
arts centers; gymnastics facilities; country bluecrossma.com/medicare 14
clubs; tennis, aerobic, or pool-only facilities;
social clubs; and sports teams/ leagues.
You cannot receive the Fitness Benefit
for personal training, lessons, coaching,
or clothing.

PRESCRIPTION DRUG BENEFITS

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

Deductible $300 per year $320 per year $200 per year $260 per year
Initial for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5 for Tiers 3, 4, 5
Coverage
After you pay your yearly deductible, you pay the following until your total yearly drug costs reach
$4,430. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

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

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

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

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

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

Preferred Retail Cost Sharing

Drug Tier 30- 60- 90- 30- 60- 90- 30- 60- 90- 30- 60- 90-
Tier 1 day day day day day day day day day day day day
(Preferred supply supply supply supply supply supply supply supply supply supply supply supply
Generic)
$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0
copay copay copay copay copay copay copay copay copay copay copay copay

Tier 2 $8 $16 $24 $6 $12 $18 $5 $10 $15 $5 $10 $15
(Generic) copay copay copay copay copay copay copay copay copay copay copay copay

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

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

Tier 5 28% N/A N/A 27% N/A 29% N/A 28% N/A
(Specialty Tier) of the of the N/A of the N/A of the N/A
cost cost cost cost

Standard Retail Cost-Sharing

Drug Tier 30- 60- 90- 30- 60- 90- 30- 60- 90- 30- 60- 90-
day day day day day day day day day day day day
Tier 1 supply supply supply supply supply supply supply supply supply supply supply supply
(Preferred
Generic) $8 $16 $24 $8 $16 $24 $6 $12 $18 $6 $12 $18
Tier 2 (Generic) copay copay copay copay copay copay copay copay copay copay copay copay

$20 $40 $60 $12 $24 $36 $10 $20 $30 $10 $20 $30
copay copay copay copay copay copay copay copay copay copay copay copay

15 2022 Summary of Benefits

Tier 3 Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
(Preferred SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Brand)
Tier 4 $47 $94 $141 $47 $94 $141 $47 $94 $141 $47 $94 $141
(Non-Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Brand)
$100 $200 $300 $100 $200 $300 $100 $200 $300 $100 $200 $300
copay copay copay copay copay copay copay copay copay copay copay copay

Tier 5 28% N/A N/A 27% N/A 29% N/A 28% N/A
(Specialty Tier) of the of the N/A of the N/A of the N/A
cost cost cost cost

Mail Order Cost Sharing

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

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

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

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

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

Tier 5 28% N/A N/A 27% N/A 29% N/A 28% N/A
(Specialty Tier) of the of the N/A of the N/A of the N/A
cost cost cost cost

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

Coverage Gap Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s
a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly
drug cost (including what our plan has paid and what you have paid) reaches $4,430

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

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

bluecrossma.com/medicare 16

PRE-ENROLLMENT CHECKLIST

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

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

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

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2023.

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

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

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

Independent Licensees of the Blue Cross and Blue Shield Association.
H2261_2094_C

17 2022 Summary of Benefits

Contact Information and Hours of Operation

Members

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

Monday - Friday

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

Non-Members

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

Monday - Friday

Our website: bluecrossma.com/medicare-options

bluecrossma.com/medicare 18

NONDISCRIMINATION NOTICE

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

Blue Cross Blue Shield of Massachusetts provides:

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

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

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

19 2022 Summary of Benefits

Translation Resources

TRANSLATION RESOPUrRofiCciEenScy of Language Assistance Services

Proficiency of Language Assistance Services

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

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

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

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

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

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

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

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

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

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

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

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

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

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-800-200-4255 (TTY: 711).
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

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

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

bluecrossma.com/medicare 20

 Medicare Plan Sales

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

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

bluecrossma.com/medicare

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

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

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks and TM
Trademarks are the property of their respective owners. © 2021 Blue Cross and Blue Shield
of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

001321800 H2261_2178_M 55-0604-22 (12/21)

IMPORTANT INFORMATION:

2022 Medicare Star Ratings

Blue Cross Blue Shield of Massachusetts - H2261

For 2022, Blue Cross Blue Shield of Massachusetts - H2261 received the following Star
Ratings from Medicare:

Overall Star Rating:

Health Services Rating:
Drug Services Rating:

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

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

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

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

Get More Information on Star Ratings Online

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

Questions about this plan?

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

H2261_21227_M 000908911_HMO | 99-0288-22 (10/21) 1/1



02

Resources



JOIN US AND LEARN MORE ABOUT MEDICARE

The best plan is the kind you understand. Join one of our upcoming Medicare seminars
to learn more about your options and get answers to your questions. Topics include:

    

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

(Medicare Supplement) (PDP)

UPCOMING SEMINARS

To view the full list of upcoming seminars including in-person and online
options, and to sign up, scan the QR code or visit bluecrossma.com/seminar.

Seminar Type Date Time Location

Medicare Advantage Monday, April 18 2:00 p.m. - 3:00 p.m. Online
(HMO & PPO) Tuesday, April 19 9:30 a.m. - 10:15 a.m. Online
Tuesday, April 19 10:30 a.m. - 11:15 a.m. Online
Original Medicare & Medex Tuesday, April 19 4:30 p.m. - 5:00 p.m. Online
(Medicare Supplement) Tuesday, April 19 5:30 p.m. - 6:00 p.m. Online
Wednesday, April 20 1:00 p.m. - 2:00 p.m. Online
Prescription Drug Plans Wednesday, April 20 4:00 p.m. - 5:00 p.m. Online
(PDP) Thursday, April 21 5:00 p.m. - 5:45 p.m. Online
Thursday, April 21 6:00 p.m. - 6:45 p.m. Online
Dental Blue 65 Friday, April 22 9:30 a.m. - 10:30 a.m. Online
Monday, April 25 2:00 p.m. - 3:00 p.m. Online
GeoBlue Travel Insurance Tuesday, April 26 2:00 p.m. - 2:45 p.m. Online

Medicare Advantage
(HMO & PPO) In Spanish

Medicare Advantage
(HMO & PPO)

Original Medicare & Medex
(Medicare Supplement)

Prescription Drug Plans
(PDP)

Medicare Advantage
(HMO & PPO)

Medicare Advantage
(HMO & PPO)

Original Medicare & Medex
(Medicare Supplement)

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

Seminar Type Date Time Location

Prescription Drug Plans Tuesday, April 26 3:00 p.m. - 3:45 p.m. Online
(PDP) Wednesday, April 27 4:00 p.m. - 5:00 p.m. Online
Thursday, April 28 9:30 a.m. - 10:15 a.m. Online
Medicare Advantage Thursday, April 28 10:30 a.m. - 11:15 a.m. Online
(HMO & PPO) Friday, April 29 9:30 a.m. - 10:30 a.m. Online
Monday, May 2 2:00 p.m. - 3:00 p.m. Online
Original Medicare & Medex Tuesday, May 3 2:00 p.m. - 2:45 p.m. Online
(Medicare Supplement) Tuesday, May 3 3:00 p.m. - 3:45 p.m. Online
Wednesday, May 4 4:00 p.m. - 5:00 p.m. Online
Prescription Drug Plans Thursday, May 5 9:30 a.m. - 10:00 a.m. Online
(PDP) Thursday, May 5 10:30 a.m. - 11:00 a.m. Online
Friday, May 6 9:30 a.m. - 10:30 a.m. Online
Medicare Advantage Monday, May 9 2:00 p.m. - 3:00 p.m. Online
(HMO & PPO) Tuesday, May 10 9:30 a.m. - 10:15 a.m. Online

Medicare Advantage
(HMO & PPO)

Original Medicare & Medex
(Medicare Supplement)

Prescription Drug Plans
(PDP)

Medicare Advantage
(HMO & PPO)

Dental Blue 65

GeoBlue Travel Insurance

Medicare Advantage
(HMO & PPO)

Medicare Advantage
(HMO & PPO)

Original Medicare & Medex
(Medicare Supplement)

A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP,
and Medicare Supplement plan options and benefits. Visit the website below to view the agenda.

They can answer your questions and assist with enrollment when you’re ready.

Not seeing a date that works for you? NEED HELP SIGNING UP?

There are plenty more to choose from. For assistance signing up for a seminar,
Check out our full list of events at or for accommodations for persons with
bluecrossma.com/seminar or scan special needs, call 1-800-262-BLUE (2583)
the QR Code. (TTY: 711) 7:00 a.m. – 12:00 midnight,
seven days a week (excluding holidays).

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.

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield
of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2022 Blue Cross
and Blue Shield of Massachusetts, Inc. or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

001449150 Y0014_2220_M S2893_2202_M 99-0645-22 (3/22)

MEDICARE ADVANTAGE

TOP 100 DRUG LIST

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

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

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

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

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

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

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

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

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

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

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

Medicare HMO Blue (HMO)

IS YOUR PRIMARY CARE PROVIDER (PCP)
IN THE MEDICARE HMO BLUE NETWORK?

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

1. 2. 3.

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

or open the MyBlue app. then click Search.

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

The Easy Way to Find Care  

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

for more than 1,500
common procedures.

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

WE’RE HERE TO HELP

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

A representative is available to help you:

 

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

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

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

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

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

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

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

000914405 H2261_2179_C 50-0239-22 (9/21)

03

Disclosures



NONDISCRIMINATION NOTICE

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

Blue Cross Blue Shield of Massachusetts provides:

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

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

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

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

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

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

Complaint forms are available at hhs.gov.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the
Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and
Blue Shield Association. © 2021 Blue Cross and Blue Shield of Massachusetts, Inc.,
or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
000892700 55-1490A (9/21)



TRANSLATION RESOURCES

Translation Resources

Proficiency of Language Assistance Services

Proficiency of Language Assistance Services

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and Blue Shield of Massachusetts HMO Blue, Inc.

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

OUR COMMITMENT TO CONFIDENTIALITY

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

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

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

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

Use and Disclosure of Information

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

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

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

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

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

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

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

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

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

Special Notes Regarding Disclosure

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

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