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

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Published by it, 2018-10-24 14:55:17

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

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

Keywords: BCBSMA HMO Sales Kit Booklet 11/01/2018

Medicare Advantage Plans

Coverage you need
From a name you can trust

Medicare HMO Blue (HMO) 2019

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

H2261_18222_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 HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

2019 Summary of Benefits

H2261 PLANS 024, 022, 023, 005

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
H2261_1880_M



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

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.

Summary of Benefits

January 1, 2019 - December 31, 2019

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

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what Medicare HMO Blue SaverRx
(HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO Blue FlexRx (HMO-POS) and
Medicare HMO Blue PlusRx (HMO) 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 HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx
(HMO), Medicare HMO Blue FlexRx (HMO-POS) and Medicare HMO Blue PlusRx (HMO)

• 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 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

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 HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), Medicare HMO
Blue FlexRx (HMO-POS) and Medicare HMO Blue PlusRx (HMO), 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 HMO Blue SaverRx (HMO), Medicare HMO Blue ValueRx (HMO), and Medicare HMO Blue
PlusRx (HMO) have a network of doctors, hospitals, pharmacies, and other providers. You must
receive your care from a network provider. In most cases, care you receive from an out-of-network
provider (a provider who is not part of our plan’s network) will not be covered.

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.
2

Medicare HMO Blue FlexRx (HMO-POS) has a network of doctors, hospitals, pharmacies,
and other providers. For some services you can use providers that are not in our network.

As a member of our Medicare HMO plans, you must choose a network Primary Care Physician (PCP).
Your PCP will provide most of your care and will coordinate or help you arrange the rest of the covered
services you get as a member of our plan. In most situations, your network PCP must give you approval
in advance before you can use other providers in the plan’s network, such as specialists, hospitals,
skilled nursing facilities, or home health care agencies. This is called giving you a “referral.” Referrals
from your PCP are not required for emergency care or urgently needed 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/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.

3

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

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 $292 per month $96 per month
Maximum
Out-of-Pocket Worcester County: Worcester County: Worcester County: Worcester County:
Responsibility $0 per month $56 per month $292 per month $106 per month
(does not
include costs You must continue to pay your Medicare Part B premium.
related to
prescription These plans do not have a medical deductible.
drugs)
$320 per year for $320 per year for $200 per year for $260 per year for
Inpatient Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5 Tiers 3, 4, 5
Hospital
Coverage Your yearly limit(s) Your yearly limit(s) Your yearly limit(s) Your yearly limit(s)
in this plan: in this plan: in this plan: in this plan:

• $6,700 for services • $4,900 for services • $3,400 for services • $3,900 for services

you receive from you receive from you receive from you receive from

in-network providers.. in-network providers. in-network providers. in-network providers.

• $9,900 for services

you receive from out-

of-network providers.

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

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

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

• $350 copay per day • $275 copay per day • $150 copay per day In-network:
for days 1 through 5 for days 1 through 5 for days 1 through 5 • $200 copay per day

• You pay nothing • You pay nothing • You pay nothing per for days 1 through 5
per day for days 6 per day for days 6 day for days 6 through • You pay nothing per day
through 90 through 90 90 for days 6 through 90

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

beyond beyond beyond beyond

Per admission benefit. Per admission benefit. Per admission benefit. Out-of-network:
• 20% of the cost per stay

4

Outpatient Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
Hospital SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
Coverage
$280/visit $250/visit $150/visit In-Network:
$200/visit

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

Authorization rules may apply

Doctor’s Office Visits

Primary Care $20 copay $20 copay $15 copay In-network:
Physician: $15 copay

Out-of-network:
$65 copay

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

Out-of-network:
$65 copay

Authorization rules may apply

Referral from your doctor may be required.

Preventive In-network:
Care You pay nothing

You pay nothing You pay nothing You pay nothing Out-of-network:
$65 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
• 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
• Lung cancer screening (low dose computed tomography (LDCT))
• 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.
Authorization rules may apply

*If any other medical condition including polyp or other tissue is found and removed during the procedure this 5
would be considered minimally invasive surgery.

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

Preventive You pay $0 for a You pay $0 for a You pay $0 for a • You pay $0 in-
Care
(continued) supplemental annual supplemental annual supplemental annual network and $65

physical exam. Includes physical exam. Includes physical exam. Includes out-of-network for a

a detailed medical/ a detailed medical/ a detailed medical/ supplemental annual

family history and a family history and a family history and a physical exam.

head to toe assessment head to toe assessment head to toe assessment Includes a detailed

with hands-on with hands-on with hands-on medical/family

examination of all body examination of all body examination of all body history and a head

systems to assess systems to assess systems to assess to toe assessment

overall general health. overall general health. overall general health. with hands-on

examination of

all body systems

to assess overall

general health.

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

Urgently $20-$45 copay per visit $20–$40 copay per visit $15–$35 copay per visit In network:
Needed $15–$35 copay per visit
Services
Out of network:
$65 copay per visit

Diagnostic Services/Labs/Imaging

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

Authorization rules may apply

Diagnostic tests $10 copay per day $10 copay per day $10 copay per day In-network:
and procedures $10 copay per day

Out-of-network:
20% of the cost

Authorization rules may apply

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

Out-of-network:
20% of the cost

Authorization rules may apply

6

Outpatient Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
x-rays: SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)
In-network:
$10 copay per day $10 copay per day $10 copay per day $10 copay per day
Out-of-network:
Authorization rules may apply 20% of the cost

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

Hearing Services $20–$40 copay $15–$35 copay In-network:
$20–$40 copay $15–$35 copay
Routine Exam— $20-$45 copay Not covered
up to one per Out-of-network:
year: $45 copay

Non Routine $20-$45 copay $15–$35 copay In-network:
Exam: $15–$35 copay

Out-of-network:
$65 copay

Hearing Aids: Not covered Our plan pays up to $400 Our plan pays up to $400

every three years for every three years for

hearing aids hearing aids

Dental Services

Limited $45 copay $40 copay $35 copay In-network:
Medicare- $40 copay $35 copay $35 copay
covered dental
services: Out-of-network:
$65 copay or 20%
Routine dental $60 copay
services: In-network:
Single copay $35 copay
for visit that
includes: Out-of-network:
Cleaning (for $45 copay
up to 1 every
six months);
prophylaxis only -
does not include
periodontal
cleaning
Dental x-ray(s)*
(for up to 1 every
six months)
Oral exam (for
up to 1 every six
months)

7

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

Vision Services $20-$40 copay $15-$35 copay In-network:
$15-$35 copay
Medicare- $20-$45 copay Out-of-Network:
Covered Eye $65 copay
Exam: In and Out-of-Network:
$0 copay
Eyewear after $0 copay $0 copay $0 copay
cataract surgery: $20 copay $35 copay In-network:
(for Medicare- $15 copay
covered standard Out-of-Network:
eyewear) Not covered
In-network:
Routine eye $20 copay Our plan pays up to
exam: (up to $150 every two years
1 per year) for eyewear
Out-of-network:
Eyewear: Our plan pays up to Our plan pays up to Our plan pays up to Not covered
(For covered $150 every two years $150 every two years $150 every two years
eyewear, you for eyewear for eyewear for eyewear In-network:
pay any balance • $200 copay per day
in excess of the • $275 copay per day • $150 copay per day
$150 limit.) for days 1 through 5 for days 1 through 5 for days 1 through 5
• You pay nothing
Mental Health Services • You pay nothing • You pay nothing
per day for days 6 per day for days 6 per day for days 6
Inpatient Visit: • $300 copay per day through 90 through 90 through 90
for days 1 through 5 • You pay nothing per
• You pay nothing per • You pay nothing per day for days 91 and
• You pay nothing day for days 91 and day for days 91 and beyond
per day for days 6 beyond beyond Out-of-network:
• 20% of the cost per
through 90 stay

• You pay nothing per In-network:
day for days 91 and $35 copay
Out-of-network:
beyond 20% of the cost
In-network:
Authorization rules may apply. $35 copay
Out-of-network:
Outpatient $40 copay $40 copay $35 copay 20% of the cost
group therapy
visit:

Outpatient $40 copay $40 copay $35 copay
individual
therapy visit:

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

8

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

Skilled Our plan covers up to Our plan covers up to Our plan covers up to Our plan covers up to
Nursing
Facility 100 days in a SNF. 100 days in a SNF. 100 days in a SNF. 100 days in a SNF.
(SNF)
• You pay nothing • You pay nothing • $20 copay per day for In-network:

per day for days 1 per day for days 1 days 1 through 20 • You pay nothing

through 20 through 20 • $100 copay per day for per day for days 1

• $160 copay per day for • $160 copay per day for days 21 through 44 through 20

days 21 through 44 days 21 through 44 • You pay nothing • $140 copay per day for

• You pay nothing • You pay nothing per day for days 45 days 21 through 44

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

through 100 through 100 per day for days 45

through 100

Out-of-network:

• 20% of the cost per
stay

Authorization rules may apply

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

Out-of-network:
20% of the cost

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

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

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

Medicare 20% coinsurance 15% coinsurance 10% coinsurance In and Out-of-network:
Part B Drugs 10% coinsurance
(Including
chemotherapy) Authorization rules may apply

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
diabetes-related nerve diabetes-related nerve diabetes-related nerve diabetes-related nerve
services) damage and/or meet damage and/or meet damage and/or meet damage and/or meet
certain conditions: certain conditions: certain conditions: certain conditions:
$20-$45 copay $20–$40 copay $15–$35 copay
In-network:
$15–$35 copay

Out-of-network:
$65 copay

Referral from your doctor may be required

9

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 You pay nothing In-network:
You pay nothing
Diabetes You pay nothing Out-of-network:
monitoring 20% of the cost
supplies: In-network:
You pay nothing
Diabetes self- You pay nothing You pay nothing You pay nothing Out-of-network:
management 20% of the cost
training: In-network:
You pay nothing
Therapeutic You pay nothing You pay nothing You pay nothing Out-of-network:
shoes or 20% of the cost
inserts: In-network:
10% of the cost
Durable 20% of the cost 20% of the cost 10% 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 10% of the cost
devices: Out-of-network:
20% of the cost
Related medical 20% of the cost 20% of the cost 10% of the cost
supplies: $150 per calendar year

Wellness Programs

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

Weight Loss: $150 per calendar year $150 per calendar year $150 per calendar year $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 HMO Blue SaverRx (HMO)
Medicare HMO Blue ValueRx (HMO)
Medicare HMO Blue FlexRx (HMO-POS)
Medicare HMO Blue PlusRx (HMO)

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

What is the Fitness Benefit?

Enroll in a qualified health club or fitness facility and receive up to $150 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 HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

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

Initial After you pay your yearly deductible, you pay the following until your total yearly drug costs reach
Coverage $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 HMO Blue Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
SaverRx (HMO) ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Preferred Retail Cost Sharing

Drug Tier 30 day 60 day 90 day 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 supply supply supply

Tier 1 $3 $6 $9 $3 $6 $9 $1 $2 $3 $1 $2 $3
(Preferred copay copay copay copay copay copay copay copay copay copay copay copay
Generic)

Tier 2 $11 $22 $33 $7 $14 $21 $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 26% 26% 26% 26% 26% 26% 25% 25% 25% 26% 26% 26%
(Specialty of the of the of the of the of the of the of the of the of the of the of the of the
Tier) cost cost cost cost cost cost cost cost cost cost cost cost

12

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

Standard Retail Cost-Sharing

Drug Tier 30 day 60 day 90 day 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 supply supply supply

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

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

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

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

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

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

Mail Order Cost-Sharing

Drug Tier 30 day 60 day 90 day 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 supply supply supply

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

Tier 2 $11 $22 $22 $7 $14 $14 $5 $10 $10 $5 $10 $10
(Generic) copay copay copay copay copay copay copay copay copay copay copay copay

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

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

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

cost cost cost cost cost cost cost cost cost cost cost cost

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

13

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

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 the
Coverage 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

■ 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).

■ For our HMO-POS plans: Our plan allows you to see providers outside of our network

(non-contracted providers). However, while we will pay for covered services provided by
a non-contracted provider, the provider must agree to treat you. Except in an emergency
or urgent situations, non-contracted providers may deny care. In addition, you will pay
a higher co-pay for services received by non-contracted providers.

Independent Licensees of the Blue Cross and Blue Shield Association. H2261_18167_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/PluoelCsrkois:sUBlWueAShGieAld:ofJMeżaessliacmhuóswetitsszispaonpInodlespkeun,dmenot LżiecseznssekeoorfzthyestBalćuezCbroeszspałnadtnBeluj epSohmieoldcAyssociation
językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

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

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



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.

188127M 55-0604-19 (09/18)

Blue Cross Blue Shield of Massachusetts - H2261
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: 4.5 Stars

Drug Plan Services:
4.5 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).

175265 | 99-0288-18 (HMO) H2261_18239_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 HMO BlueSM (HMO)

How To Find a Doctor

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

In fact, your current physician may already be part of our network. To locate a
participating physician, visit our website at www.bluecrossma.com/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 tool, If you need help finding a doctor, or if you don’t
you can find out more about a particular physician have Internet access, just call us at 1-800-678-2265
or office, such as: (TTY: 711). A representative is available to help you:

• What medical school a physician attended • April 1 through September 30,
8:00 a.m. to 8:00 p.m. ET,
• Whether the office is handicap-accessible Monday through Friday

• Whether weekend or evening office hours • October 1 through March 31,
are available and more 8:00 a.m. to 8:00 p.m. ET,
seven days a week.

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.

187888M 50-0239-19 (08/18)
H2261_18142_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)


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