BCBSMA PDP_SalesKit Book 12/01/2020 Approved By Angela Gagnon 11/25/2020 2:22 PM

Blue MedicareRx (PDP) Plans

BLUE MEDICARERX (PDP) 2021

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.

S2893_2021_C (12/01/20)



Connecticut | Massachusetts Blue MedicareRx (PDP)
Rhode Island | Vermont

Dear Medicare Beneficiary: Choosing the Plan
That’s Best for You
Thank you for your interest in the Blue MedicareRx
prescription drug plan (PDP). It’s important to understand each plan
Blue MedicareRx (PDP) delivers comprehensive before you can determine which one is
drug coverage to Medicare beneficiaries like you. right for you. That’s why we’ve enclosed
the following materials to help you with
We offer two plans to choose from: your decision:

• Blue MedicareRx Value Plus (PDP) • Plan Brochure: Answers questions
• Blue MedicareRx Premier (PDP) about Medicare Part D, and highlights
key features of the Blue MedicareRx
Key Features of Our 2021 Plans: plans

• $1 copayments on Tier 1 generic drugs at network • Summary of Benefits: Gives you
retail pharmacies that offer preferred cost sharing an overview of Blue MedicareRx
for both Value Plus and Premier plans plan options

• $0 annual deductible on generic and preferred • Medicare Star Rating Sheet:
generic drugs for Blue MedicareRx Value Plus Shows you the Medicare program’s
members summary rating of Blue MedicareRx’s
overall plan quality and performance
• $0 annual deductible on all drugs for
Blue MedicareRx Premier members • Top 100 Drug List: Gives you a list
of the 100 most commonly used
• Opportunity to save with lower cost sharing brand-name and generic drugs
at more than 21,000 preferred retail pharmacies we cover

• Prescription mail-order service that saves you • Network Chain Pharmacies:
money and delivers your prescriptions directly Gives you a list of our extensive
to your home. Get a three-month supply of your network of chain pharmacies
eligible drugs and pay as little as one copayment.
continued

P.O. Box 30011 | Pittsburgh, PA 15222-0330 | rxmedicareplans.com S2893_2023_M
Independent licensees of the Blue Cross and Blue Shield Association.

Learn More Today!

Visit RxMedicarePlans.com, or call us today and let our team of experts guide you.

Connecticut Residents: Massachusetts Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
Rhode Island Residents:
1-800-505-2583 (TTY: 711) Vermont Residents:
10/1-3/31, 8:00 a.m. to 8:00 p.m., 7 days a week 1-888-496-4178 (TTY: 711)
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday 24 hours a day, 7 days a week
You can use our automated answering service outside
of these hours.

Questions About How Medicare Works?

Call Medicare at 1-800-633-4227 (TTY: 1-877-486-2048), 24 hours a day, 7 days a week
or visit medicare.gov.
We look forward to providing you with convenient, high-quality prescription drug coverage.
If you have any questions, don’t hesitate to call us.

Sincerely,

Blue MedicareRx (PDP)

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 (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield

of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

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

Star Ratings are calculated each year and may change from one year to the next.
Star Ratings can be found at medicare.gov.

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross

and Blue Shield Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners.

© 2020 All Rights Reserved.

000407274 PL-21 99-0652-21 (9/20)

IN THIS BOOKLET

01 Plan Information
• Sales Brochure
• Summary of Benefits
• Pre-Enrollment Checklist
• Plan Rating Sheet

02 Resources
• Seminar Information
• Top Covered Drugs
• Network Chain Pharmacy List

03 Disclosures
• Nondiscrimination Notice
and Translation Resources Notice
• Privacy Notice

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont Prescription Drug Plan (PDP)

2021 PRESCRIPTION DRUG
PLAN INFORMATION

TOP-RATED AND AFFORDABLE COVERAGE TO FIT YOUR NEEDS

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_2024_M

Thank you for your interest in our
2021 Prescription Drug Plans.

CONTENTS

Two Plans to Choose From . . . . . . 1
90-Day Supply for as Low as $1 . . . . 1
Why Choose Blue MedicareRx? . . . . 2
Pharmacy Network . . . . . . . . . . . 5
2021 Blue MedicareRx Plan
Comparison Chart . . . . . . . . . . . 7
Formulary Coverage . . . . . . . . . . 9
What Is Medicare Part D? . . . . . . 10
Frequently Asked Questions . . . . . 11

TWO PLANS TO CHOOSE FROM

Our Blue MedicareRx Value Plus (PDP), and Blue MedicareRx Premier (PDP)
plans include the following features:

Blue MedicareRx Value Plus Blue MedicareRx Premier

$0 $0

ANNUAL DEDUCTIBLE ANNUAL DEDUCTIBLE

on Tier 1 preferred generic drugs on all covered drugs
and Tier 2 generic drugs
– Also –
– Also –
Additional plan coverage of Tier 1 preferred
Cost savings through preferred cost sharing generic drugs and Tier 2 generic drugs
at participating network retail pharmacies in the Coverage Gap

Cost savings through preferred cost sharing
at participating network retail pharmacies

Get a 90-Day Supply for as Low as $1

When you order a Tier 1 preferred generic prescription medication through our mail order
pharmacy, you’ll pay the same amount for a 90-day supply as you would for a 30-day supply
purchased from a preferred cost-sharing retail pharmacy. See below:

Preferred Generic Prescription Drug Blue MedicareRx Value Plus Blue MedicareRx Premier
Plan Copayment for a 90-day supply
$1 $1

1 Blue MedicareRx Prescription Drug Plan

WHY CHOOSE Blue MedicareRx?

Our Blue MedicareRx plans are standalone prescription drug plans that give you
the flexibility, service, and support that you need in a Medicare Part D plan.
They’re offered to residents of Connecticut, Massachusetts, Rhode Island,
and Vermont who qualify for Medicare.

 Great service and support

Through Blue MedicareRx, your prescription drug coverage is backed by the Blue Cross
and Blue Shield Association and a long-standing history of offering you high-quality service
and support. Our representatives are available to answer your questions and offer suggestions,
so whether you’re new to Medicare Part D or switching plans, we make it easy for you to get
the coverage that’s right for you. Just call us at one of the numbers below.

Contact Us:

Connecticut Residents: Massachusetts Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;

4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.; 24 hours a day, 7 days a week

4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.

You can use our automated answering system outside

of these hours.

Online: rxmedicareplans.com

 More pharmacies to choose from nationwide

With more than 65,000+ pharmacies in our network—including national chains and independent
pharmacies—you’ll have the freedom to travel anywhere in the United States with the confidence
that you can use your coverage when and where you need it. Check page 5 for more details on
our pharmacy network.

You’ll have the security of knowing that the Blue Cross and Blue Shield Association has been
providing peace of mind to nearly seven million Medicare members like you nationwide.

rxmedicareplans.com 2

Example:
Blue MedicareRx Value Plus

Paul is healthy and only takes
medications on occasion.
He wants more for less:

• Lower monthly premium
• $0 deductible on Tier 1 and Tier 2,

which contain some of the most
commonly used generic drugs

 Paul’s Choice:
Blue MedicareRx Value Plus

 65,000+
PHARMACIES
IN OUR NETWORK

Plans That Fit Your Needs

We offer you a choice of two Blue MedicareRx plans with different premiums, coverage levels,
and out-of-pocket costs: Blue MedicareRx Value Plus and Blue MedicareRx Premier. Our Blue
MedicareRx plans offer great service, access to more than 65,000+ network pharmacies
nationwide, and mail order savings.

Blue MedicareRx Value Plus Blue MedicareRx Premier

Large Network of Retail Pharmacies
Network Retail Pharmacies with
Preferred Cost Sharing
Mail Order Service
Includes most Medicare Part D-
eligible generic drugs
Some of the most commonly used
generics are available at the lowest
copayment (Tier 1)
Additional Plan Coverage for
Tier 1 preferred generic drugs
and Tier 2 generic drugs in the
Coverage Gap

rxmedicareplans.com 4

PHARMACY NETWORK

What pharmacies can I use?

You must use a network pharmacy to access your prescription drug benefits, except under
non-routine circumstances (e.g., a medical emergency or urgent care, or when a network
pharmacy is unavailable). Quantity limitations and restrictions may apply.

What is preferred cost sharing for the Blue MedicareRx plans?

More than 21,000+ of the total 65,000+ pharmacies in our network offer preferred cost sharing
for both of the Blue MedicareRx plans. You pay lower copays at these pharmacies than at
network pharmacies that offer standard cost sharing.

Which pharmacies offer preferred cost sharing?1

Enjoy cost savings in the form of lower copays at network retail preferred cost-sharing
pharmacies, which include:

Types of network pharmacies

• Retail pharmacies • Home-infusion pharmacies
• Mail order pharmacies • Indian Health/Tribal pharmacies
• Long-term care pharmacies

Visit our website RxMedicarePlans.com to locate a pharmacy in our network.

1. Other pharmacies are available in our network.

5 Blue MedicareRx Prescription Drug Plan

Example:
Blue MedicareRx Premier

Martha takes several expensive
drugs and reaches the coverage gap.

She wants the most coverage:

• A plan with no annual deductible
• More extensive coverage of her

generic medications even after
she’s reached the coverage gap

 Martha’s Choice:
Blue MedicareRx Premier

rxmedicareplans.com 6

2021 Blue MedicareRx PLAN COMPARISON CHART

Monthly Premium2 Blue MedicareRx Value Plus Network Retail Pharmacy
Annual Deductible with Standard Cost Sharing
$50.50 30-Day Supply Retail
Initial Coverage Tier 1: $6
A copayment or co-insurance $0 (Tier 1 and Tier 2) Tier 2: $20
for covered prescription drugs, $445 (Tier 3, Tier 4, and Tier 5) Tier 3: $47
until the annual cost of prescription Tier 4: 50%
drug expenses you pay and we pay Network Retail Pharmacy Tier 5: 25%
reaches $4,130. Any deductible, with Preferred Cost Sharing
copayments, or co-insurance you 30-Day Supply Retail
pay counts toward the $4,130. Tier 1: $1
Tier 2: $6
Coverage Gap Tier 3: $36
The cost for covered prescription Tier 4: 40%
drug expenses between $4,130 in Tier 5: 25%
drug costs and $6,550 in annual
out-of-pocket costs. 90-Day Supply Mail Order
Tier 1: $1
Tier 2: $12
Tier 3: $72
Tier 4: 40%
Tier 5: N/A3

For covered generics, you pay
25% of the costs.
For covered brand-names, you pay
25% of the negotiated price
(excluding the dispensing fee).

Catastrophic Coverage For covered generics (including drugs treated as generics), you pay
The cost for covered prescription $3.70 or 5%, whichever is greater.
drugs after you and others on your
behalf have paid $6,550 in annual For all other covered drugs, you pay $9.20 or 5%, whichever is greater.
out-of-pocket costs. You pay a flat-
dollar amount, or 5%, whichever
is greater.

2. You must continue to pay your Medicare Part B premium.

3. Specialty Tier drugs aren’t available at an extended
day supply.

7 Blue MedicareRx Prescription Drug Plan

Blue MedicareRx Premier
$135.00
$0

Network Retail Pharmacy with Network Retail Pharmacy with
Preferred Cost Sharing Standard Cost Sharing
30-Day Supply Retail 30-Day Supply Retail
Tier 1: $1 Tier 1: $6
Tier 2: $12
Tier 2: $7 Tier 3: $40
Tier 4: 45%
Tier 3: $30 Tier 5: 33%

Tier 4: 35%

Tier 5: 33%

90-Day Supply Mail Order
Tier 1: $1
Tier 2: $14
Tier 3: $60
Tier 4: 35%
Tier 5: N/A3

For covered generics, on Tier 1 and Tier 2 you pay:

30-Day Supply Retail with Preferred 30-Day Supply Retail with Standard 90-Day Supply Mail Order
Cost Sharing Cost Sharing Tier 1: $1
Tier 2: $14
Tier 1: $1 Tier 1: $6

Tier 2: $7 Tier 2: $12

For covered generics on other tiers, you pay 25% of the costs.
For covered brands, you pay 25% of the negotiated price (excluding the dispensing fee).

For covered generics (including drugs treated as generics), you pay $3.70 or 5%, whichever is greater.
For all other covered drugs, you pay $9.20 or 5%, whichever is greater.

rxmedicareplans.com 8

FORMULARY COVERAGE

We offer coverage for a comprehensive number of generic and brand-name
drugs. The chart below outlines the formulary tiering structure for the
Blue MedicareRx plans.

2021 Drug Tier Label Blue MedicareRx Blue MedicareRx
Tier 1: Preferred Generic Value Plus covers: Premier covers:
Tier 2: Generic
Tier 3: Preferred Brand Certain generic drugs available at the lowest copayment.

Tier 4: Non-preferred Drug Higher cost generic drugs available at a higher copayment than
Tier 1 generic drugs.

Many common brand-name drugs and some higher cost generic drugs,
many of which may have lower cost options available on Tier 1 or Tier 2.

Higher cost generic and non-preferred drugs, many of which may
have lower cost options available on Tier 1, Tier 2, and Tier 3.

Tier 5: Specialty Tier Unique and/or very high-cost brand and some generic drugs for which you
pay a percentage of the total drug cost, which may require special handling
and/or close monitoring.

Remember: In general, many drugs in the higher tiers have lower-cost options available in the lower tiers.
Ask your doctor if they could work for you.

Convenient mail order service: You can get prescription drugs shipped to your home through our network mail order
delivery program. For refills of your mail order prescriptions, you have the option to sign up for an automatic refill
program. Typically, you should expect to receive your prescription drugs within 10 calendar days from the time
that the mail order pharmacy receives the order.

You’ll pay the same amount for a 90-day supply of a Tier 1 prescription drug ordered through mail order as you
would pay for a 30-day supply purchased from a retail preferred cost sharing pharmacy.

9 Blue MedicareRx Prescription Drug Plan

WHAT IS MEDICARE PART D?

Medicare Part D is prescription drug coverage that is available to you
if you’re eligible for Medicare. This prescription drug benefit is administered
by private insurance companies, like Blue Cross and Blue Shield, that
contract with the Centers for Medicare and Medicaid Services (CMS).

How Part D works:

(Information provided below is specific to 2021)

In addition to the monthly premium, Medicare Part D plans have four different stages:
Annual Deductible (if applicable), Initial Coverage, Coverage Gap, and Catastrophic Coverage.

Here's how they work:

Annual Deductible The Blue MedicareRx Value Plus plan has an annual deductible only on Tiers 3, 4, and 5.
(if applicable) The Blue MedicareRx Premier plan has no annual deductible.
Refer to the Plan Comparison Chart on pages 7-8 for more details.

Initial Coverage There is a $4,130 initial coverage limit. This includes your copayments, co-insurance,
and payments made by the plan for covered prescriptions.

Coverage Gap There is a coverage gap that starts once total drug costs (member and plan payments)
Catastrophic reach $4,130 and ends when your out-of-pocket prescription drug costs reach $6,550.
Coverage
When you're in the Coverage Gap stage, you pay 25% of the costs of generic drugs.
For brand-name drugs, you pay 25% of the negotiated price (excluding the dispensing
fee). You continue paying 25% for generic drugs and 25% of the negotiated price
(excluding the dispensing fee) for brand-name drugs until yearly out-of-pocket costs
paid by you and others on your behalf reach $6,550. The payments made on your behalf
(excludes payments made by Blue MedicareRx) count toward your out-of-pocket costs.

Refer to the Plan Comparison Chart on pages 7-8 for your costs in the Coverage Gap for
each of the Blue MedicareRx plans.

Takes effect after you and others on your behalf have paid $6,550 in annual
out-of-pocket prescription costs.

Am I eligible?

You’re eligible for Medicare prescription drug coverage and Blue MedicareRx membership if:

• You have Medicare Part A or Medicare Part B (or you have both Part A and Part B)

» and—you’re a United States citizen or are lawfully present in the United States
» and—you live in our geographic service area

rxmedicareplans.com 10

FREQUENTLY ASKED QUESTIONS

Enrolling in a Blue MedicareRx Plan

Q: How can I enroll?

A: You can enroll by:
• Filling out and mailing a paper application.
• Filling out a secure online application on our website at rxmedicareplans.com.
• Complete an application by phone:

Contact Us:

Connecticut Residents: 1-866-832-9702 (TTY: 711) Massachusetts Residents: 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;

4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)

10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.; 24 hours a day, 7 days a week

4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.

You can use our answering system outside of these hours.

Online: rxmedicareplans.com

Calling 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day, 7 days a
week. Visiting the CMS Medicare Online Enrollment Center located at medicare.gov.

Q: When can I enroll?

A: You can enroll in a Blue MedicareRx plan only during specific times of the year unless
you’re newly 65.

Q: Is financial assistance available?

A: If you need financial assistance covering your Prescription Drug Plan costs, you may be
eligible to receive Extra Help, including reduced premiums, deductibles, copayments, and
co-insurance. If you qualify for Extra Help, Medicare will tell us how much assistance you’ll
receive when you enroll in our plan, and we’ll inform you of the amount you’ll be responsible
for paying. To see if you qualify for Extra Help, call:
• 1-800-MEDICARE (1-800-633-4227), TTY: 1-877-486-2048, 24 hours a day, 7 days a week.
• The Social Security Administration at 1-800-772-1213, TTY: 1-800-325-0778
between 7:00 a.m. and 7:00 p.m. ET, Monday through Friday.
• Your state Medicaid office.

Q: What is the late enrollment penalty?

A: If you choose not to enroll in a Medicare Prescription Drug Plan during your initial enrollment
period or had a continuous period of 63 days or more without “creditable” prescription drug
coverage, (“Creditable” means the drug coverage is expected to pay, on average, at least
as much as Medicare’s standard prescription drug coverage) you may be subject to a late
enrollment penalty when you do enroll. The penalty is 1% of the national average monthly
premium for each month you were eligible, but weren’t enrolled. The penalty will be added
to your premium for as long as you’re enrolled in a Medicare Prescription Drug Plan.

11 Blue MedicareRx Prescription Drug Plan

Drug Coverage

Q: What if I already have drug coverage?

A: Eligible individuals may only enroll in one Medicare Prescription Drug Plan at a time.
If you already have a Medicare Advantage plan or other insurance that includes Part D
coverage, enrolling in this plan will automatically disenroll you from your current plan.
If you get your health care benefits from TRICARE®´ or the U.S. Department of Veterans
Affairs, joining a Medicare Prescription Drug Plan might not be a cost-effective option,
unless you qualify for Extra Help. If you get your coverage through your employer or union,
contact your benefits administrator to compare your options.

Q: What drugs are covered?

A: For a full list of covered drugs, visit rxmedicareplans.com, or call us at the number on the
back page. We must give you at least 30 days’ advance notice of the change or give you
notice of the change and a 30-day refill of the drug you are taking at a network pharmacy.

Q: What if I’m currently taking a drug that isn't on the drug list?

A: You should first contact us and confirm that your drug isn't covered. You can ask us for a
list of similar drugs that are covered by our plan. You can also ask us to make an exception
to cover your drug. We encourage you to talk to your doctor to determine the course of
action that best suits your needs. We may cover your drug in certain cases during the first
90 days that you're a new member of our plan. Visit rxmedicareplans.com, or call us at the
number on the back page for details about how to request a prescription drug exception
and to find out about our transition supply policy.

Common Terms Special Enrollment Period

Initial Enrollment Period A Special Enrollment Period is available in certain
The Initial Enrollment Period is the period when you situations, such as:
first become Medicare eligible because:
• Permanently moving into our plan’s service area,
• You turn 65 (beginning 3 months before your losing employer group prescription drug coverage,
birthday and extending to 3 months after your qualifying for Extra Help, or if you become eligible
birthday). for both Medicare and Medicaid. If you think you
may be eligible for a Special Enrollment Period,
• You qualify due to disability or End-Stage Renal contact your current plan, or call us at the number
Disease (3 months before to 3 months after your on the back page.
25th month of disability).
• Medicare Advantage enrollees may disenroll from
Annual Election Period their plan and return to Original Medicare between
The Annual Election Period occurs from October 15 January 1 and March 31. If you’re a Medicare
through December 7 each year. During this time, you Advantage enrollee and you decide to leave the
may enroll in or change Medicare prescription drug plan to return to Original Medicare during this
plans. Coverage will be effective January 1 period, you may join a standalone prescription
of the following year. drug plan like Blue MedicareRx.

rxmedicareplans.com 12

FOR QUESTIONS, OR TO ENROLL:

Connecticut Residents:
1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week

Massachusetts Residents:
1-800-678-2265 (TTY: 711)
10/1–3/31, 8:00 a.m. to 8:00 p.m., 7 days a week;
4/1–9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents:
1-800-505-2583 (TTY: 711) Monday through Friday, 8:00 a.m. to 8:00 p.m.

(Open 7 days a week, 8:00 a.m. to 8:00 p.m. from
October 1 – March 31.) You can use our automated answering

system outside of these hours.

Vermont Residents:
1-888-496-4178 (TTY: 711) 24 hours a day, 7 days a week

VISIT RXMEDICAREPLANS.COM

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP)
and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents
of Connecticut, Massachusetts, Rhode Island, and Vermont. Coverage is available to residents of the
service area or members of an employer or union group and separately issued by one of the following plans:
Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield of Massachusetts,
Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.
This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711

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 (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.
Blue MedicareRx 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.

Connecticut | Massachusetts
Rhode Island | Vermont

Independent Licensees of the Blue Cross and Blue Shield Association.
® Registered Marks of the Blue Cross and Blue Shield Association. © 2020 All Rights Reserved.
®´, SM, TM Registered Marks, Service Marks, and Trademarks are property of their respective owners.

000407325 BRC-21 55-0597-21 (9/20)

Pre-Enrollment Checklist

Before making an enrollment decision, it’s important that you fully understand
our benefits and rules. If you have any questions, you can call and speak to a
customer service representative at the phone numbers listed below.

Contact Us:

Connecticut Residents: 1-866-832-9702 (TTY: 711) Massachusetts Residents: 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 4/1-9/30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday.
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week.

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)
4/1-9-30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday. 24 hours a day, 7 days a week
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, 7 days a week.

You can use our automated answering system
outside of these hours

Online: rxmedicareplans.com.

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 rxmedicareplans.com or call Customer Service to receive
a copy of the EOC.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicine
is in the network. If the pharmacy isn’t listed, you’ll likely have to select a new pharmacy
for your prescriptions.

Understanding Important Rules

Benefits, premiums, and/or copayments/co-insurance may change on January 1, 2022.

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_2026_C

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 that have

contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are
the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved

Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711

®Registered Marks of the Blue Cross and Blue Shield Association.
®´, SM, TM Registered Marks and Trademarks are property of their respective owners. © 2020 All Rights Reserved.

000407577 PEC-21 55-2048-21 (9/20)

Blue MedicareRx (PDP)

2021 SUMMARY OF BENEFITS i

Blue MedicareRx Value Plus (PDP)
Blue MedicareRx Premier (PDP)

Independent licensees of the Blue Cross and Blue Shield Association.
S2893_2025_M



Blue MedicareRx Value Plus (PDP)
Blue MedicareRx Premier (PDP)

(a Medicare Prescription Drug Plan (PDP)

offered by ANTHEM INSURANCE CO. & Blue Cross
and Blue Shield of Massachusetts, Blue Cross
& Blue Shield of Rhode Island, and Blue Cross

and Blue Shield of Vermont with a Medicare contract)

SUMMARY OF BENEFITS

January 1, 2021 – December 31, 2021

This booklet summarizes what we cover and what you pay. It doesn’t list every service that we
cover or list every limitation or exclusion. For a complete list of services we cover, call us and ask
for the “Evidence of Coverage.”

Contact Us:

Connecticut Residents: Massachusetts Residents:
1-866-832-9702 (TTY: 711) 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 10/1-3/31, 8:00 a.m. to 8:00 p.m.,
seven days a week

4/1-9/30, 8:00 a.m. to 8:00 p.m.,
Monday through Friday

Rhode Island Residents: Vermont Residents:
1-800-505-2583 (TTY: 711) 1-888-496-4178 (TTY: 711)
10/1-3/31, seven days a week, 8:00 a.m. to 8:00 p.m.; 24 hours a day, seven days a week

4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Online: rxmedicareplans.com

For More Information

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 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.

This document is available in other
formats such as Braille and large print.

1 2021 Summary of Benefits

SUMMARY OF BENEFITS: INTRODUCTION

Who can join?

To join Blue MedicareRx Value Plus or Blue MedicareRx Premier, you must be entitled
to Medicare Part A, and/or be enrolled in Medicare Part B, be a U.S. citizen or be lawfully
present in the United States, and live in our service area.
Our service area includes the following: Central New England
(Connecticut, Massachusetts, Rhode Island, and Vermont).

Which drugs are covered?

You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website
(rxmedicareplans.com). Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs? Which pharmacies can I use?

Our plans group each medication into one of five We have a network of pharmacies and you
tiers. You’ll need to use your formulary to locate must generally use these pharmacies to fill your
what tier your drug is on to determine how much prescriptions for covered Part D drugs.
it will cost you. The amount you pay depends on
the drug’s tier and what stage of the benefit you Some of our network pharmacies have preferred
have reached. There are four benefit stages in your cost sharing. You may pay less if you use these
Medicare prescription drug coverage: Deductible pharmacies.
Stage, Initial Coverage Stage, Coverage Gap
Stage, and Catastrophic Coverage Stage. For more You can see our plans’ pharmacy directories at our
information about formulary tiers and stages website (rxmedicareplans.com), or call us and we’ll
of the benefit, please see the plan’s formulary send you a copy of the pharmacy directory.
and the Evidence of Coverage on our website at
rxmedicareplans.com, or contact Customer Care.

rxmedicareplans.com 2

SUMMARY OF BENEFITS:

Stage 1: Annual Deductible

How much is the Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)
monthly premium? $50.50 per month $135.00 per month
How much is the
deductible? $445.00 per year for Part D This plan doesn’t have a deductible.
prescription drugs except for drugs
listed on Tier 1 and Tier 2, which are
excluded from the deductible.

SUMMARY OF BENEFITS:

Stage 2: Initial Coverage Stage

Initial Coverage Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

After you pay your yearly deductible, You pay the following until your total
you pay the following until your total yearly drug costs reach $4,130.
yearly drug costs reach $4,130. Total yearly drug costs are the total
Total yearly drug costs are the total drug costs paid by you and our
drug costs paid by you and our Part D plan.
Part D plan.
You may get your drugs at network
You may get your drugs at network retail pharmacies and mail order
retail pharmacies and mail order pharmacies.
pharmacies.
If you reside in a long-term care
If you reside in a long-term care facility, you pay the same as at a
facility, you pay the same as at a standard retail pharmacy.
standard retail pharmacy.
You may get drugs from an out-of-
You may get drugs from an out-of- network pharmacy, but may pay
network pharmacy, but may pay more than you pay at an in-network
more than you pay at an in-network pharmacy.
pharmacy.

3 2021 Summary of Benefits

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Preferred Retail Cost Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
$3 copay $1 copay $3 copay
Tier 1 (Preferred Generic) $1 copay $18 copay $7 copay $21 copay
$108 copay $30 copay $90 copay
Tier 2 (Generic) $6 copay 40% of the cost 35% of the cost 35% of the cost
N/A 33% of the cost N/A
Tier 3 (Preferred Brand) $36 copay
Three-month
Tier 4 (Non-Preferred Drug) 40% of the cost supply
$18 copay
Tier 5 (Specialty Tier) 25% of the cost $60 copay
$141 copay
Standard Retail Cost Sharing 50% of the cost
N/A
Tier One-month One-month Three-month
supply Three-month supply supply
supply $6 copay $18 copay
Tier 1 (Preferred Generic) $6 copay $1 copay $12 copay $36 copay
$12 copay $40 copay $120 copay
Tier 2 (Generic) $20 copay $72 copay 45% of the cost 45% of the cost
40% of the cost 33% of the cost N/A
Tier 3 (Preferred Brand) $47 copay N/A

Tier 4 (Non-Preferred Drug) 50% of the cost

Tier 5 (Specialty Tier) 25% of the cost

Mail Order Cost Sharing

Tier One-month One-month Three-month
supply supply supply
$1 copay $1 copay
Tier 1 (Preferred Generic) $1 copay $7 copay $14 copay
$30 copay $60 copay
Tier 2 (Generic) $6 copay 35% of the cost 35% of the cost
33% of the cost N/A
Tier 3 (Preferred Brand) $36 copay

Tier 4 (Non-Preferred Drug) 40% of the cost

Tier 5 (Specialty Tier) 25% of the cost

rxmedicareplans.com 4

SUMMARY OF BENEFITS: STAGE 3:

Coverage Gap Stage

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Coverage Gap Most Medicare drug plans have Most Medicare drug plans have
a coverage gap (also called the a coverage gap (also called the
“donut hole”). This means that there’s “donut hole”). This means that there’s
a temporary change in what you’ll a temporary change in what you’ll
pay for your drugs. The coverage gap pay for your drugs. The coverage gap
begins after the total yearly drug cost begins after the total yearly drug cost
(including what our plan has paid and (including what our plan has paid and
what you have paid) reaches $4,130. what you have paid) reaches $4,130.

After you enter the coverage gap, you After you enter the coverage gap, you
pay 25% of the plan’s cost for covered pay 25% of the plan’s cost for covered
brand-name drugs and 25% of the brand-name drugs and 25% of the
plan’s cost for covered generic drugs plan’s cost for covered generic drugs
until your costs total $6,550.00, which until your costs total $6,550.00, which
is the end of the coverage gap. Not is the end of the coverage gap. Not
everyone will enter the coverage gap. everyone will enter the coverage gap.

Under this plan, you may pay even
less for the brand and generic drugs
on the formulary. Your cost varies by
tier. You’ll need to use your formulary
to locate your drug’s tier. See the chart
that follows to find out how much it
will cost you.

5 2021 Summary of Benefits

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Preferred Retail Cost Sharing

Tier One-month Three-month One-month Three-month
supply supply supply supply
$3 copay
Tier 1 After you enter the coverage gap, you $1 copay $21 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $7 copay
Tier 2 (Generic) brand-name drugs and 25% of the Three-month
plan’s cost for covered generic drugs supply
until your costs total $6,550, which $18 copay
is the end of the coverage gap. Not $36 copay
everyone will enter the coverage gap.
Three-month
Standard Retail Cost Sharing supply
$1 copay
Tier One-month Three-month One-month $14 copay
supply supply supply

Tier 1 After you enter the coverage gap, you $6 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $12 copay
Tier 2 (Generic) brand-name drugs and 25% of the
plan’s cost for covered generic drugs
until your costs total $6,550, which
is the end of the coverage gap. Not
everyone will enter the coverage gap.

Mail Order Cost Sharing

Tier One-month Three-month One-month
supply supply supply

Tier 1 After you enter the coverage gap, you $1 copay
(Preferred Generic) pay 25% of the plan’s cost for covered $7 copay
Tier 2 (Generic) brand-name drugs and 25% of the
plan’s cost for covered generic drugs
until your costs total $6,550, which
is the end of the coverage gap. Not
everyone will enter the coverage gap.

rxmedicareplans.com 6

SUMMARY OF BENEFITS: STAGE 4:

Catastrophic Coverage Stage

Blue MedicareRx Value Plus (PDP) Blue MedicareRx Premier (PDP)

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased
through your retail pharmacy and through mail order) reach $6,550.00,
you pay the greater of:

• 5% of the cost,

• or a $3.70 copay for generic drugs (including brand drugs treated as generic)
and a $9.20 copay for all other drugs.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP)
and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents
of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and
separately issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut,
Blue Cross Blue Shield of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross
and Blue Shield of Vermont.

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 (PDP) plans. The joint enterprise is a Medicare-approved
Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917; Rhode Island:
1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

7 2021 Summary of Benefits

If you believe that Blue MedicareRx 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:

Blue MedicareRx (PDP) You can file a grievance in person, by mail,
or fax. If you need help filing a grievance,
Grievance Department Coordinator Blue MedicareRx Grievance Department
P.O. Box 30016 is available to help you.
Pittsburgh, PA 15222-0330
Phone: 1-866-884-9478
Fax: 1-866-217-3353

You can also file a civil rights complaint with the U.S. Department of Health
and Human Services, Office for Civil Rights, electronically through the Office
for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/
lobby.jsf, or by mail or phone at:

U.S. Department of Health Complaint forms are available at
and Human Services hhs.gov/ocr/office/file/index.html.

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, TTY: 1-800-537-7697

rxmedicareplans.com 8

Connecticut Residents: 1-866-832-9702 (TTY: 711) 24 hours a day, 7 days a week

Massachusetts Residents: 1-800-678-2265 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., seven days a week
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday

Rhode Island Residents: 1-800-505-2583 (TTY: 711)
10/1-3/31, 8:00 a.m. to 8:00 p.m., seven days a week,
4/1-9/30, 8:00 a.m. to 8:00 p.m., Monday through Friday
You can use our automated answering system outside of these hours.

Vermont Residents: 1-888-496-4178 (TTY: 711) 24 hours a day, 7 days a week

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP)
and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents
of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield

of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

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 (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

® Independent Licensees of Blue Cross and Blue Shield Association. Registered Marks of the Blue Cross and Blue Shield
Association. ®´, SM, TM Registered Marks and Trademarks are property of their respective owners.

000407376 99-0653-21 SB-21 (9/20)

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2. Summary Star Ratings that focus on our medical or our prescription drug services.
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HHHoowowwwwweelelllolouoururrpdlpaolncatnhoehrlsepldspesotueorcutrmimlelnmeembsseberesrsaunsuedserkereceeocpmommmememnedbneddresdahnaednadlstahsfyae;feprpersecsrcipritpiotinonmmedeidciactaiotinosn.s.

How well our plan helps our members use recommended and safe prescription medications.
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For 2021, Blue MedicareRx received the following Overall Star Rating fromMedicare.
4.45.5SStatrasrs

WWeererceecievievdedthtehefoflolollwowinigngSSumummmarayrySStatrarRRataintignsgsfofrorBBluleueMMedeidciacraerRe4Rx.5'xs'Sshtehaaerlsathlt/hd/rdurgugplpalnansesrevrivciecse:s:

HWHeeaelartheltchPePliavlneadnSSethreevrivcfoieclsleo:sw: ing Summary Star Ratings for Blue MedicareRNNxo'stoothfeofaefflretehrd/eddrug plan services:

Health Plan Services: Not offered
DDrurgugPPlalnanSSerevrivciecse:s: 4.45.5SStatrasrs
TDThrehuegnunPmulambnebrSeroerfovsfitcsaetrassr:sshsohwows shohwowwwelelloluorurplpalnanpeprefrofromrms.s.
4.5 Stars

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LLeaeranrnmmoroereabaobuotuot uorurplpalnananadndh1ohwsotwawrwe- eparoaeoredridffieffreernetnftrformomotohtehrerplpalnasnsatawt wwwww.m.medeidciacraer.eg.ogvo.v.

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

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 (PDP) plans. The joint enterprise is a
Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-543-4917 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-888-543-4917 (TTY: 711).

SS22889933__22002277__MM 000407628 (10/20) 11/1/1

S2893_2027_M 1/1



02

Resources



Medicare Plan Options

JOIN US TO LEARN MORE ABOUT MEDICARE COVERAGE

When Medicare seems overwhelming or confusing, we’re here to make it easier to understand.
Register for one of our informational online webinars to find out how Medicare works, get answers
to your questions, and learn about our extensive plan options, including Medicare Advantage
plans (HMO & PPO), Medicare Supplement plans (Medigap), and Prescription Drug Plans (PDP).

Visit bluecrossma.com/seminar to:

 

Register for a live Register for a live Watch a
online webinar online Q&A session pre-recorded seminar
with a Medicare expert

Live Webinar Topics: Date Time
Medicare Advantage (HMO & PPO) 1/5/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex®' (Medicare Supplement) 1/6/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 1/6/2021 11:30 a.m. - 12:15 p.m.
Dental Blue® 65 1/7/2021 2:00 p.m. - 2:30 p.m.
GeoBlue Travel Insurance 1/7/2021 3:00 p.m. - 3:30 p.m.
Medicare Advantage (HMO & PPO) 1/8/2021 10:00 a.m. - 11:00 a.m.
Medicare Advantage (HMO & PPO) 1/11/2021 2:00 p.m. - 3:00 p.m.
Original Medicare & Medex (Medicare Supplement) 1/12/2021 2:00 p.m. - 2:45 p.m.
Prescription Drug Plans (PDP) 1/12/2021 3:30 p.m. - 4:15 p.m.
Medicare Advantage (HMO & PPO) 1/13/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 1/14/2021 5:00 p.m. - 5:45 p.m.
Medicare Advantage (HMO & PPO) 1/15/2021 9:00 a.m. - 10:00 a.m.
Dental Blue 65 1/19/2021 4:30 p.m. - 5:00 p.m.
GeoBlue Travel Insurance 1/19/2021 5:30 p.m. - 6:00 p.m.

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

Live Webinar Topics: Date Time
Original Medicare & Medex (Medicare Supplement) 1/21/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 1/21/2021 6:30 p.m. - 7:15 p.m.
Medicare Advantage (HMO & PPO) 1/22/2021 12:00 p.m. - 1:00 p.m.
Original Medicare & Medex (Medicare Supplement) 1/25/2021 1:00 p.m. - 1:45 p.m.
Prescription Drug Plans (PDP) 1/25/2021 2:30 p.m. - 3:15 p.m.
Medicare Advantage (HMO & PPO) 1/26/2021 5:00 p.m. - 6:00 p.m.
Prescription Drug Plans (PDP) 1/27/2021 5:00 p.m. - 5:45 p.m.
Medicare Advantage (HMO & PPO) 1/28/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 1/29/2021 12:00 p.m. - 12:45 p.m.
Prescription Drug Plans (PDP) 1/29/2021 2:00 p.m. - 2:30 p.m.
Medicare Advantage (HMO & PPO) 2/1/2021 5:00 p.m. - 6:00 p.m.
Medicare Advantage (HMO & PPO) in SPANISH 2/2/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 2/3/2021 1:00 p.m. - 1:45 p.m.
Prescription Drug Plans (PDP) 2/3/2021 2:30 p.m. - 3:15 p.m.
Dental Blue 65 2/4/2021 11:00 a.m. - 11:30 a.m.
GeoBlue Travel Insurance 2/4/2021 12:00 p.m. - 12:30 p.m.
Original Medicare & Medex (Medicare Supplement) 2/5/2021 10:30 a.m. - 11:15 a.m.
Prescription Drug Plans (PDP) 2/5/2021 12:00 p.m. - 12:45 p.m.
Medicare Advantage (HMO & PPO) 2/8/2021 9:30 a.m. - 10:30 a.m.
Original Medicare & Medex (Medicare Supplement) 2/9/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 2/9/2021 6:30 p.m. - 7:15 p.m.
Medicare Advantage (HMO & PPO) 2/10/2021 2:00 p.m. - 3:00 p.m.
Original Medicare & Medex (Medicare Supplement) 2/11/2021 10:30 a.m. - 11:15 a.m.
Prescription Drug Plans (PDP) 2/11/2021 12:00 p.m. - 12:45 p.m.
Medicare Advantage (HMO & PPO) 2/12/2021 1:30 p.m. - 2:30 p.m.
Medicare Advantage (HMO & PPO) 2/16/2021 5:00 p.m. - 6:00 p.m.
Dental Blue 65 2/17/2021 1:00 p.m. - 1:30 p.m.
GeoBlue Travel Insurance 2/17/2021 2:00 p.m. - 2:30 p.m.
Medicare Advantage (HMO & PPO) 2/18/2021 1:00 p.m. - 2:00 p.m.
Original Medicare & Medex (Medicare Supplement) 2/19/2021 9:30 a.m. - 10:15 a.m.
Prescription Drug Plans (PDP) 2/19/2021 11:00 a.m. - 11:45 a.m.

continued

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

Live Webinar Topics: Date Time
Medicare Advantage (HMO & PPO) 2/22/2021 1:00 p.m. - 2:00 p.m.
Medicare Advantage (HMO & PPO) 2/23/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 2/24/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 2/25/2021 5:00 p.m. - 5:45 p.m.
Medicare Advantage (HMO & PPO) 2/26/2021 10:00 a.m. - 11:00 a.m.
Medicare Advantage (HMO & PPO) 3/1/2021 2:00 p.m. - 3:00 p.m.
Original Medicare & Medex (Medicare Supplement) 3/3/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 3/3/2021 6:00 p.m. - 6:45 p.m.
Medicare Advantage (HMO & PPO) 3/4/2021 1:00 p.m. - 2:00 p.m.
Original Medicare & Medex (Medicare Supplement) 3/8/2021 2:00 p.m. - 2:45 p.m.
Prescription Drug Plans (PDP) 3/8/2021 3:00 p.m. - 3:45 p.m.
Medicare Advantage (HMO & PPO) 3/10/2021 5:00 p.m. - 6:00 p.m.
Original Medicare & Medex (Medicare Supplement) 3/11/2021 9:30 a.m. - 10:15 a.m.
Dental Blue 65 3/12/2021 10:00 a.m. - 10:30 a.m.
GeoBlue Travel Insurance 3/12/2021 11:00 a.m. - 11:30 a.m.
Medicare Advantage (HMO & PPO) 3/15/2021 1:00 p.m. - 2:00 p.m.
Original Medicare & Medex (Medicare Supplement) 3/16/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 3/16/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 3/17/2021 10:00 a.m. - 11:00 a.m.
Prescription Drug Plans (PDP) 3/18/2021 9:00 a.m. - 9:45 a.m.
Medicare Advantage (HMO & PPO) 3/19/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 3/22/2021 5:00 p.m. - 5:45 p.m.
Prescription Drug Plans (PDP) 3/22/2021 6:00 p.m. - 6:45 p.m.
Medicare Advantage (HMO & PPO) 3/23/2021 1:00 p.m. - 2:00 p.m.
Dental Blue 65 3/24/2021 9:00 a.m. - 9:30 a.m.
GeoBlue Travel Insurance 3/24/2021 10:00 a.m. - 10:30 a.m.
Prescription Drug Plans (PDP) 3/25/2021 5:00 p.m. - 5:45 p.m.
Medicare Advantage (HMO & PPO) 3/26/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 3/29/2021 1:00 p.m. - 1:45 p.m.
Prescription Drug Plans (PDP) 3/29/2021 2:30 p.m. - 3:15 p.m.
Medicare Advantage (HMO & PPO) 3/30/2021 5:00 p.m. - 6:00 p.m.
Medicare Advantage (HMO & PPO) 3/31/2021 10:00 a.m. - 11:00 a.m.

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

Register Today

Visit bluecrossma.com/seminar to see the latest list of webinar times and dates.

Can’t attend? No problem! Call us to speak to one of our
sales representatives directly at, 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

A Blue Cross Blue Shield of Massachusetts representative will present the webinar and discuss our Medicare HMO,
PPO, PDP, and Medicare Supplement plan options and benefits, answer your questions, and explain how to enroll.

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

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross
& Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities which have contracted

as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities
for Blue MedicareRx plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield
of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. © 2020 Blue Cross and Blue

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

000711361 Y0014_2053_M S2893_2041_M 99-0645-21 (11/20)

Connecticut | Massachusetts Blue MedicareRx (PDP)
Rhode Island | Vermont

WE’VE GOT YOU COVERED:
OUR MOST COMMONLY COVERED DRUGS

Below is a list of the most common brand-name and generic drugs covered in the
Blue MedicareRx (PDP) plans.

ADVAIR DISKUS ezetimibe metoprolol succinate er
albuterol sulfate hfa famotidine metoprolol tartrate
alendronate sodium finasteride mirtazapine
allopurinol FLOVENT HFA montelukast sodium
alprazolam fluoxetine hcl nitrofurantoin monohydrat
amlodipine besylate fluoxetine hydrochloride omeprazole
amos levothyroxine sodium fluticasone propionate omeprazole dr
amoxicillin furosemide oxybutynin chloride er
amoxicillin/clavulanate p gabapentin oxycodone hydrochloride
atenolol glimepiride oxycodone/acetaminophen
atorvastatin calcium glipizide pantoprazole sodium
azithromycin glipizide er potassium chloride er
BASAGLAR KWIKPEN hydrochlorothiazide pravastatin sodium
bupropion hydrochloride e hydrocodone/acetaminophe prednisolone acetate
carbidopa/levodopa ibuprofen prednisone
carvedilol INCRUSE ELLIPTA quetiapine fumarate
celecoxib isosorbide mononitrate er ranitidine hcl
cephalexin JANUVIA rosuvastatin calcium
chlorthalidone ketoconazole sertraline hcl
ciprofloxacin hydrochlori lamotrigine sertraline hydrochloride
citalopram hydrobromide latanoprost SHINGRIX
clonazepam levothyroxine sodium simvastatin
clopidogrel lisinopril spironolactone
diltiazem hydrochloride e lisinopril/hydrochlorothi sulfamethoxazole/trimetho
donepezil hcl lorazepam SYMBICORT
donepezil hydrochloride losartan potassium SYNTHROID
doxycycline hyclate lovastatin tamsulosin hydrochloride
duloxetine hydrochloride meloxicam timolol maleate
ELIQUIS memantine hydrochloride torsemide
escitalopram oxalate metformin hydrochloride tramadol hcl
estradiol metformin hydrochloride e trazodone hydrochloride

continued

Independent licensees of the Blue Cross and Blue Shield Association. S2893_2028_C

triamcinolone acetonide venlafaxine hcl er zolpidem tartrate
triamterene/hydrochloroth warfarin sodium
valsartan XARELTO

• Drugs listed in all CAPS identify brand-name drugs (e.g. SYNTHROID).
• Drugs listed in lowercase italics identify generic drugs (e.g. azithromycin).
• Please note this list can change per CMS requirements.

Blue MedicareRx plans include most eligible Medicare Part D generic drugs.

This is not a complete list of drugs covered by our plan. For a complete listing, please call us at one of the numbers below.
The comprehensive formulary may be amended at any time throughout the plan year. We’ll provide notice in advance
to affected members of any formulary changes. You can obtain more information by visiting rxmedicareplans.com for a
complete list of medications or to look up a specific drug.

Contact Us: Massachusetts Residents: 1-800-678-2265 (TTY: 711)
4/1-9/30, 8:00 a.m. to 8:00 p.m. ET,
Connecticut Residents: 1-866-832-9702 (TTY: 711) Monday through Friday.
24 hours a day, 7 days a week
10/1-3/31, 8:00 a.m. to 8:00 p.m. ET, seven days a week.
Rhode Island Residents: 1-800-505-2583 (TTY: 711)
4/1-9/30, Monday through Friday 8:00 a.m. to 8:00 p.m. Vermont Residents: 1-888-496-4178 (TTY: 711)
You can use our automated answering system outside 24 hours a day, 7 days a week
of these hours.
10/1-3/31, 7 days a week, 8:00 a.m. to 8:00 p.m.
Online: rxmedicareplans.com

The formulary may change at any time. You’ll receive notice when necessary. Effective as of January 1, 2021.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP)

and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents

of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately

issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield

of Massachusetts, Blue Cross and Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

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 (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment

in Blue MedicareRx (PDP) depends on contract renewal.

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross

and Blue Shield Association. ®´, SM, TM Registered Marks, Service Marks, and Trademarks

are property of their respective owners. © 2020 All Rights Reserved.

000412472 99-0654-21 TDL-21 (9/20)

Connecticut | Massachusetts Blue MedicareRx
Rhode Island | Vermont

NETWORK CHAIN PHARMACIES

We have more than 65,000 pharmacies in our network and we also contract with many independent
pharmacies for your convenience. Below is a list of the chain pharmacies for our Blue MedicareRx
Value Plus (PDP) and Blue MedicareRx Premier (PDP) plans that may be in your area. The pharmacies
highlighted in blue are our retail network pharmacies that offer preferred cost sharing. Plan members
pay a lower copay at these pharmacies than at our other network pharmacies.

For a complete and most up-to-date list of our network pharmacies, including many independent
pharmacies, please call us at one of the numbers below.

Contact Us:

Connecticut Residents: 1-866-832-9702 (TTY: 711) Massachusetts Residents: 1-800-678-2265 (TTY: 711)
24 hours a day, 7 days a week 4/1–9/30: 8:00 a.m. to 8:00 p.m.
ET, Monday through Friday.

10/1–3/31: 8:00 a.m. to 8:00 p.m. ET, 7 days a week.

Rhode Island Residents: 1-800-505-2583 (TTY: 711) Vermont Residents: 1-888-496-4178 (TTY: 711)
4/1–9/30: Monday through Friday 8:00 a.m. to 8:00 p.m. 24 hours a day, 7 days a week
10/1–3/31: 7 days a week, 8:00 a.m. to 8:00 p.m.
You can use our automated answering system outside
of these hours.

Online: rxmedicareplans.com

Acme Fresh Markets Cashwise Pharmacy Fruth Pharmacy
Acme Pharmacy City Market Pharmacy Fry’s Pharmacy
AHS-St John Pharmacy Coborn’s Pharmacy Gerbes Pharmacy
Albertsons Market Community (A Walgreens Pharmacy) Giant Eagle Pharmacy
Albertsons Pharmacy Copps Food Center Giant Pharmacy
Aurora Pharmacy Costco Pharmacy Group Health Pharmacy
B & B Pharmacy Cub Foods Haggen Pharmacy
Baker’s Pharmacy CVS Pharmacy Hannaford Food & Drug
Bartell Drug Dierbergs Family Pharmacies
Beacon Prescriptions Dillon Pharmacy Harmons Pharmacy
Bel Air Pharmacy Discount Drug Mart Harps Food Stores
Big Y Pharmacy Duane Reade Harris Teeter Pharmacy
Bi-Lo Pharmacy Fairview Pharmacy Hartig Drug
Bi-Mart Pharmacy Food City Pharmacy Harvard Vanguard Medical
Brookshire Brothers Food Lion Pharmacy Associates Pharmacy
Brookshire Pharmacy Fred Meyer Pharmacy Harveys Supermarkets
Carrs Pharmacy Fresh Market Pharmacy HEB Pharmacy
Hen House Pharmacy

S2893_2029_C continued

Homeland Pharmacy Medicap Pharmacy Sav-On Pharmacy
Hometown Pharmacy Medicine Shoppe Scotts Pharmacy
Hy-Vee Pharmacy Meijer Pharmacy Shaw’s / Star Markets
Ingles Markets Metro Market Pharmacy ShopRite
Intermountain Healthcare Navarro Pharmacy Smith’s Pharmacy
Jay C Plus Pharmacy Osco Pharmacy Stop & Shop Pharmacy
Kessel Pharmacy Patient First Pharmacy Super 1 Pharmacy
King Kullen Pharmacy Pavilion’s Pharmacy Thrifty White Pharmacy
King Soopers Pick ‘n Save Pharmacy Times Pharmacy
Kinney Drugs Price Chopper (KS-MO) Tom Thumb
Klein’s ShopRite Pharmacy Price Chopper (NY-New England) Tops Markets
Klingensmith’s Drug Stores Price Cutter Pharmacy United Market Street Pharmacy
Kmart Pharmacy Publix Pharmacy United Pharmacy
Kroger Pharmacy QFC Pharmacy Vons Pharmacy
Kroger Sav-On Raley’s Walgreens
Lewis Family Drug Ralphs Pharmacy Walmart
Longs Drugs Randall’s Pharmacy Wegmans Pharmacy
Marc’s ReCept Pharmacy Weis Markets
Mariano’s Pharmacy Rite Aid Pharmacy White Drug
Market 32 Safeway Pharmacy Winn-Dixie Stores
Martin’s Pharmacy Sam’s Club
Martin’s Super Markets (IN-MI) Save Mart Pharmacy

Pharmacy network may change on January 1, 2022. Please also note that pharmacies may have been added to or
removed from this list since its publication. This list can change at any time; you’ll receive notice when necessary.

Eligible beneficiaries must use network pharmacies to access prescription drug benefits, except under non-routine
circumstances. Quantity limitations and restrictions may apply.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP)
and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available
to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately
issued by one of the following plans: Anthem Blue Cross® and Blue Shield® of Connecticut, Blue Cross Blue Shield

of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

This information is not a complete description of benefits. Call Customer Care for more information.
For residents of Connecticut: 1-888-620-1747; Massachusetts: 1-888-543-4917;
Rhode Island: 1-888-620-1748; Vermont: 1-888-620-1746. TTY users call: 711.

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 (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor.
Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

Independent Licensees of the Blue Cross and Blue Shield Association. ® Registered Marks
of the Blue Cross and Blue Shield Association. © 2020 Blue Cross and Blue Shield Association. All rights reserved.

000412923 | 99-0655-21 NWCP-21 (9/20)