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®´
LANTUS SOLOSTAR ®´ FENOFIBRATE ADVAIR DISKUS ®´
®´
TRIAMTERENE- AMOXICILLIN-CLAVULANATE BD ULTRA-FINE™ PEN NEEDLE
HYDROCHLOROTHIAZIDE POTASSIUM
GLIPIZIDE ER
SPIRIVA ®´ BRIMONIDINE TARTRATE
TERAZOSIN HCL
VENLAFAXINE HCL ER BUPROPION HCL SR
LOSARTAN-HYDROCHLOROTHIAZIDE
GLIPIZIDE GLIMEPIRIDE
ELIQUIS ®´
TIMOLOL MALEATE XARELTO ®´
CLOBETASOL PROPIONATE
DILTIAZEM 24HR ER TRIAMCINOLONE ACETONIDE
MEMANTINE HCL
PREDNISOLONE ACETATE AMITRIPTYLINE HCL
NAPROXEN
SPIRONOLACTONE DOXAZOSIN MESYLATE
DIGOXIN
MONTELUKAST SODIUM BUPROPION XL
DIAZEPAM
QUETIAPINE FUMARATE LEVOFLOXACIN
CHLORTHALIDONE
SULFAMETHOXAZOLE-TRIMETHOPRIM DORZOLAMIDE-TIMOLOL
VERAPAMIL ER
®´
SYMBICORT ®´ ACCU-CHEK AVIVA PLUS
LAMOTRIGINE

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 co-payments/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.
* Based on prescriptions filled as of June 2016

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. © 2016 Blue Cross and Blue Shield
of Massachusetts, Inc. Printed at Blue Cross and Blue Shield of Massachusetts, Inc.
163008M 50-0177-17 (09/16)

Y0014_1693 Accepted 08302016