Health Savings Account (HSA) Preventive Medication List

Last updated: January 1, 2025 Health Savings Account (HSA) Preventive Medication List For plans that use the: Blue Cross Blue Shield of Massachusetts Formulary  THE PHARMACY THAT COMES TO YOU AND SAVES YOU MONEY With the mail service pharmacy, most maintenance medications can be automatically refilled and shipped every 90 days at a lower cost.* To start, create an account at bluecrossma.org. Once signed in, click Pharmacy Benefit Manager under My Medications, then go to Start Rx Delivery by Mail under the Prescriptions tab. You can also call CVS Customer Care at 1-877-817-0477 (TTY: 711). *Not all medications are available through the mail service pharmacy. Check your plan details to see if the mail service pharmacy is included with your plan. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Preventive Medications Covered 1 by HSA-Qualified “Saver” Plans The medications on this list are commonly prescribed to help you stay healthy by preventing complications or secondary conditions. Depending on your plan, you may not be required to pay the deductible for some of the medications. In some cases, your employer may also exempt the copayment or co-insurance. Check your benefit materials for details. 2 This isn’t a complete list of covered medications, and inclusion on this list doesn’t guarantee coverage. You must have a valid prescription from a licensed health provider to receive coverage for these medications. Some medications may also be subject to pharmacy management programs, such as step therapy, prior authorization, or quality care dosing, or have other coverage requirements. NOTE: Some medications on this list may be considered non-covered, including new medications under review by Blue Cross. Your doctor may request an exception for a non-covered medication when 3 medically necessary. Learn more about your coverage For more information about coverage for these medications, sign in to MyBlue at bluecrossma.org then go to Medication Lookup Tool under My Medications. If you're not a member, you can get more information by visiting bluecrossma.org/medication. 1. Blue Cross Blue Shield of Massachusetts plans that are HSA-qualified include the term “Saver” in the plan name. For example: Blue Care Elect Saver or HMO Blue New England Saver $2,000. 2. Not all medications listed are covered by all prescription plans. Check your benefit materials for details. 3. If approved, you’d pay the highest-tier cost. 2

Medication class Medication name ACE inhibitors/angiotensin II receptor antagonists ACCUPRIL and combination agents ACCURETIC ALTACE AMLODIPINE/BENAZEPRIL ATACAND ATACAND HCT AVALIDE AVAPRO BENAZEPRIL BENAZEPRIL/HYDROCHLOROTHIAZIDE BENICAR BENICAR HCT CANDESARTAN CANDESARTAN/HYDROCHLOROTHIAZIDE CAPTOPRIL CAPTOPRIL/HYDROCHLOROTHIAZIDE COZAAR DIOVAN DIOVAN HCT EDARBI EDARBYCLOR ENALAPRIL ENALAPRIL/HYDROCHLOROTHIAZIDE EPANED FOSINOPRIL FOSINOPRIL/HYDROCHLOROTHIAZIDE HYZAAR IRBESARTAN IRBESARTAN/HYDROCHLOROTHIAZIDE LISINOPRIL LISINOPRIL/HYDROCHLOROTHIAZIDE 3

Medication class Medication name ACE inhibitors/angiotensin II receptor antagonists LOSARTAN and combination agents (continued) LOSARTAN/HYDROCHLOROTHIAZIDE LOTENSIN LOTENSIN HCT LOTREL MICARDIS MICARDIS HCT MOEXIPRIL OLMESARTAN OLMESARTAN/HYDROCHLOROTHIAZIDE PERINDOPRIL PRESTALIA QBRELIS QUINAPRIL QUINAPRIL/HYDROCHLOROTHIAZIDE RAMIPRIL TELMISARTAN TELMISARTAN/HYDROCHLOROTHIAZIDE TRANDOLAPRIL TRANDOLAPRIL/VERAPAMIL ER VALSARTAN VALSARTAN/HYDROCHLOROTHIAZIDE VASERETIC VASOTEC ZESTORETIC ZESTRIL Agents for chemical dependency ACAMPROSATE CALCIUM BRIXADI BUPRENORPHINE SUBLINGUAL BUPRENORPHINE/NALOXONE SUBLINGUAL DEPADE 4

Medication class Medication name Agents for chemical dependency (continued) DISULFIRAM NALTREXONE SUBLOCADE SUBOXONE FILM VIVITROL ZUBSOLV Allergenic extracts GRASTEK ODACTRA ORALAIR PALFORZIA RAGWITEK Anaphylaxis therapy agents ADRENALIN ADYPHREN AUVI-Q EPINEPHRINE EPINEPHRINE PRO EPIPEN EPIPEN-JR EPISNAP SYMJEPI Anti-arrhythmic agents AMIODARONE BETAPACE BETAPACE AF DISOPYRAMIDE DOFETILIDE FLECAINIDE MULTAQ NORPACE NORPACE CR PACERONE PROPAFENONE 5

Medication class Medication name Anti-arrhythmic agents (continued) PROPAFENONE ER SOTALOL SOTALOL AF SOTYLIZE TIKOSYN Anti-coagulants ARIXTRA DABIGATRAN ELIQUIS ENOXAPARIN FONDAPARINUX FRAGMIN JANTOVEN LOVENOX PRADAXA PRADAXA PAK SAVAYSA WARFARIN XARELTO Anti-convulsants APTIOM BANZEL BRIVIACT CARBAMAZEPINE CARBAMAZEPINE ER CARBATROL CELONTIN CLOBAZAM CLONAZEPAM DEPAKOTE DEPAKOTE ER DIACOMIT DILANTIN 6

Medication class Medication name Anti-convulsants (continued) DIVALPROEX SODIUM DR DIVALPROEX SODIUM ER ELEPSIA XR EPIDIOLEX EPITOL EPRONTIA ETHOSUXIMIDE FELBAMATE FELBATOL FINTEPLA FYCOMPA KEPPRA KEPPRA XR KLONOPIN LACOSAMIDE LAMICTAL LAMICTAL XR LAMOTRIGINE LAMOTRIGINE ER LEVETIRACETAM LEVETIRACETAM ER METHSUXIMIDE MOTPOLY XR MYSOLINE ONFI OXCARBAZEPINE OXCARBAZEPINE ER OXTELLAR XR PHENOBARBITAL PHENYTEK PHENYTOIN 7

Medication class Medication name Anti-convulsants (continued) PHENYTOIN SODIUM ER PRIMIDONE QUDEXY XR ROWEEPRA RUFINAMIDE SABRIL TEGRETOL TEGRETOL-XR TIAGABINE TOPAMAX TOPIRAMATE TOPIRAMATE ER TRILEPTAL TROKENDI XR VALPROIC ACID VIGABATRIN VIGAFYDE VIMPAT XCOPRI ZARONTIN ZONEGRAN ZONISADE ZONISAMIDE ZTALMY Anti-depressants AMITRIPTYLINE AMOXAPINE ANAFRANIL APLENZIN AUVELITY BUPROPION BUPROPION ER 8

Medication class Medication name Anti-depressants (continued) CELEXA CITALOPRAM CYMBALTA DESIPRAMINE DESVENLAFAXINE ER DOXEPIN DRIZALMA SPRINKLE DULOXETINE DR EFFEXOR XR EMSAM ESCITALOPRAM FETZIMA FLUOXETINE FLUOXETINE 60 MG FLUOXETINE DR FORFIVO XL IMIPRAMINE HCL IMIPRAMINE PAMOATE IRENKA LEXAPRO MARPLAN MIRTAZAPINE NARDIL NORPRAMIN NORTRIPTYLINE OLEPTRO PAMELOR PARNATE PAROXETINE HCL PAROXETINE HCL ER PAXIL 9

Medication class Medication name Anti-depressants (continued) PAXIL CR PHENELZINE PRISTIQ PROTRIPTYLINE PROZAC REMERON SERTRALINE TRANYLCYPROMINE TRAZODONE TRIMIPRAMINE TRINTELLIX VENLAFAXINE VENLAFAXINE ER VIIBRYD VILAZODONE WELLBUTRIN SR WELLBUTRIN XL ZOLOFT Anti-estrogens SOLTAMOX TAMOXIFEN Anti-hyperlipidemics ALTOPREV ANTARA ATORVALIQ ATORVASTATIN CHOLESTYRAMINE COLESEVELAM COLESTID COLESTIPOL CRESTOR EZALLOR SPRINKLE EZETIMIBE 10

Medication class Medication name Anti-hyperlipidemics (continued) FENOFIBRATE FENOFIBRIC ACID FENOFIBRIC ACID DR FENOGLIDE FIBRICOR FLOLIPID FLUVASTATIN FLUVASTATIN ER GEMFIBROZIL ICOSAPENT ETHYL LESCOL XL LIPITOR LIPOFEN LIVALO LOPID LOVASTATIN NEXLETOL NEXLIZET NIACIN ER NIACOR PITAVASTATIN PRALUENT PRAVASTATIN PREVALITE QUESTRAN/QUESTRAN LIGHT REPATHA ROSUVASTATIN SIMVASTATIN TRICOR TRILIPIX VASCEPA 11

Medication class Medication name Anti-hyperlipidemics (continued) WELCHOL ZETIA ZOCOR ZYPITAMAG Anti-malarial agents ARAKODA ATOVAQUONE/PROGUANIL CHLOROQUINE MALARONE MEFLOQUINE PRIMAQUINE Anti-manics LITHIUM LITHIUM CARBONATE LITHIUM CARBONATE ER LITHOBID ER Anti-obesity agents CONTRAVE SAXENDA WEGOVY ZEPBOUND Anti-psychotics ABILIFY ABILIFY ASIMTUFII ABILIFY MAINTENA ABILIFY MYCITE ARIPIPRAZOLE ARISTADA ASENAPINE CAPLYTA CHLORPROMAZINE CLOZAPINE CLOZARIL EQUETRO FANAPT 12

Medication class Medication name Anti-psychotics (continued) FLUPHENAZINE FLUPHENAZINE DECANOATE GEODON HALDOL DECANOATE HALOPERIDOL INVEGA INVEGA SUSTENNA INVEGA TRINZA LATUDA LOXAPINE LURASIDONE LYBALVI OLANZAPINE OLANZAPINE ORALLY DISINTEGRATING TABS PALIPERIDONE PERPHENAZINE PERSERIS QUETIAPINE QUETIAPINE ER REXULTI RISPERDAL RISPERDAL CONSTA RISPERIDONE RYKINDO SAPHRIS SECUADO SEROQUEL SEROQUEL XR THIORIDAZINE THIOTHIXENE TRIFLUOPERAZINE 13

Medication class Medication name Anti-psychotics (continued) UZEDY VERSACLOZ VRAYLAR ZIPRASIDONE ZYPREXA ZYPREXA ZYDIS Anti-retroviral agents APRETUDE DESCOVY EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE 200/300 MG TRUVADA 200/300 MG Aromatase inhibitors ANASTROZOLE ARIMIDEX AROMASIN EXEMESTANE FEMARA LETROZOLE Beta-blockers and combination agents ACEBUTOLOL ATENOLOL ATENOLOL/CHLORTHALIDONE BETAXOLOL BISOPROLOL BISOPROLOL/HYDROCHLOROTHIAZIDE BYSTOLIC CARVEDILOL CARVEDILOL PHOSPHATE ER COREG COREG CR CORGARD INDERAL LA KAPSPARGO 14

Medication class Medication name Beta-blockers and combination agents (continued) LABETALOL LEVATOL LOPRESSOR METOPROLOL METOPROLOL SUCCINATE ER METOPROLOL/HYDROCHLOROTHIAZIDE NADOLOL NEBIVOLOL PINDOLOL PROPRANOLOL PROPRANOLOL ER TENORETIC TENORMIN TIMOLOL MALEATE TOPROL-XL TRANDATE Bowel preparations CLENPIQ GAVILYTE GOLYTELY MOVIPREP OSMOPREP PEG 3350/ELECTROLYTES PLENVU SODIUM SULFATE/POTASSIUM SULFATE/MAGNESIUM SULFATE SUFLAVE SUPREP SUTAB Calcium channel blockers and combination agents AMLODIPINE CARDIZEM CARDIZEM CD 15

Medication class Medication name Calcium channel blockers and combination agents CARDIZEM LA (continued) CARTIA XT CONJUPRI DILT-XR DILTIAZEM DILTIAZEM ER DILTIAZEM XR FELODIPINE ER ISOPTIN SR ISRADIPINE KATERZIA LEVAMLODIPINE MATZIM LA NICARDIPINE NIFEDIAC CC NIFEDIPINE NIFEDIPINE ER NISOLDIPINE ER NORLIQVA NORVASC PROCARDIA XL SULAR TIAZAC VERAPAMIL VERAPAMIL ER VERELAN VERELAN PM Combination anti-hyperlipidemics AMLODIPINE/ATORVASTATIN CADUET EZETIMIBE/SIMVASTATIN VYTORIN 16

Medication class Medication name Contraceptives ALL PRESCRIPTION FORMULATIONS Dental caries prevention PEDIATRIC MULTIVITAMINS WITH FLUORIDE - ALL PRESCRIPTION FORMULATIONS SODIUM FLUORIDE Diagnostic agents and supplies BLOOD GLUCOSE STRIPS - ALL FORMULATIONS CONTROL SOLUTIONS INSULIN DELIVERY DEVICES INSULIN SYRINGES, INFUSION SETS, AND NEEDLES - ALL FORMULATIONS KETONE BLOOD TEST STRIPS - ALL FORMULATIONS LANCETS, LANCET DEVICES URINE TESTING STRIPS - ALL FORMULATIONS Diuretics ALDACTAZIDE AMILORIDE/HYDROCHLOROTHIAZIDE CHLORTHALIDONE DIURIL HYDROCHLOROTHIAZIDE INDAPAMIDE SPIRONOLACTONE/HYDROCHLOROTHIAZIDE THALITONE TRIAMTERENE/HYDROCHLOROTHIAZIDE Hereditary angioedema agents CINRYZE HAEGARDA ORLADEYO TAKHZYRO Immunizations ALL FORMULATIONS Immunosuppressive agents ASTAGRAF XL CELLCEPT CYCLOSPORINE CAPS ENVARSUS XR EVEROLIMUS GENGRAF 17

Medication class Medication name Immunosuppressive agents (continued) MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM DR MYFORTIC MYHIBBIN NEORAL NULOJIX PROGRAF RAPAMUNE SANDIMMUNE SIROLIMUS TACROLIMUS ZORTRESS Inhaled diabetes agents AFREZZA Injectable diabetes agents ADMELOG APIDRA BASAGLAR BYDUREON BCISE BYETTA FIASP HUMALOG HUMULIN INSULIN ASPART INSULIN DEGLUDEC INSULIN GLARGINE INSULIN LISPRO LANTUS LEVEMIR LYUMJEV MOUNJARO MYXREDLIN NOVOLIN 18

Medication class Medication name Injectable diabetes agents (continued) NOVOLOG OZEMPIC REZVOGLAR SEMGLEE SOLIQUA SYMLINPEN TOUJEO TRESIBA TRULICITY VICTOZA XULTOPHY Miscellaneous CHOLECALCIFEROL (D3) INPEFA LODOCO Multiple sclerosis agents AUBAGIO AVONEX BAFIERTAM BETASERON BRIUMVI COPAXONE DIMETHYL FUMARATE DR EXTAVIA FINGOLIMOD GILENYA GLATIRAMER KESIMPTA LEMTRADA MAVENCLAD MAYZENT OCREVUS PLEGRIDY 19

Medication class Medication name Multiple sclerosis agents (continued) PONVORY REBIF TASCENSO ODT TECFIDERA TYSABRI VUMERITY ZEPOSIA Obsessive compulsive disorder CLOMIPRAMINE FLUVOXAMINE FLUVOXAMINE ER Oral anti-anginal agents ISORDIL ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER Oral diabetes agents ACARBOSE ACTOPLUS MET ACTOPLUS MET XR ACTOS ALOGLIPTIN ALOGLIPTIN/METFORMIN ALOGLIPTIN/PIOGLITAZONE AMARYL BEXAGLIFLOZON BRENZAVVY DAPAGLIFLOZIN DAPAGLIFLOZIN/METFORMIN ER DUETACT FARXIGA GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER 20

Medication class Medication name Oral diabetes agents (continued) GLIPIZIDE/METFORMIN GLUCOTROL XL GLUMETZA GLYXAMBI INVOKAMET INVOKAMET XR INVOKANA JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR KAZANO METAGLIP METFORMIN METFORMIN ER MIGLITOL NATEGLINIDE NESINA ONGLYZA OSENI PIOGLITAZONE PIOGLITAZONE/GLIMEPIRIDE PIOGLITAZONE/METFORMIN QTERN REPAGLINIDE RIOMET RYBELSUS SAXAGLIPTIN SAXAGLIPTIN/METFORMIN ER 21

Medication class Medication name Oral diabetes agents (continued) SEGLUROMET SITAGLIPTIN SITAGLIPTIN/METFORMIN STEGLATRO STEGLUJAN SYNJARDY SYNJARDY XR TRADJENTA TRIJARDY XR XIGDUO XR ZITUVIO Osteoporosis ACTONEL ALENDRONATE ATELVIA BINOSTO CALCITONIN CALCITONIN/SALMON EVENITY EVISTA FORTEO FOSAMAX FOSAMAX PLUS D IBANDRONATE MIACALCIN NASAL SPRAY PROLIA RALOXIFENE RECLAST RISEDRONATE TERIPARATIDE TYMLOS ZOLEDRONIC ACID 5 MG/100 ML 22

Medication class Medication name Other anti-hypertensive agents ALISKIREN AMLODIPINE/OLMESARTAN AMLODIPINE/TELMISARTAN AMLODIPINE/VALSARTAN/HCTZ AZOR CATAPRES-TTS CLONIDINE CLONIDINE TRANSDERMAL EXFORGE EXFORGE HCT GUANFACINE HYDRALAZINE HYDROCHLOROTHIAZIDE METHYLDOPA MINOXIDIL OLMESARTAN/AMLODIPINE/HCTZ TEKTURNA TEKTURNA HCT TRIBENZOR TRYVIO Platelet aggregation inhibitors ASPIRIN 81 MG BRILINTA CLOPIDOGREL DIPYRIDAMOLE DIPYRIDAMOLE ER/ASPIRIN EFFIENT PLAVIX PRASUGREL YOSPRALA ZONTIVITY 23

Medication class Medication name Prenatal vitamins ALL PRESCRIPTION FORMULATIONS FOLIC ACID Respiratory agents ACCOLATE ADVAIR ADVAIR HFA AIRDUO RESPICLICK ALVESCO ARNUITY ELLIPTA ASMANEX ASMANEX HFA BEYFORTUS BREO ELLIPTA BREYNA BUDESONIDE SUSPENSION BUDESONIDE/FORMOTEROL CINQAIR CROMOLYN SODIUM NEBULIZER SOLUTION DULERA FASENRA FLUTICASONE FUROATE/VILANTEROL FLUTICASONE PROPIONATE DISKUS FLUTICASONE PROPIONATE HFA FLUTICASONE/SALMETEROL MONTELUKAST NUCALA PULMICORT PULMICORT FLEXHALER QVAR REDIHALER SINGULAIR SPIRIVA RESPIMAT 1.25 MCG SYMBICORT 24

Medication class Medication name Respiratory agents (continued) SYNAGIS TEZSPIRE TRELEGY ELLIPTA WIXELA INHUB XOLAIR ZAFIRLUKAST ZILEUTON ER ZYFLO Respiratory therapy supplies PEAK FLOW METERS SPACER DEVICES SPACER SUPPLIES Smoking deterrents BUPROPION ER NICODERM CQ NICORETTE GUM NICORETTE LOZENGE NICOTINE POLACRILEX NICOTINE TRANSDERMAL NICOTROL INHALER NICOTROL NS VARENICLINE Transdermal/topical anti-anginal agents NITRO-BID NITRO-DUR NITROGLYCERIN TRANSDERMAL 25

Translation Resources Translation Resources Translation resources Proficiency of Language Assistance Services Proficiency of Language Assistance Services Proficiency of Language Assistance Services Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的号码联系会员服务部（TTY 号码：711）。 Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan TTY: 711). Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711). Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте (телетайп: 711). Arabic/برية: .(711 :”TTY“ مكبلاو مصلل صينلا فتاهلا زاهج ) كتيو ه ةقاطب لىع دوجولما مقرلا لىع ءاضعلأا تامدخب لصتا .كل ةبسنلاب ا ًناجم ةيوغللا ةدعاسلما تامدخ رفوتتف ،ةيبرعلا ةغللا ثدحتت تنك اذإ :هابتنا ُ Mon-Khmer, Cambodian/ខ្មែរ: ការជូនដំណឹ ង៖ ប្រសិនប្រើអ្នកនិយាយភាសា ខ្មែរ បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្្នកបសវាសរាជិកតាមបេ្បៅបេើ្រ័ណ្ណ សរាគា េ់្នរ្រសលៃ ់អ្នក (TTY: 711)។ ួ French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré (TTY: 711). Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa (TTY: 711). Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오. Greek/λληνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας, δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID card) (TTY: 771111). Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze (TTY: 711). Hindi/हिंदी: ध्यान द: ्दद आप दिनददी बोलते ि, तो भयाषया सिया्तया सेवयाएँ, आप के ललए नन:शलक उपलब्ध ि। सदस् सेवयाओं को ें ैं ैं ु आपके आई.डी. कयाड्ड पर ददए गए नंबर पर कॉल कर (टदी.टदी.वयाई.: 711). ें Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે. તમયારયા આઈડી કયાડ્ડ પર આપેલયા નંબર પર Member Service ને કૉલ કરો (TTY: 711). Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID card (TTY: 711). Japanese/日本語: お知らせ：日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。IDカードに記 載の電話番号を使用してメンバーサービスまでお電話ください（TTY: 711）。 German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an (TTY: 711). Persian/نایسراپ: سامت »اضعا تامدخ« شخب اب دوخ ییاسانش تراک یور رب جردنم نفلت رامش اب .دریگ یم رارق امش رایتخا رد ناگیار تروص ب ینابز کمک تامدخ ،تسا یسراف امش نابز رگا :جوت .(TTY: 711) دیریگب ້ ້ ່ ້ Lao/ພາສາລາວ: ຂຄວນໃສໃຈ: ຖາເຈາເວາພາສາລາວໄດ, ມການບລການຊວຍເຫ ອດານພາສາໃຫທານໂດຍບ ເສຍຄາ. ໂທ ຫາ ຼ ໍ ່ ້ ້ ໍ ່ ້ ້ ່ ໍ ່ ີ ິ ື ົ ົ ່ ຝາຍບລການສະມາ ຊກທໝາຍເລກໂທລະສບຢໃນບດຂອງທານ (TTY: 711). ູ ່ ໍ ່ ່ ິ ິ ີ ັ ັ Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih (TTY: 711). Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross 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. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. and Blue Shield Association. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 164711MB 55-1493 (11/19) 199872M 55-1493 (11/19) 26

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. ATTENTION: If you don’t speak English, language assistance services, free of charge, are available to you. Call Member Service at the number on your ID card (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación (TTY: 711). ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID (TTY: 711). CaremarkPCS Health, LLC (“CVS Caremark”) is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Blue Cross Blue Shield of Massachusetts. CVS Caremark is part of the CVS Health family of companies. 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. ®’ Registered Marks and TM Trademarks are the property of their respective owners. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 003181301 55-001546643 (11/24)