Save on Medications with Mail Service Pharmacy

SAVE MONEY ON YOUR MEDICATIONS WITH THE MAIL SERVICE PHARMACY Maintenance medications, also known as long-term medications, are used to treat chronic or ongoing conditions. Save 33% when you order them in 90-day 1 supplies through the mail service pharmacy. BENEFITS OF USING THE MAIL SERVICE PHARMACY You’ll pay 33% less for There’s no Signing up for automatic 90-day supplies of most additional cost for refills makes it less likely maintenance medications standard delivery. to miss a dose. (that’s one less copay). 2 EXAMPLE OF HOW YOU’LL SAVE TYPE OF PRESCRIPTION MEDICATION COPAY Tier 1 Tier 2 Tier 3 $15 $30 $50 30-day supply, retail pharmacy 90-day supply, mail service pharmacy $30 $60 $150 1. In most cases for eligible maintenance medications. Check plan materials for more details. 2. For illustrative purposes only, using a 3-tier plan. (continued) Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

HOW TO USE THE MAIL SERVICE PHARMACY Download the MyBlue app or create an account at bluecrossma.org. Once signed in, click Pharmacy Benefit Manager under My Medications, then go to the Prescriptions tab. To: TRANSFER PRESCRIPTIONS ORDER REFILLS SET UP AUTOMATIC REFILLS Click Click Click Start Rx Delivery by Mail View/Refill All Prescriptions Manage Automatic Refills You can also fill prescriptions by calling CVS Customer Care at 1-877-817-0477 (TTY: 711), or by using the included order form. WHY ISN’T MY MEDICATION AVAILABLE THROUGH THE MAIL SERVICE PHARMACY? Certain medications that require immediate administration or are used for short periods of time aren’t available through the mail service pharmacy. In addition, some specialty medications are only available through specialty pharmacies. Please Note: Certain prescribed medications may be subject to Prescription information about members and dependents other dispensing limitations and to the professional is used to administer your prescription program. That judgment of the pharmacist. If you have any questions information is reported to Blue Cross Blue Shield of about your medication, call CVS Customer Care at Massachusetts, and is used for reporting and analysis, 1-877-817-0477 (TTY: 711). without identifying individual patients in accordance It’s the patient’s responsibility to report any changes with applicable laws. in drug allergies, health conditions, chronic diseases, and drug sensitivities. Questions? If you have any questions, call CVS Customer Care at 1-877-817-0477 (TTY: 711). 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. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. 001542278 55-001542278 (10/22)

® Mail Service Order Form Mail this form to: USVUUVTTVVTUUUVUUVUUVTTUUUTSUUSTSUUSSVUUTTVUVSUVTVSVUVSUSTUSUSTUV CVS Caremark PO BOX 659541 SAN ANTONIO, TX 78265-9541 Member ID # (if not shown or if different from above) Prescription Plan Sponsor or Company Name Instructions: Please use blue or black ink and print in capital letters. Fill in both sides of this form. New Prescriptions - Mail your new prescriptions with this form. Number of New prescriptions: Refills - Order by Web, phone, or write in Rx number(s) below. Number of Refill prescriptions: ORDER SOONER request refills or new prescriptions online at bluecrossma.org. TO RECEIVE YOUR Go to 90-Day Mail Service under My Medications. AShipping Address. To ship to an address different from the one printed above, enter the changes here. Last Name First Name MI Suffix (JR, SR) Street Address Apt./Suite # Use shipping address for this order only. City State ZIP Code Daytime Phone #: Evening Phone #: B Refills. To order mail service refills, enter your prescription number(s) here. 1) 2) 3) 4) 5) 6) 7) 8) CVS Caremark wants to provide you with high quality medicines at the best possible price. In order to do this, we will substitute equivalent generic medicines for brand name medicines whenever possible. If you do not want XVWRVXEVWLWXWHJHQHULFVSOHDVHSURYLGHVSHFL¿FLQVWUXFWLRQVLQFOXGLQJGUXJQDPHVLQWKH “Special Instructions” section of this form. 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. We may package all of these prescriptions together unless you tell us not to. All claims for prescriptions submitted to CVS Caremark Mail Service Pharmacy using this form ZLOOEHVXEPLWWHGWR\RXUSUHVFULSWLRQEHQH¿WSODQIRUSD\PHQW,I\RXGRQRWZDQWWKHPVXEPLWWHG to your plan, do not use this form. You may call Customer Care to make alternate arrangements for submission of your order and payment. ©2020 CVS Caremark. All rights reserved. P13-N

C Tell us about the people ordering prescriptions. If there are more than two people, please complete another form. First person with a refill or new prescription. Spanish forms and labels Last Name First Name MI Suffix Nickname (JR,SR) Date of birth: MM-DD-YYYY E-mail address: Date new prescription written: Doctor’s last name Doctor’s first name Doctor’s phone # Tell us about new health information for 1st person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Other: Medical conditions: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid Other: Second person with a refill or new prescription. Spanish forms and labels Last Name First Name MI Suffix Nickname (JR,SR) Date of birth: MM-DD-YYYY E-mail address: Date new prescription written: Doctor’s last name Doctor’s first name Doctor’s phone # Tell us about new health information for 2nd person if never provided or if changed. Allergies: None Aspirin Cephalosporin Codeine Erythromycin Peanuts Penicillin Sulfa Other: Medical conditions: Arthritis Asthma Diabetes Acid reflux Glaucoma Heart problem High blood pressure High cholesterol Migraine Osteoporosis Prostate issues Thyroid Other: D Special instructions: E How would you like to pay for this order? (If your copay is $0, you do not need to provide payment information.) Electronic check. Pay from your bank account. (You must first register online or call Customer Care.) ® ® ® ® Credit or debit card. (VISA , MasterCard , Discover , or American Express ) Use your card on file. Use a new card or update your card’s expiration date. Exp.Date MMYY Credit card holder signature/Date Check or money order. Amount: $ . Regular delivery is free and takes up to 5 • Make check or money order payable to CVS Caremark. days after your order is processed. ‡ :ULWH\RXUSUHVFULSWLRQEHQH¿W,'QXPEHURQ\RXU If you want faster delivery, choose: check or money order. 2nd business day ($17) Faster delivery can only be • If your check is returned, we will charge you up to $40. sent to a Next business day ($23) street address, Payment for Balance Due and Future Orders: If you choose not a PO Box electronic check or a credit or debit card, we will use it to pay Expected processing time from receipt of this form: for any balance due and for future orders unless you provide • Refills: 1-2 days • New/renewed prescriptions: Within 5 days unless additional another form of payment. information is needed from your doctor Fill in this oval if you DO NOT want us to use this payment (Charges subject to change) method for future orders. MOF WEB 0122 BCBSMA