BCBSMA Medex Core Sapphire Bronze_SalesKit Book 06/01/2021 Approve by Danielle Roy 05/25/2021 4:45 PM

Medicare (Part B)—Medical Services—Per Calendar Year (continued)

Services Medicare Pays Plan Pays You Pay
$0
Clinical Laboratory Services $0

Blood tests for diagnostic services 100% $203
(Part B deductible)
Special Medical Formulas Mandated by Law $0
Balance
Covered by Medicare

First $203 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%
Not covered by Medicare $0 All allowed charges

Medicare (Parts A & B) Medicare Pays Plan Pays You Pay
100% $0
Services $0
$0
Home Health Care—Medicare-Approved Services 20% $203
Medically necessary skilled care services (Part B deductible)
and medical supplies $0
Durable medical equipment

First $203 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

Other Benefits—Not Covered By Medicare Medicare Pays Plan Pays You Pay
Services $0
Outpatient Prescription $0 $0 All costs
Drugs—Not Covered by Medicare
$150 per All charges after
Fitness Program—Not Covered by Medicare calendar year $150
$150 per All charges
Weight-Loss Program—Not Covered by Medicare $0 calendar year after $150
Remainder of
Foreign Travel—Not Covered by Medicare $0 charges (including $0
Only the services listed above while traveling portion normally
paid by Medicare)
outside the United States

**Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with a double
asterisk), your Part B deductible will have been met for the calendar year.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 19

BLUE CROSS BLUE SHIELD RESOURCES

bluecrossma.com/medicare | Medicare Plan Sales: 1-800-678-2265
Member Service: 1-800-258-2226 (TTY: 711)

Monday through Friday, 8:00 a.m. to 5:00 p.m. ET.

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 1-800-258-2226 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.

Ligue para 1-800-258-2226 (TTY: 711).

000708954 ® 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.

32-3000-21v2 (11/20)

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 see a full list of dates and times. You can also:



Register for a live online webinar Watch a pre-recorded seminar

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

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

Live Webinar Topics: Date Time
Medicare Advantage (HMO & PPO) 6/9/2021 10:00 a.m. - 11:00 a.m.
Dental Blue 65 6/10/2021 12:00 p.m. - 12:30 p.m.
GeoBlue Travel Insurance 6/10/2021 1:00 p.m. - 1:30 p.m.
Original Medicare & Medex (Medicare Supplement) 6/11/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 6/11/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 6/14/2021 12:00 p.m. - 1:00 p.m.
Medicare Advantage (HMO & PPO) 6/15/2021 4:30 p.m. - 5:30 p.m.
Original Medicare & Medex (Medicare Supplement) 6/16/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 6/16/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 6/17/2021 9:00 a.m. - 10:00 a.m.
Medicare Advantage (HMO & PPO) 6/21/2021 1:00 p.m. - 2:00 p.m.
Original Medicare & Medex (Medicare Supplement) 6/22/2021 10:00 a.m. - 10:45 a.m.
Prescription Drug Plans (PDP) 6/22/2021 11:30 a.m. - 12:15 p.m.
Medicare Advantage (HMO & PPO) 6/23/2021 5:00 p.m. - 6:00 p.m.
Medicare Advantage (HMO & PPO) 6/24/2021 10:00 a.m. - 11:00 a.m.
Original Medicare & Medex (Medicare Supplement) 6/25/2021 9:00 a.m. - 9:45 a.m.
Prescription Drug Plans (PDP) 6/25/2021 10:30 a.m. - 11:15 a.m.
Medicare Advantage (HMO & PPO) 6/28/2021 12:00 p.m. - 1:00 p.m.
Medicare Advantage (HMO & PPO) 6/29/2021 5:00 p.m. - 6:00 p.m.
Dental Blue 65 6/30/2021 5:00 p.m. - 5:30 p.m.
GeoBlue Travel Insurance 6/30/2021 6:00 p.m. - 6:30 p.m.

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

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

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. © 2021 Blue Cross and Blue

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

000768460 Y0014_2053_M S2893_2041_M 99-0645-21 (5/21)

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

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. © 2021 Blue Cross and Blue

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

000768460 Y0014_2053_M S2893_2041_M 99-0645-21 (5/21)

Medex®´ Core | Medex®´ Sapphire | Medex®´ Bronze

IT PAYS TO STAY BLUE

If you’re 65 or older and eligible for Medicare for the first time,
you may qualify for a discount on your premium.

If you qualify, enroll now to save 15 percent on your Medex®´ monthly plan premium
for the first year, 10 percent the second year, and 5 percent the third year.

Plan Full Rate* First Year: Second Year: Third Year:
15% Discount* 10% Discount* 5% Discount*
$102.48
Medex Core $107.88 $91.70 $97.09 $174.30
$204.67
Medex Sapphire $183.48 $155.96 $165.13

Medex Bronze $215.45 $183.13 $193.90

*Rates effective January 1, 2021 to December 31, 2021.

Member Perks and Wellness Benefits

Now there are even more reasons to get and stay healthy. These discounts
and services make healthy living easier—and more affordable—than ever.

• Mange your Medex plan online with a • Add a vision and hearing benefit package
MyBlue account. Get personalized and to your Medex Core, Medex Sapphire,
secure access to your benefit information, or Medex Bronze plan. Call the number
claims history, doctor’s visits, and more. below for more details.
Members can log in at bluecrossma.org.
• Complement your coverage with a
• Fitness and weight-loss benefits are dental plan from Blue Cross that fits
included in direct-billed Medex Core, your specific needs. Call us at the
Medex Sapphire, and Medex Bronze number below for more information.
plans. Members are entitled to a fitness
benefit ($150 a year) and a weight-loss • Pay your premiums online with eBill.
benefit ($150 a year).

To find out if you qualify medicare.bluecrossma.com
and for more information:
1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 5:00 p.m.

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



Medex®´ Core
Medex®´ Sapphire

Medex®´ Bronze

VISION AND HEARING BENEFITS

If you have a direct-billed Medex Core, Medex Sapphire, or Medex Bronze plan,
here’s an easy way to help cover your vision and hearing expenses, while limiting
your out-of-pocket costs.

Good eyesight and hearing are important to your quality of life, but glasses
and hearing aids aren’t covered by Medicare. The Medex Vision and Hearing
benefit plan covers these benefits, so you can more easily afford the glasses

and hearing aids you need—all for one low price of $2.31/month.

 What additional vision care  What additional hearing care
services benefits will I get? benefits will I get?

With the Medex Vision and Hearing plan, With the Medex Vision and Hearing plan,
you’ll receive the following vision care services: you’ll get the following routine hearing
care services:
• Routine vision exams: Covers one routine • Routine hearing exams: Reimbursement
vision exam every calendar year to
determine if you need corrective lenses. for one routine hearing exam every
Any Blue Cross and Blue Shield two calendar years, when the exam is
participating physician or optometrist, furnished by a Blue Cross and Blue Shield
or any licensed ophthalmologist or participating physician or audiologist,
optometrist outside of Massachusetts, or any licensed physician outside of
can perform your exam. Massachusetts.
• Hearing aids: Reimbursement for up to
• Eyeglasses or contact lenses: Covers $200 every two calendar years for one
up to $150 every calendar year for one hearing aid (or one set of binaural hearing
set of frames and prescription lenses or aids) from a licensed hearing aid dealer.
contact lenses (in place of eyeglasses) This $200 benefit payment includes costs
from any licensed vision care supplier. for dispensing fees, acquisition costs,
This $150 benefit payment includes costs batteries, and hearing aid repairs.
for measurement, fitting, and adjustments.
Note: No coverage is provided for costs to replace lost
Note: No coverage is provided for amounts more than hearing aids, unless you’ve gone more than two calendar
$150 every calendar year; non-prescription lenses; years without receiving a hearing aid benefit.
sunglasses that don’t require a prescription; safety
glasses; replacement of lost or broken frames or lenses;
and special procedures, such as vision training and
subnormal-vision aids, and similar procedures and devices.

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

Is it easy to get reimbursed for vision How much does the Medex Vision
and hearing care services? and Hearing plan cost?

Yes. At the time you buy your glasses, Effective January 1, 2021, and until December
contacts, or hearing aid(s), or at a later date, 31, 2021, the additional benefit coverage cost
the provider may ask you to pay all charges. is $2.31 per month. This amount will be added
If this happens, you’ll need to file a claim to your direct-billed Medex premium.
with Blue Cross Blue Shield of Massachusetts
for repayment of these covered services.
Simply complete a claim form and send it
with your original itemized bill(s). If you need a
claim form or would like help completing your
form, call Member Service at 1-800-258-2226
(TTY: 711), Monday through Friday, 8:00 a.m.
to 6:00 p.m. ET.

How do I apply?

 The easiest way to enroll is by phone.
Phone: 1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 5:00 p.m. ET

 You can also enroll by mail or fax. By mail, please complete the application
for Direct-Billed Medex and return it to:
Direct Sales
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-1753

Or fax the application to 1-617-246-3633.

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-678-2265 (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. ®´´ Registered Marks are the property of their respective owners. © 2020 Blue Cross
and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000405190 55-000405190-21 (10/20)

What is GeoBlue?

GeoBlue is a provider of health insurance for short-term travel.

Why Should I choose a GeoBlue Plan?

With GeoBlue you’ll receive valuable benefits like:

• Additional coverage wherever and whenever you travel (i.e. medical evacuation coverage)
• Hassle-free access to care, meaning no claim forms for you to deal with if you see a contracted provider
• Concierge-level member service 24/7/365
• Access to a trusted network of providers and hospitals

What short-term plan options are available?

Single-trip plans up to 180 days in length

GeoBlue Voyager - Up to $1,000,000 medical/$500,000 evacuation
• Choice of medical limits and deductibles
• Pre-existing condition coverage option
• For trips over 180 days, one policy extension is available
• Two levels of coverage: Essential and Choice

Multi-trip plans for unlimited trips that are a maximum 70 days in length

GeoBlue Trekker: - Up to $250,000 medical/$500,000 evacuation
• Choice of medical limits
• Pre-existing conditions covered
• 364 day policy (70 days max. per trip)
• Two levels of coverage are available: Essential and Choice

Other Questions?

For more information: Call 1-888-731-2195

GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Blue Cross and Blue Shield companies in select service areas.



03

Disclosures



Nondiscrimination Notice

Blue Cross Blue Shield of Massachusetts c and does not discriminate on the basis of race,
color, national origin, age, disability, sex, sexual omplies with applicable federal civil rights laws
orientation, or gender identity. It does not exclude people or treat them differently because of race,
color, national origin, age, disability, sex, sexual orientation, or gender identity.

Blue Cross Blue Shield of Massachusetts provides:
• Free aids and services to people with disabilities to communicate effectively
with us, such as qualified sign language interpreters and written information
in other formats (large print or other formats).
• Free language services to people whose primary language is not English,
such as qualified interpreters and information written in other languages.

If you need these services, call Member Service at the number on your ID card.

If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services
or discriminated in another way on the basis of race, color, national origin, age, disability, sex,
sexual orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator
by mail at Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive,
Quincy, MA 02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email
at [email protected].

If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and
Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC
20201; by phone at 1-800-368-1019 or 1-800-537-7697 (TDD/TTY).

Complaint forms are available at hhs.gov.

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

000404530 55-2067 (9/20)



Translation Resources

PrTofriacinensclyatoifoLnanRgueasgoe uAsrsciestsance 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/‫ةيبر‬:

‫ اتصل بخدمات الأعضاء على الرقم الموجود على بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬

Mon-Khmer, Cambodian/ខ្រមែ : ការជូនដំណឹ ង៖ ប្រសិនប្រើអន្កនិយាយភាសា ខ្ែរម
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្ក្ន បសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណណ្ សរាគា េ់្ួនៃល រ្រស់អនក្ (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 있
습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.
Greek/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: 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.

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/हिदं ी: ध्यान दें: ्दद आप दिनददी बोलते िंै, तो भयाषया सिया्तया सेवयाएँ, आप कके रलंे ल(टएदी.टनदीन.व:शयाईुल.:क711).
उपलब्ध िंै। सदस् सेवयाओं को आपके आई.डी. कयाड्ड पर ददए गए नबं र पर कॉल

Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગજુ રયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મલૂ ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડડ્ પર આપલે યા 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/‫پارسیان‬:
‫ با شمار تلفن مندرج بر روی کارت شناسایی‬.‫ خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد‬،‫ اگر زبان شما فارسی است‬:‫توج‬

.(TTY: 711) ‫خود با بخش «خدمات اعضا» تماس بگیر ید‬
Lao/ພາສາລາວ: ໍຂ້ ຄວນໃສ່ ໃຈ: ຖ້ າເົຈ້ າເົວ້ າພາສາລາວໄດ້ , ີມການໍບິລການຊ່ ວຍເືຫຼ ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ
່ໍບເສຍຄ່ າ. ໂທຫາຝ່ າຍໍບິລການສະມາິຊກ່ີທໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (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. ® 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.

®16R47e11gMiBstered Marks of the Blue Cross and Blue Shield Association. © 2020 5B5-l1u49e3 (8C/16r)oss and Blue Shield

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

000745124 55-2066 (12/20)

04

Enrollment



Medex®´ Core
Medex®´ Sapphire

Medex®´ Bronze

APPLICATION FOR
DIRECT BILLED MEDEX®´

Directions You’re eligible to apply for a
Medex plan if you meet all of
• Please print clearly. the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications won’t be accepted. and you actually live in Massachusetts.
Please keep a copy of the application for
your records. • You’re eligible for Medicare Part A
• Send us your application after you receive and Medicare Part B and enrolled
your red, white, and blue Medicare card. in Medicare Part B.
• Don’t send money with this application.
You’ll receive a bill when payment is due. • If you’re under age 65, you qualify for
• Please complete and return to: Medicare coverage because of disability.

Direct Sales Notes:
Blue Cross Blue Shield
of Massachusetts • Medex Bronze shall, on or after January 1,
One Enterprise Drive 2020, only be offered to eligible persons
Quincy, MA 02171-1753 who: (a) have attained 65 years of age
before January 1, 2020; or (b) first became
• Or fax the application to 1-617-246-3633. eligible for Medicare due to age or disability
• To enroll by phone, call 1-800-678-2265. before January 1, 2020. Those who are
• Medex premium rates and benefits are otherwise eligible for Medicare Part A and
B and who are enrolled in Medicare Part B,
explained in the booklet you received but who aren’t eligible to purchase Medex
with this application. If you need more Bronze, shall be eligible to purchase all
information or assistance, call us at other Direct Billed Medex plans that are
1-800-678-2265. currently offered.
• For all other questions, contact:
• If you’re covered by Medicaid, you may
Medex Member Service: or may not be eligible to enroll in Direct
1-800-258-2226 TTY: 711 Billed Medex. See paragraph (g) of the
“Important Information” section of this
application form.

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

Please answer all questions. Medex Core with Vision and Hearing Benefit
Medex Sapphire with Vision and Hearing Benefit
Check the Medex Plan of your choice: Medex Bronze with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core)
Medex Sapphire (Medicare Supplement 1A)
Medex Bronze (Medicare Supplement 1)

Your Social Security Number: How often would you like to be billed?
________ - _______ - _____________
Monthly Quarterly

Would you like your premium payment due on the 1st of the month or the 15th of the month?

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
Male
Female () –

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
If you want your Medex bill sent to an address other than your home address, complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________

Medicare Insurance Information
Please copy information from your red, white, and blue Medicare card in the spaces below.

Medicare Number:

Medicare Part A (Hospital Insurance) Effective Date:

Medicare Part B (Medical Insurance) Effective Date:

If you’re under age 65, what is your disability that qualifies you for Medicare coverage?

Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No
If yes, give your Blue Cross Blue Shield identification number:

Important Information

Please read the “Important Information” section. Then answer questions 1 through 5.

(a) You don’t need more than one Medicare supplemental you later become covered by an employer or union-
insurance policy. based group health plan, the benefits and premiums
under your Medicare supplemental insurance policy can
(b) If you newly enroll in a Medicare Supplement 1 plan, be suspended, if requested, while you’re covered under
you’re not permitted to switch within the same the employer or union-based group health plan. If you
company into a Medicare Supplement 1A plan until suspend your Medicare supplemental insurance policy
you have been covered by the company’s Medicare under these circumstances, and later lose your employer
Supplement 1 plan for at least 12 months. or union-based group health plan, your suspended
Medicare supplemental insurance policy (or, if that is no
(c) If you purchase this Policy, you may want to evaluate longer available, a substantially equivalent policy) will
your existing health coverage and decide if you need be reinstituted if requested within 90 days of losing your
multiple coverage. employer or union-based group health plan.

(d) You may be eligible for Medicaid benefits and may If the Medicare supplemental insurance policy
not need a Medicare supplemental insurance policy. provided coverage for outpatient prescription drugs
and you enrolled in Medicare Part D while your
(e) The benefits and premiums under your Medicare policy was suspended, the reinstituted policy won’t
supplemental insurance policy can be suspended, have outpatient prescription drug coverage, as you’ll
if requested, during your entitlement to benefits be enrolled in the most comparable plan without
under Medicaid for 24 months. You must request this outpatient prescription drug coverage.
suspension within 90 days of becoming eligible for
Medicaid. If you’re no longer entitled to Medicaid, (g) Counseling services are available in Massachusetts to
your Policy will be reinstituted if requested within provide advice concerning your purchase of Medicare
90 days of losing Medicaid eligibility. supplemental Insurance policy and concerning medical
assistance through the state Medicaid program, including
If the Medicare supplemental insurance policy benefits as a Qualified Medicare Beneficiary (QMB) and
provided coverage for outpatient prescription drugs a Specified Low-Income Medicare Beneficiary (SLMB).
and you enrolled in Medicare Part D while your You may call the Massachusetts Executive Office of
policy was suspended, the reinstituted policy won’t Elder Affairs insurance counseling program at
have outpatient prescription drug coverage, as you’ll 1-800-243-4636 (TTY: 1-800-872-0166), or write to
be enrolled in the most comparable plan without that office at the following address for more information:
outpatient prescription drug coverage. One Ashburton Place, 5th Floor, Boston, MA 02108.

(f) If you’re eligible for, and have enrolled in a Medicare
supplemental insurance policy by reason of disability and

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you
were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy
such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include
a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
To the best of your knowledge, [Mark Yes or No below with an “X”]

1. (a) Did you turn age 65 in the last 6 months? 2. Are you covered for medical assistance through the
Yes No state Medicaid program? [NOTE TO APPLICANT:
If you’re participating in a “Spend-Down Program”
(b) Did you enroll in Medicare Part B in the last 6 and haven’t met your “Share of Cost,” please answer
months? Yes No NO to this question.] Yes No If yes,

(c) If yes, what is the effective (a) Will Medicaid pay your premiums for this Medicare
date?_______________ supplemental policy? Yes No

(b) Do you receive any benefits from Medicaid OTHER
THAN payments toward your
Medicare Part B premium? Yes No

3. (a) If you had coverage from any Medicare plan other 4. (a) Do you have another Medicare supplemental policy
than original Medicare within the past 63 days in force? Yes No
(for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), fill in your start and end (b) If so, with what company, and what plan do
dates below. If you’re still covered under this plan, you have?
leave “END” blank. Start __/__/__ End __/__/__
(c) If so, do you intend to replace your current Medicare
(b) If you’re still covered under the Medicare plan, supplemental policy with this policy?
do you intend to replace your current coverage Yes No
with this new Medicare supplemental policy?
Yes No 5. Have you had coverage under any other health
insurance within the past 63 days? Yes No
(c) Was this your first time in this type of Medicare (For example, an employer, union, or individual plan)
plan? Yes No
(a) If so, with what company and what kind of policy?
(d) Did you drop a Medicare supplemental policy to
enroll in the Medicare plan? Yes No (b) What are your dates of coverage under the other
policy? Start __/__/__ End __/__/__
(If you’re still covered under the other policy,
leave “END” blank.)

I certify that the statements made and answers given are complete and true. I have read and carefully considered
all of the “Important Information” on this form. I also certify that I received the “Outline of Medicare Supplement
Coverage.” I understand that no health care provider, or private or government agency may sponsor, purchase,
or contribute to the cost of this Medex plan. For the purpose of processing this application, for 30 months from
the date this authorization is signed, and if I enroll in coverage, for as long as I am covered, I understand that all
of my health care providers, other insurance companies, or my employer are authorized to release all of my medical
records and other information to Blue Cross and Blue Shield of Massachusetts representatives for the purpose of
determining my coverage and administering my benefits. I or my authorized representative is entitled to receive
a copy of this authorization form. I understand that the benefits for which I am eligible are those described in the
applicable Medex´ Subscriber Certificate. I understand that Medex benefits and premium rates are subject to
change as allowed by state law. I understand that enrollment in this plan is contingent upon payment of premium.

Applicant’s Signature: _________________________________________________ Date: __________________

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-258-2226 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-258-2226 (TTY: 711).

000405241 ®, 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.

55-0936-21 (09/20)

Medex®´ Core
Medex®´ Sapphire

Medex®´ Bronze

APPLICATION FOR
DIRECT BILLED MEDEX®´

Directions You’re eligible to apply for a
Medex plan if you meet all of
• Please print clearly. the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications won’t be accepted. and you actually live in Massachusetts.
Please keep a copy of the application for
your records. • You’re eligible for Medicare Part A
• Send us your application after you receive and Medicare Part B and enrolled
your red, white, and blue Medicare card. in Medicare Part B.
• Don’t send money with this application.
You’ll receive a bill when payment is due. • If you’re under age 65, you qualify for
• Please complete and return to: Medicare coverage because of disability.

Direct Sales Notes:
Blue Cross Blue Shield
of Massachusetts • Medex Bronze shall, on or after January 1,
One Enterprise Drive 2020, only be offered to eligible persons
Quincy, MA 02171-1753 who: (a) have attained 65 years of age
before January 1, 2020; or (b) first became
• Or fax the application to 1-617-246-3633. eligible for Medicare due to age or disability
• To enroll by phone, call 1-800-678-2265. before January 1, 2020. Those who are
• Medex premium rates and benefits are otherwise eligible for Medicare Part A and
B and who are enrolled in Medicare Part B,
explained in the booklet you received but who aren’t eligible to purchase Medex
with this application. If you need more Bronze, shall be eligible to purchase all
information or assistance, call us at other Direct Billed Medex plans that are
1-800-678-2265. currently offered.
• For all other questions, contact:
• If you’re covered by Medicaid, you may
Medex Member Service: or may not be eligible to enroll in Direct
1-800-258-2226 TTY: 711 Billed Medex. See paragraph (g) of the
“Important Information” section of this
application form.

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

Please answer all questions. Medex Core with Vision and Hearing Benefit
Medex Sapphire with Vision and Hearing Benefit
Check the Medex Plan of your choice: Medex Bronze with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core)
Medex Sapphire (Medicare Supplement 1A)
Medex Bronze (Medicare Supplement 1)

Your Social Security Number: How often would you like to be billed?
________ - _______ - _____________
Monthly Quarterly

Would you like your premium payment due on the 1st of the month or the 15th of the month?

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
Male
Female () –

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
If you want your Medex bill sent to an address other than your home address, complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________

Medicare Insurance Information
Please copy information from your red, white, and blue Medicare card in the spaces below.

Medicare Number:

Medicare Part A (Hospital Insurance) Effective Date:

Medicare Part B (Medical Insurance) Effective Date:

If you’re under age 65, what is your disability that qualifies you for Medicare coverage?

Are you currently a Blue Cross Blue Shield of Massachusetts member? Yes No
If yes, give your Blue Cross Blue Shield identification number:

Important Information

Please read the “Important Information” section. Then answer questions 1 through 5.

(a) You don’t need more than one Medicare supplemental you later become covered by an employer or union-
insurance policy. based group health plan, the benefits and premiums
under your Medicare supplemental insurance policy can
(b) If you newly enroll in a Medicare Supplement 1 plan, be suspended, if requested, while you’re covered under
you’re not permitted to switch within the same the employer or union-based group health plan. If you
company into a Medicare Supplement 1A plan until suspend your Medicare supplemental insurance policy
you have been covered by the company’s Medicare under these circumstances, and later lose your employer
Supplement 1 plan for at least 12 months. or union-based group health plan, your suspended
Medicare supplemental insurance policy (or, if that is no
(c) If you purchase this Policy, you may want to evaluate longer available, a substantially equivalent policy) will
your existing health coverage and decide if you need be reinstituted if requested within 90 days of losing your
multiple coverage. employer or union-based group health plan.

(d) You may be eligible for Medicaid benefits and may If the Medicare supplemental insurance policy
not need a Medicare supplemental insurance policy. provided coverage for outpatient prescription drugs
and you enrolled in Medicare Part D while your
(e) The benefits and premiums under your Medicare policy was suspended, the reinstituted policy won’t
supplemental insurance policy can be suspended, have outpatient prescription drug coverage, as you’ll
if requested, during your entitlement to benefits be enrolled in the most comparable plan without
under Medicaid for 24 months. You must request this outpatient prescription drug coverage.
suspension within 90 days of becoming eligible for
Medicaid. If you’re no longer entitled to Medicaid, (g) Counseling services are available in Massachusetts to
your Policy will be reinstituted if requested within provide advice concerning your purchase of Medicare
90 days of losing Medicaid eligibility. supplemental Insurance policy and concerning medical
assistance through the state Medicaid program, including
If the Medicare supplemental insurance policy benefits as a Qualified Medicare Beneficiary (QMB) and
provided coverage for outpatient prescription drugs a Specified Low-Income Medicare Beneficiary (SLMB).
and you enrolled in Medicare Part D while your You may call the Massachusetts Executive Office of
policy was suspended, the reinstituted policy won’t Elder Affairs insurance counseling program at
have outpatient prescription drug coverage, as you’ll 1-800-243-4636 (TTY: 1-800-872-0166), or write to
be enrolled in the most comparable plan without that office at the following address for more information:
outpatient prescription drug coverage. One Ashburton Place, 5th Floor, Boston, MA 02108.

(f) If you’re eligible for, and have enrolled in a Medicare
supplemental insurance policy by reason of disability and

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you
were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights to buy
such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans. Please include
a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.
To the best of your knowledge, [Mark Yes or No below with an “X”]

1. (a) Did you turn age 65 in the last 6 months? 2. Are you covered for medical assistance through the
Yes No state Medicaid program? [NOTE TO APPLICANT:
If you’re participating in a “Spend-Down Program”
(b) Did you enroll in Medicare Part B in the last 6 and haven’t met your “Share of Cost,” please answer
months? Yes No NO to this question.] Yes No If yes,

(c) If yes, what is the effective (a) Will Medicaid pay your premiums for this Medicare
date?_______________ supplemental policy? Yes No

(b) Do you receive any benefits from Medicaid OTHER
THAN payments toward your
Medicare Part B premium? Yes No

3. (a) If you had coverage from any Medicare plan other 4. (a) Do you have another Medicare supplemental policy
than original Medicare within the past 63 days in force? Yes No
(for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), fill in your start and end (b) If so, with what company, and what plan do
dates below. If you’re still covered under this plan, you have?
leave “END” blank. Start __/__/__ End __/__/__
(c) If so, do you intend to replace your current Medicare
(b) If you’re still covered under the Medicare plan, supplemental policy with this policy?
do you intend to replace your current coverage Yes No
with this new Medicare supplemental policy?
Yes No 5. Have you had coverage under any other health
insurance within the past 63 days? Yes No
(c) Was this your first time in this type of Medicare (For example, an employer, union, or individual plan)
plan? Yes No
(a) If so, with what company and what kind of policy?
(d) Did you drop a Medicare supplemental policy to
enroll in the Medicare plan? Yes No (b) What are your dates of coverage under the other
policy? Start __/__/__ End __/__/__
(If you’re still covered under the other policy,
leave “END” blank.)

I certify that the statements made and answers given are complete and true. I have read and carefully considered
all of the “Important Information” on this form. I also certify that I received the “Outline of Medicare Supplement
Coverage.” I understand that no health care provider, or private or government agency may sponsor, purchase,
or contribute to the cost of this Medex plan. For the purpose of processing this application, for 30 months from
the date this authorization is signed, and if I enroll in coverage, for as long as I am covered, I understand that all
of my health care providers, other insurance companies, or my employer are authorized to release all of my medical
records and other information to Blue Cross and Blue Shield of Massachusetts representatives for the purpose of
determining my coverage and administering my benefits. I or my authorized representative is entitled to receive
a copy of this authorization form. I understand that the benefits for which I am eligible are those described in the
applicable Medex´ Subscriber Certificate. I understand that Medex benefits and premium rates are subject to
change as allowed by state law. I understand that enrollment in this plan is contingent upon payment of premium.

Applicant’s Signature: _________________________________________________ Date: __________________

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-258-2226 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-258-2226 (TTY: 711).

000405241 ®, 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.

55-0936-21 (09/20)



FOR MORE INFORMATION, OR TO ENROLL:

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
8:00 a.m. to 5:00 p.m. ET, Monday through Friday

bluecrossma.com/Medicare

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

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

and Blue Shield of Massachusetts HMO Blue, Inc.

000404734 99-0680-21 ((096/2/001)/21)