BCBSMA Medex Core Sapphire Bronze SalesBook 2002 (V4_012022_0493) Approved by Angela Gagnon 01/21/2022 1:33 PM

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

Services Medicare Pays Plan Pays You Pay
Clinical Laboratory Services $0
Blood tests for diagnostic services 100% $0
Special Medical Formulas Mandated by Law
Covered by Medicare $0 $0 $233
(Part B deductible)
First $233 of Medicare-approved amounts**
80% 20% $0
Remainder of Medicare-approved amounts
Not covered by Medicare $0 All allowed charges Balance

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay
Home Health Care—Medicare-Approved Services
Medically necessary skilled care services 100% $0 $0
and medical supplies
Durable medical equipment $0 $0 $233
80% 20% (Part B deductible)
First $233 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts

Other Benefits—Not Covered By Medicare

Services Medicare Pays Plan Pays You Pay
Outpatient Prescription
Drugs—Not Covered by Medicare $0 $0 All costs

Fitness Program—Not Covered by Medicare $0 $150 per All charges after
calendar year $150
Weight-Loss Program—Not Covered by Medicare All charges
$0 $150 per after $150
Foreign Travel—Not Covered by Medicare calendar year
Only the services listed above while traveling outside $0
the United States Remainder of

$0 charges (including
portion normally

paid by Medicare)

**Once you have been billed $233 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 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 18

 Medicare Plan Sales: 1-800-678-2265
Member Service: 1-800-258-2226 (TTY: 711)
BLUE CROSS Monday through Friday,
BLUE SHIELD 8:00 a.m. to 5:00 p.m. ET.
RESOURCES 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, 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).

® 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.

001034528 32-3000-22 V2 (12/21)

JOIN US AND LEARN MORE ABOUT MEDICARE

Find out how Medicare works, get answers to your questions, and learn about
our extensive plan options, including Medicare Advantage plans (HMO and PPO),
Medicare Supplement plans (Medigap), and Prescription Drug Plans (PDP).

topics We Cover

We offer different plan seminars several days a week. Topics include:

    

Medicare Original Prescription Dental GeoBlue®
Advantage Medicare Drug Plans Blue® 65 Travel Insurance
(HMO and PPO) and Medex®´
(Medicare (PDP)
Supplement)

See the Full List Can’t Attend? No Problem!
of Upcoming Seminars
Call us to speak to one of our sales
Visit bluecrossma.com/seminar representatives directly at
for the latest list of dates and times, 1-800-678-2265 (TTY: 711 ),
and to register for a seminar or watch
April 1 through September 30,
a pre-recorded webinar. 8:00 a.m. to 8:00 p.m. ET,
For assistance with registering, call Monday through Friday, or

1-800-262-BLUE (2583) (TTY: 711) October 1 through March 31,
7:00 a.m.–12:00 midnight, seven days a week 8:00 a.m. to 8:00 p.m. ET,
seven days a week.
(excluding holidays).

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

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 1-800-678-2265 (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.

000887105 99-0645-22 (9/21)

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, sticking with us
could qualify you for these savings on your premium when you enroll in Medex®´:

15% 10% 5%

FIRST-YEAR SECOND-YEAR THIRD-YEAR
SAVINGS SAVINGS SAVINGS

To determine if you’re eligible for the discount, call 1-800-678-2265.

How These Savings Work

Plan Full Rate* First Year: Second Year: Third Year:
15% Discount* 10% Discount* 5% Discount*
Medex Core $113.58 $107.90
Medex Sapphire $190.55 $96.55 $102.22 $181.02
Medex Bronze $226.29 $214.98
$161.97 $171.50

$192.35 $203.66

*Rates effective January 1, 2022 to December 31, 2022

Benefits for a Healthier You • Vision and Hearing—Easily add a vision
and hearing benefit to your Medex plan
• MyBlue—Tap into all of your plan’s benefits, by calling us at the number below.
all in one place. Sign up at bluecrossma.org,
or download the MyBlue app. • Dental Blue® 65—Complement your plan
with dental benefits to smile about.
• Fitness and Weight-Loss Reimbursements— Call us to learn more.
Medex members are eligible for up to $150
a year for each reimbursement. • eBilling—Conveniently pay your bills online.

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



Learn More

For more information, visit bluecrossma.com/medicare,
or call us at 1-800-678-2265 (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,
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).

® 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.

000895198 99-0290-22 (9/21)

Medex®´ Core, Medex®´ Sapphire,
Medex®´ Bronze

VISION AND
HEARING BENEFITS

If you have a direct-billed
Medex Core, Medex Sapphire,
or Medex Bronze plan,
take a look at these
benefits. They’ll help cover
your vision and hearing
expenses, while limiting
your out-of-pocket costs.

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

COMPLETE YOUR COVERAGE

Glasses and hearing aids aren’t covered by Medicare. That’s why our Medex®´
Vision and Hearing benefit plan offers the coverage you’re missing. Plus, from
January 1, 2022 to December 31, 2022, it’s just $2.52 per month. This amount
will be added to your direct-billed Medex premium. With the Medex Vision
and Hearing plan, you’ll get the following benefits:

Hearing Care Benefits Vision Care Benefits

• Routine hearing exams: Covers one routine • Routine vision exams: Covers one routine
hearing exam per calendar year, when the vision exam per calendar year to determine if
exam is furnished by a TruHearing®´´ network you need corrective lenses. You pay nothing
provider. You pay nothing when seen by a when seen by an EyeMed®´´ network provider.
TruHearing network provider.
• Eyeglasses or contact lenses: Covers up
• Hearing aids: Coverage for one hearing aid to $1501 per calendar year for one set of
per hearing impaired ear per calendar year, frames and prescription lenses or contact
when furnished by a TruHearing supplier. lenses (in place of eyeglasses), from any
You pay $699 or $999 for each covered licensed vision care supplier. If you choose to
TruHearing hearing aid.2 purchase eyeglasses or contact lenses from
an EyeMed supplier, you may be eligible to
What if the licensed hearing care provider receive additional discounts from the supplier
is not an TruHearing provider? for your vision supplies. This $150 benefit
No coverage is provided for routine hearing payment includes costs for measurement,
exams furnished by providers that are not fitting, and adjustments.
TruHearing providers.
What if the licensed vision care provider
What if the hearing care supplier is not is not an EyeMed provider?
an TruHearing supplier? When your exam is furnished by a provider
No coverage is provided for hearing aids that are that is not an EyeMed provider, the provider
not purchased from a TruHearing supplier and may ask you to pay all charges. In this case,
hearing aids that are not TruHearing‑branded you will have to send a claim to EyeMed for
hearing aids. If you have additional benefit repayment of up to $50 for a covered exam.
questions, please call TruHearing Member
Service at 1-844-813-8129, Monday through What if the vision care supplier is not
Friday, 6:00 a.m. to 7:00 p.m. ET. an EyeMed supplier?
When you purchase eyeglasses or contact
lenses from a supplier that is not an EyeMed
supplier, the supplier may ask you to pay all
charges. If this happens, you will have to send
a claim to EyeMed for repayment of up to
$150 for covered eyeglasses or contact lenses.
Complete the claim form and send it with
your original itemized bill(s). If you need a
claim form, call EyeMed Member Service at
1-866-525-5126, October 1‑March 31: Sunday
through Saturday, 8:00 a.m. to 11:00 p.m. ET;
April 1‑September 30: Monday through
Saturday, 8:00 a.m. to 11:00 p.m. ET and
Sunday 11:00 a.m. to 8:00 p.m. ET.

HOW TO GET REIMBURSED

It’s easy to get reimbursed for vision and hearing care services.

 

BUY YOUR GLASSES, FILE A CLAIM WITH
CONTACTS, OR HEARING AID(S) BLUE CROSS BLUE SHIELD

Your provider may ask you OF MASSACHUSETTS
to pay all charges at the time of Complete a claim form and send
your purchase or at a later date. it in with your original itemized

bill(s) for repayment.

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

Enroll by mail or fax:

Complete the application for Direct-Billed Medex.
Mail to: Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-1753
Or fax to:1-617-246-3633.

1. No coverage is provided for amounts more than $150 per are delivered, and the services rendered to the insured
calendar year; orthoptic or vision training, subnormal vision person are within 31 days from the date of such order;
aids and any associated supplemental testing; Aniseikonic services or materials provided by any other group benefit
lenses; medical and/or surgical treatment of the eye, eyes, plan providing vision care; lost or broken lenses, frames,
or supporting structures; any eye or vision examination, glasses, or contact lenses will not be replaced except in
or any corrective eyewear required by a policyholder as a the next benefit frequency when vision materials would
condition of employment; safety eyewear services provided next become available.
as a result of any Workers’ Compensation law, or similar
legislation, or required by any governmental agency or 2. No coverage is provided for hearing aids that are not
program whether federal, state, or subdivisions thereof; purchased from a TruHearing supplier; hearing aids that are
Plano (non-prescription) lenses and/or contact lenses; not TruHearing-branded hearing aids; ear molds; hearing
non-prescription sunglasses; two pair of glasses in lieu aid accessories; additional costs for optional hearing aid
of bifocals; services rendered after the date an insured rechargeability; costs associated with loss and damage
person ceases to be covered under the policy, except warranty claims; and replacement hearing aid batteries
when vision materials ordered before coverage ended beyond the set number of batteries that are provided by
TruHearing at the time of the hearing aid purchase.

 Medicare Plan Sales:

FOR MORE 1-800-678-2265 (TTY: 711)
INFORMATION, 8:00 a.m. to 5:00 p.m. ET, Monday through Friday
OR TO ENROLL: 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.
®´´ Registered Marks are the property of their respective owners.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

000908752 55‑000405190‑22 (10/21)

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 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. 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.
000893478 55-2067 (9/21)



Translation Resources

Proficiency of Language ATsRsAisNtSaLnAcTeIOSNeRrvEiScOeUsRCES

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: LƯUÝ: Nếu quý vị nóiTiếngViệt,các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho
quý vị miễnphí.Gọi cho Dịch vụ Hội viêntheosố trên thẻ ID của quý vị (TTY: 711).
Russian/Русский: ВНИМАНИЕ:если Выговорите по-русски,Выможете воспользоваться бесплатными
услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанномув Вашей
идентификационнойкарте (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/ខ្រែម : ការជូនដំណឹ ង៖ ប្រសិនប្រើអនក្ និយាយភាសា ខ្មែរ
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អន្ក។ សូមទូរស័ព្ទបៅខ្ន្កបសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណណ្ សរាគា េ់្ួលៃនរ្រស់អ្នក (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/Eλληνικά: 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 AssociationBlue 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 दंे: ्दद आप दिनददी बोलते िंै, तो भयाषया सिया्तया सेवयाएँ, आप कके रलंे ल(टएदी.टनदीन.व:शयाईलु .:क711).
उपलब्ध िंै। सदस् सेवयाओं को आपके आई.डी. कयाडड् पर ददए गए नबं र पर कॉल

Gujarati/ગુજરાતી: ધ્યાન આપો: જો તમે ગજુ રયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મૂલ્ે 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
່ໍLບaເoສ/ຍພຄ່ າາສ.າໂລທາຫວາ:ຝໍ່ຂ້ າຄຍວໍບນິລໃກສ່ າໃຈນ:ສຖະ້ ມາເາົຈ້ິຊາກເົວ່ີທ້ າໝພາາສຍາເລລາກວໂໄທດ້ ລ, ະີມສັ ກບາຢູ່ ນໃໍບນິລບັ ກດາຂນອຊ່ ງວທ່ ຍາເນືຫຼ (ອTTດ້ Yາ:ນ7ພ11າ)ສ. າໃຫ້ ທ່ ານໂດຍ
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).

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2021 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue CrossBlue 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.
000893531 and Blue Shield of Massachusetts HMO Blue, Inc. 55-2066-22 (6/21)164711MB
55-1493 (8/16)

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
• Please print clearly. of the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications will not be and you actually live in Massachusetts.
accepted. 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
• Please complete and return to: for Medicare coverage because
Blue Cross Blue Shield of Massachusetts of disability.
Enrollment Department
P.O. Box 55011 Notes: Medex Bronze shall, on or after
Boston, MA 02205 January 1, 2020, only be offered to eligible
• Or, fax the application to 1-617-246-3633. persons who: (a) have attained 65 years
• To enroll by phone, call 1-800-678-2265. of age before January 1, 2020; or (b) first
• Medex premium rates and benefits are became eligible for Medicare due to
explained in the booklet you received age or disability before January 1, 2020.
with this application. If you need more Those who are otherwise eligible for
information or assistance, call us at Medicare Part A and B and who are
1-800-678-2265. enrolled in Medicare Part B, but who
• For all other questions, call: aren’t eligible to purchase Medex
Medex Member Service: Bronze, shall be eligible to purchase
1-800-258-2226 (TTY: 711) all other Direct Billed Medex plans that
are currently offered.
If you’re covered by Medicaid, you may
or may not be eligible to enroll in Direct
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.

Check the Medex plan of your choice: Medex Core with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core) Medex Sapphire with Vision and Hearing Benefit
Medex Sapphire (Medicare Supplement 1A) Medex Bronze with Vision and Hearing Benefit
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 (—M M—/—D D—/—Y —Y —Y —Y )
() –

Your permanent home address:
Number and Street

City: State: ZIP Code:

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 Code:

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 below section, then answer questions 1 through 5.

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

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

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

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 six 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” and haven’t
(b) Did you enroll in Medicare Part B in the last met your “Share of Cost,” please answer NO to this
six months? Yes No question.] Yes No

(c) If Yes, what is the effective If Yes,
date?_______________
(a) Will Medicaid pay your premiums for this
Medicare 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
than original Medicare within the past 63 days policy 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
(b) If you’re still covered under the Medicare plan, Medicare 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 plan? (For example, an employer, union, or individual 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 1-800-678-2265 (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.

000908805 55-0936-22 (9/21)

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
• Please print clearly. of the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications will not be and you actually live in Massachusetts.
accepted. 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
• Please complete and return to: for Medicare coverage because
Blue Cross Blue Shield of Massachusetts of disability.
Enrollment Department
P.O. Box 55011 Notes: Medex Bronze shall, on or after
Boston, MA 02205 January 1, 2020, only be offered to eligible
• Or, fax the application to 1-617-246-3633. persons who: (a) have attained 65 years
• To enroll by phone, call 1-800-678-2265. of age before January 1, 2020; or (b) first
• Medex premium rates and benefits are became eligible for Medicare due to
explained in the booklet you received age or disability before January 1, 2020.
with this application. If you need more Those who are otherwise eligible for
information or assistance, call us at Medicare Part A and B and who are
1-800-678-2265. enrolled in Medicare Part B, but who
• For all other questions, call: aren’t eligible to purchase Medex
Medex Member Service: Bronze, shall be eligible to purchase
1-800-258-2226 (TTY: 711) all other Direct Billed Medex plans that
are currently offered.
If you’re covered by Medicaid, you may
or may not be eligible to enroll in Direct
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.

Check the Medex plan of your choice: Medex Core with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core) Medex Sapphire with Vision and Hearing Benefit
Medex Sapphire (Medicare Supplement 1A) Medex Bronze with Vision and Hearing Benefit
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 (—M M—/—D D—/—Y —Y —Y —Y )
() –

Your permanent home address:
Number and Street

City: State: ZIP Code:

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 Code:

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 below section, then answer questions 1 through 5.

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

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

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

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 six 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” and haven’t
(b) Did you enroll in Medicare Part B in the last met your “Share of Cost,” please answer NO to this
six months? Yes No question.] Yes No

(c) If Yes, what is the effective If Yes,
date?_______________
(a) Will Medicaid pay your premiums for this
Medicare 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
than original Medicare within the past 63 days policy 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
(b) If you’re still covered under the Medicare plan, Medicare 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 plan? (For example, an employer, union, or individual 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 1-800-678-2265 (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.

000908805 55-0936-22 (9/21)



 Medicare Plan Sales:

FOR MORE 1-800-678-2265 (TTY: 711)
INFORMATION, 8:00 a.m. to 5:00 p.m. ET, Monday through Friday
OR TO ENROLL: 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. © 2021 Blue Cross and Blue Shield
of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000893637 99-0680-22 (9/21)