BCBSMA PPO SalesKit Book 03/01/2019 Approved by Angela Gagnon 02/25/2019 3:26 PM

Our Commitment to Confidentiality

This Notice describes how medical information about you
may be used and disclosed and how you can get access to
this information. Please review it carefully.

Our Commitment: We respect your right to privacy. We will not disclose personally
identifiable information about you without your permission, unless the disclosure is
necessary to provide our services to you or is otherwise in accordance with the law.

Collection of Information

We collect only personal or medical information we need to carry out our business.
• Examples of personal information are name, address, date of birth, and social security number.

Most often, you and your employer supply this information to enroll you in a plan.
• Examples of medical information are diagnoses, treatments, and names of providers who treat

you. Most often, your providers supply this information.

Use and Disclosure of Information

We are required by law to protect the confidentiality of your personal and medical information and
to notify you in case of a breach affecting your personal or medical information. We will supply
your information to you upon your request or to help you understand treatment options and other
benefits available to you.

We also may use and disclose your information without your written authorization for the
following purposes, and as otherwise permitted or required by law:

• Treatment—to help providers manage or coordinate your health care and related services.
For example, to refer you to another provider or remind you of appointments.

• Payment—to obtain payment for your coverage, provide you with health benefits, and assist
another health plan or provider in its payment activities. For example, to manage enrollment
records, make coverage determinations, administer claims, or coordinate benefits with other
coverage you may have.

• Health Care Operations—to operate our business, including accreditation, credentialing,
customer service, disease management, and fraud-prevention activities. For example,
to do business planning, arrange for medical review, or conduct quality assessment and
improvement activities.

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

• Legal Compliance—to comply with applicable laws. For example, to respond to regulatory
authorities responsible for oversight of government benefit programs or our operations; to
parties or courts in the course of judicial or administrative proceedings; to law enforcement
officials duringan investigation; and as necessary to comply with workers’ compensation laws.

• Research and Public Health—for medical research studies in accordance with laws for the
protection of human research subjects, and to report to public health authorities and otherwise
prevent or lessen a serious and imminent threat to health or safety. For example, for the
purpose of preventing or controlling disease, injury, or disability.

• To an Account (such as an employer) or Party It Designates—for administration of its
health plan. For example, to a self-insured account for claim review and audits. We will disclose
your information only to designated individuals. That, along with contract obligations, helps
protect your information from unauthorized use.

To carry out these purposes, we share information with entities that perform functions for us
subject to contracts that limit use and disclosure to intended purposes. We use physical, electronic,
and procedural safeguards to protect your privacy. Even when allowed, uses and disclosures are
limited to the minimum amount reasonably necessary for the intended task.

Special Notes Regarding Disclosure

Special protections apply to information about certain medical conditions. For example, with very
few exceptions allowed by law, we will not disclose any information regarding HIV or AIDS to
any party without your written permission. We will not disclose mental health treatment records
to you without first receiving approval from your treating provider or another equally qualified
mental health professional. Also, we are prohibited from using or disclosing genetic information
for underwriting purposes.

Except as provided in this notice, we will not use or disclose your personal or medical information
without your written authorization. A form for this purpose is available on our website or by calling
Member Service. Specifically, we must have your written authorization to use or disclose your
information for:

• Marketing purposes;

• The sale of PHI;

• Most use and disclosures of psychotherapy notes.

You may revoke your authorization at any time. Your authorization must be in writing. Your
revocation will not affect any action that we have already taken in reliance on your authorization.

Your Privacy Rights

You have the following rights with respect to your personal and medical information. To exercise
any of these rights, contact us using the information listed at the end of this notice.

• You have the right to receive information about privacy protections. Your member-education
materials include a notice of your rights, and you may request a paper copy of this notice at
any time.

• You have the right to inspect and get copies of information we collect about you. We will
provide access to this information within 30 days of receiving a written request. We may
charge a reasonable fee for copying and mailing records. You may also ask your providers for
access to your records.

• You have the right to receive an accounting of disclosures. Your request must be in writing.
Our response will exclude any disclosures made in support of treatment, payment, and health
care operations or that you authorized (among others). An example of a disclosure that would
be reported to you is a disclosure of your information in response to a subpoena.

• You have the right to ask us to correct or amend information you believe to be incorrect.
Your request to correct, amend, or delete information should be in writing. We will notify you if
we make an adjustment as a result of your request. If we do not make an adjustment, we will
send you a letter explaining why within 30 days. In this case, you may ask us to make your
request part of your records, or ask the commissioner of insurance to review our decision. We
may also provide notice of your requested changes to others who received this information in
the past two years.

• You have the right to designate someone to receive information and interact with us on
your behalf. Your personal representative has the same rights concerning your information as
you. Your designation and any subsequent revocation must be in writing, and a form for this
purpose is available on our website or by calling Member Service.

• You have the right to ask that we restrict or refuse to disclose personally identifiable
information, and that we direct communications to you by alternative means or to
alternative locations. While we may not always be able to agree, we will make reasonable
efforts to accommodate requests. Your request and any subsequent revocation must be in
writing.

• If you believe your privacy rights have been violated, you have the right to complain to us,
using the standard grievance process outlined in your benefit materials, or to the secretary
of the U.S. Department of Health and Human Services, without fear of retaliation.

About This Notice

This notice is effective September 23, 2013. We are required by law to provide this notice to you
and to abide by it while it is in effect. We reserve the right to change this notice. Any changes will
apply to all personal and medical information that we maintain, regardless of when it was created or
received. Before we make any material changes in our privacy practices, we will post a new notice
on our website. We will provide information about the changes to our privacy practices and how to
obtain a new notice in our next annual mailing to members who are then covered by one of our
health plans.

If you have any questions, contact Member Service. We’re here to help. Please call the Member
Service toll-free number on the front of your ID card or visit our website at
www.bluecrossma.com.

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts

HMO Blue, Inc.

189249 Y0014_18157_C 37-0830 (09/18)

04

Enrollment



Medicare PPO Blue SaverRx (PPO) 2019
Medicare PPO Blue ValueRx (PPO)
Medicare PPO Blue PlusRx (PPO)

To Complete Your Enrollment Form:

Be sure to complete all information, sign, and date your enrollment form. Please keep a copy of the
enrollment form for your records. Return the completed form(s) in the enclosed envelope. If you lose the return
envelope, mail your application to: Blue Cross Blue Shield of Massachusetts, Enrollment Department,
P.O. Box 55011, Boston, MA 02205. We will contact you in writing when we receive your enrollment form,
and then again to notify you of your effective date.

To Enroll in Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx,
or Medicare PPO Blue PlusRx, Please Provide the Following Information:

Medicare PPO Medicare PPO Medicare PPO
Blue SaverRx Blue ValueRx Blue PlusRx

Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, $0 $76 $262
Middlesex, Norfolk, Plymouth, Suffolk counties per month per month per month
Worcester County $0 $86 $262
per month per month per month

Last Name First Name Middle Initial Mr. Mrs. Ms.

Birth Date (MM/DD/YYYY) Sex Email Address Home Phone Number

// MF ()–

Permanent Residence Street Address (P.O. Box is not allowed) Alternate Phone Number

Number and Street ()–

City State Zip Code

Mailing Address (only if different from your Permanent Residence Address) Zip Code
Number and Street
City State

Emergency Contact Name Phone Number Relationship
to You

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare Name (as it appears on your Medicare card):
card to complete this section.
• Fill out this information as it appears Medicare Number: Effective Date:
on your Medicare card. Is Entitled to:
-OR-
• Attach a copy of your Medicare card Hospital (Part A)
or your letter from Social Security or the
Railroad Retirement Board. Medical (Part B)
You must have Medicare Part A and Part B
to join a Medicare Advantage plan.

Blue Cross Blue Shield of Massachusetts is an Independent H2230_1879_C
Licensee of the Blue Cross and Blue Shield Association

Paying Your Plan Premium

If you enroll in our $0 premium plan and we determine that you owe a late enrollment penalty (or if you
currently have a late enrollment penalty), we will send you a paper bill for your monthly late enrollment
penalty. If you receive a paper bill and are interested in learning more about our alternative payment
options, please contact our Member Service Department at 1-800-200-4255, (TTY: 711).

For other plan options, you can pay your monthly plan premium (including any late enrollment penalty
that you currently have or may owe) by mail, Electronic Funds Transfer (EFT) each month. You can also
choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement
Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly
Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible
for paying this extra amount in addition to your plan premium. You will either have the amount withheld
from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Medicare
HMO Blue SaverRx/ValueRx/FlexRx/PlusRx the Part D-IRMAA.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible,
Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage
gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For
more information about this Extra Help, contact your local Social Security office, or call Social Security
at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at
www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all
or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the
amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:
Get a bill monthly
Electronic Funds Transfer (EFT) from your bank account each month. We will send you a brochure and
form to enroll. (Please pay your premium by mail until you receive notification that your EFT payment
option is activated.)

Automatic deduction from your monthly
Social Security or
Railroad Retirement Board (RRB) benefit check

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB
approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic
deduction, the first deduction from your Social Security or RRB benefit check will include all premiums
due from your enrollment effective date up to the point withholding begins. If Social Security or RRB
does not approve your request for automatic deduction, we will send you a paper bill for your monthly
premiums.)

Please Read and Answer These Important Questions

1. Do you have End Stage Renal Disease (ESRD)? Yes No
If you have had a successful kidney transplant and/or you don’t need regular dialysis No
any more, please attach a note or records from your doctor showing you have had
a successful kidney transplant or you don’t need dialysis, otherwise we may need to
contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, Yes
TRICARE, Federal employee health benefits coverage, VA benefits, or state
pharmaceutical assistance programs. Will you have other prescription drug coverage in
addition to Medicare PPO Blue SaverRx/ValueRx/PlusRx?

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage

Name of other coverage:

ID# for this coverage:

Group# for this coverage:

3. Do you, either on your own or through your spouse, have any health coverage other than Yes No
Medicare, such as private insurance?

What kind of coverage? Name of your insurance company

4. Are you a resident in a long-term care facility, such as a nursing home? Yes No

If “yes”, please provide the following information:
Name & Address of Institution:

Phone Number of Institution: Yes No
5. Are you enrolled in your State Medicaid program?

If “yes”, please provide your Medicaid Number:

6. Do you or your spouse work? Yes No

7. Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period
from October 15 through December 7 of each year. There are exceptions that may allow you to enroll
in a Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you.
By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible
for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
Please check any statement below that is true for you. We may contact you for additional information.

I am new to Medicare.

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage
Open Enrollment Period (MA OEP).

I recently moved outside of the service area formy current plan or I recently moved and this plan is a new
option for me. I moved on (insert date) _______________________.

I recently was released from incarceration. I was released on (insert date) _______________________.

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on
(insert date) _______________________.

I recently obtained lawful presence status in the United States. I got this status on (insert date)
_______________________.

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or
lost Medicaid) on (insert date) _______________________.

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra
Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) _______________________.

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help
paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or
long term care facility). I moved/will move into/out of the facility on (insert date)_______________________.

I recently left a PACE program on (insert date) ___________________________.

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost
my drug coverage on (insert date) _________________________.

I am leaving employer or union coverage on (insert date) _______________________.

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that
plan started on (insert date) _______________________.

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in
that plan. I was disenrolled from the SNP on (insert date) _____________________________.

I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency
Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my
enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact Member Service at the number
listed below to see if you are eligible to enroll

Please contact Member Service at the number listed below if you need information in an accessible format
such as large print or braille.

Please choose the name of a Provider of Choice (POC): Please list your POC’s ID Number: Yes No

Are you a current patient?

Questions? Contact Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET,
Monday–Friday, from Apr. 1 to Sept. 30; and 8:00 a.m. to 8:00 p.m. ET, 7 days a week, from Oct. 1 to Mar. 31.

STOP Please Read This Important Information STOP

If you currently have health coverage from an employer or union, joining Medicare PPO Blue
SaverRx/ValueRx/PlusRx could affect your employer or union health benefits. You could lose your
employer or union health coverage if you join Medicare PPO Blue SaverRx/ValueRx/PlusRx. Read the
communications your employer or union sends you. If you have questions, visit their website, or contact
the office listed in their communications. If there isn’t any information on whom to contact, your benefits
administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

Medicare PPO Blue SaverRx/ValueRx/PlusRx is a Medicare Advantage plan and has a contract with the federal
government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a
time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare
health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that
I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave
this plan or make changes only at certain times of the year when an enrollment period is available (Example:
October 15–December 7 of every year), or under certain special circumstances.

Medicare PPO Blue SaverRx/ValueRx/PlusRx serves a specific service area. If I move out of the area that
Medicare PPO Blue SaverRx/ValueRx/PlusRx serves, I need to notify the plan so I can disenroll and find a new
plan in my new area. Once I am a member of Medicare PPO Blue SaverRx/ValueRx/PlusRx, I have the right to
appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document
from Medicare PPO Blue SaverRx/ValueRx/PlusRx when I get it to know which rules I must follow to get
coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered
under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Medicare PPO Blue SaverRx/ValueRx/PlusRx coverage begins, using
services in-network can cost less than using services out-of-network, except for emergency or urgently needed
services or out-of-area dialysis services. If medically necessary, Medicare PPO Blue SaverRx/ValueRx/PlusRx
provides refunds for all covered benefits, even if I get services out-of-network. Services authorized by Medicare
PPO Blue SaverRx/ ValueRx/PlusRx and other services contained in my Medicare PPO Blue SaverRx/ValueRx/
PlusRx Evidence of Coverage document (also known as a member contract or subscriber agreement) will be
covered. Without authorization, NEITHER MEDICARE NOR MEDICARE PPO BLUE SAVERRX/VALUERX/
PLUSRX WILL PAY FOR THE SERVICES.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by
or contracted with Medicare PPO Blue SaverRx/ValueRx/PlusRx, he/she may be paid based on my
enrollment in Medicare PPO Blue SaverRx/ValueRx/PlusRx.

Release of Information: By joining this Medicare health plan, I acknowledge that Medicare PPO Blue
SaverRx/ ValueRx/ PlusRx will release my information to Medicare and other plans as is necessary for
treatment, payment, and health care operations. I also acknowledge that Medicare PPO Blue SaverRx/
ValueRx/PlusRx will release my information, including my prescription drug event data to Medicare,
who may release it for research and other purposes which follow all applicable Federal statutes and
regulations. The information on this enrollment form is correct to the best of my knowledge. I understand
that my signature (or the signature of the person authorized to act on my behalf under the laws of the state
where I live) on this application means that I have read and understand the contents of this application.
If signed by an authorized individual (as described above), this signature certifies that:
1) this person is authorized under state law to complete this enrollment and
2) documentation of this authority is available upon request from Medicare.

Your Signature Today’s Date

If you are the authorized representative, you must sign above and provide the following information:

Name Phone Number: ( )

Address Relationship to Enrollee

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. 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.

®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross

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

188153M 55-0171-19 (09/18)

Medicare PPO Blue SaverRx (PPO) 2019
Medicare PPO Blue ValueRx (PPO)
Medicare PPO Blue PlusRx (PPO)

To Complete Your Enrollment Form:

Be sure to complete all information, sign, and date your enrollment form. Please keep a copy of the
enrollment form for your records. Return the completed form(s) in the enclosed envelope. If you lose the return
envelope, mail your application to: Blue Cross Blue Shield of Massachusetts, Enrollment Department,
P.O. Box 55011, Boston, MA 02205. We will contact you in writing when we receive your enrollment form,
and then again to notify you of your effective date.

To Enroll in Medicare PPO Blue SaverRx, Medicare PPO Blue ValueRx,
or Medicare PPO Blue PlusRx, Please Provide the Following Information:

Medicare PPO Medicare PPO Medicare PPO
Blue SaverRx Blue ValueRx Blue PlusRx

Barnstable, Bristol, Essex, Franklin, Hampden, Hampshire, $0 $76 $262
Middlesex, Norfolk, Plymouth, Suffolk counties per month per month per month
Worcester County $0 $86 $262
per month per month per month

Last Name First Name Middle Initial Mr. Mrs. Ms.

Birth Date (MM/DD/YYYY) Sex Email Address Home Phone Number

// MF ()–

Permanent Residence Street Address (P.O. Box is not allowed) Alternate Phone Number

Number and Street ()–

City State Zip Code

Mailing Address (only if different from your Permanent Residence Address) Zip Code
Number and Street
City State

Emergency Contact Name Phone Number Relationship
to You

Please Provide Your Medicare Insurance Information

Please take out your red, white and blue Medicare Name (as it appears on your Medicare card):
card to complete this section.
• Fill out this information as it appears Medicare Number: Effective Date:
on your Medicare card. Is Entitled to:
-OR-
• Attach a copy of your Medicare card Hospital (Part A)
or your letter from Social Security or the
Railroad Retirement Board. Medical (Part B)
You must have Medicare Part A and Part B
to join a Medicare Advantage plan.

Blue Cross Blue Shield of Massachusetts is an Independent H2230_1879_C
Licensee of the Blue Cross and Blue Shield Association

Paying Your Plan Premium

If you enroll in our $0 premium plan and we determine that you owe a late enrollment penalty (or if you
currently have a late enrollment penalty), we will send you a paper bill for your monthly late enrollment
penalty. If you receive a paper bill and are interested in learning more about our alternative payment
options, please contact our Member Service Department at 1-800-200-4255, (TTY: 711).

For other plan options, you can pay your monthly plan premium (including any late enrollment penalty
that you currently have or may owe) by mail, Electronic Funds Transfer (EFT) each month. You can also
choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement
Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly
Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible
for paying this extra amount in addition to your plan premium. You will either have the amount withheld
from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Medicare
HMO Blue SaverRx/ValueRx/FlexRx/PlusRx the Part D-IRMAA.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible,
Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums,
annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage
gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For
more information about this Extra Help, contact your local Social Security office, or call Social Security
at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at
www.socialsecurity.gov/prescriptionhelp.

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all
or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the
amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:
Get a bill monthly
Electronic Funds Transfer (EFT) from your bank account each month. We will send you a brochure and
form to enroll. (Please pay your premium by mail until you receive notification that your EFT payment
option is activated.)

Automatic deduction from your monthly
Social Security or
Railroad Retirement Board (RRB) benefit check

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB
approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic
deduction, the first deduction from your Social Security or RRB benefit check will include all premiums
due from your enrollment effective date up to the point withholding begins. If Social Security or RRB
does not approve your request for automatic deduction, we will send you a paper bill for your monthly
premiums.)

Please Read and Answer These Important Questions

1. Do you have End Stage Renal Disease (ESRD)? Yes No
If you have had a successful kidney transplant and/or you don’t need regular dialysis No
any more, please attach a note or records from your doctor showing you have had
a successful kidney transplant or you don’t need dialysis, otherwise we may need to
contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, Yes
TRICARE, Federal employee health benefits coverage, VA benefits, or state
pharmaceutical assistance programs. Will you have other prescription drug coverage in
addition to Medicare PPO Blue SaverRx/ValueRx/PlusRx?

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage

Name of other coverage:

ID# for this coverage:

Group# for this coverage:

3. Do you, either on your own or through your spouse, have any health coverage other than Yes No
Medicare, such as private insurance?

What kind of coverage? Name of your insurance company

4. Are you a resident in a long-term care facility, such as a nursing home? Yes No

If “yes”, please provide the following information:
Name & Address of Institution:

Phone Number of Institution: Yes No
5. Are you enrolled in your State Medicaid program?

If “yes”, please provide your Medicaid Number:

6. Do you or your spouse work? Yes No

7. Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period
from October 15 through December 7 of each year. There are exceptions that may allow you to enroll
in a Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you.
By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible
for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.
Please check any statement below that is true for you. We may contact you for additional information.

I am new to Medicare.

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage
Open Enrollment Period (MA OEP).

I recently moved outside of the service area formy current plan or I recently moved and this plan is a new
option for me. I moved on (insert date) _______________________.

I recently was released from incarceration. I was released on (insert date) _______________________.

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on
(insert date) _______________________.

I recently obtained lawful presence status in the United States. I got this status on (insert date)
_______________________.

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or
lost Medicaid) on (insert date) _______________________.

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra
Help, had a change in the level of Extra Help, or lost Extra Help) on (insert date) _______________________.

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help
paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or
long term care facility). I moved/will move into/out of the facility on (insert date)_______________________.

I recently left a PACE program on (insert date) ___________________________.

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost
my drug coverage on (insert date) _________________________.

I am leaving employer or union coverage on (insert date) _______________________.

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that
plan started on (insert date) _______________________.

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in
that plan. I was disenrolled from the SNP on (insert date) _____________________________.

I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency
Management Agency (FEMA). One of the other statements here applied to me, but I was unable to make my
enrollment because of the natural disaster.

If none of these statements applies to you or you’re not sure, please contact Member Service at the number
listed below to see if you are eligible to enroll

Please contact Member Service at the number listed below if you need information in an accessible format
such as large print or braille.

Please choose the name of a Provider of Choice (POC): Please list your POC’s ID Number: Yes No

Are you a current patient?

Questions? Contact Member Service at 1-800-200-4255 (TTY: 711), 8:00 a.m. to 8:00 p.m. ET,
Monday–Friday, from Apr. 1 to Sept. 30; and 8:00 a.m. to 8:00 p.m. ET, 7 days a week, from Oct. 1 to Mar. 31.

STOP Please Read This Important Information STOP

If you currently have health coverage from an employer or union, joining Medicare PPO Blue
SaverRx/ValueRx/PlusRx could affect your employer or union health benefits. You could lose your
employer or union health coverage if you join Medicare PPO Blue SaverRx/ValueRx/PlusRx. Read the
communications your employer or union sends you. If you have questions, visit their website, or contact
the office listed in their communications. If there isn’t any information on whom to contact, your benefits
administrator or the office that answers questions about your coverage can help.

Please Read and Sign Below

By completing this enrollment application, I agree to the following:

Medicare PPO Blue SaverRx/ValueRx/PlusRx is a Medicare Advantage plan and has a contract with the federal
government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a
time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare
health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that
I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave
this plan or make changes only at certain times of the year when an enrollment period is available (Example:
October 15–December 7 of every year), or under certain special circumstances.

Medicare PPO Blue SaverRx/ValueRx/PlusRx serves a specific service area. If I move out of the area that
Medicare PPO Blue SaverRx/ValueRx/PlusRx serves, I need to notify the plan so I can disenroll and find a new
plan in my new area. Once I am a member of Medicare PPO Blue SaverRx/ValueRx/PlusRx, I have the right to
appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document
from Medicare PPO Blue SaverRx/ValueRx/PlusRx when I get it to know which rules I must follow to get
coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered
under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Medicare PPO Blue SaverRx/ValueRx/PlusRx coverage begins, using
services in-network can cost less than using services out-of-network, except for emergency or urgently needed
services or out-of-area dialysis services. If medically necessary, Medicare PPO Blue SaverRx/ValueRx/PlusRx
provides refunds for all covered benefits, even if I get services out-of-network. Services authorized by Medicare
PPO Blue SaverRx/ ValueRx/PlusRx and other services contained in my Medicare PPO Blue SaverRx/ValueRx/
PlusRx Evidence of Coverage document (also known as a member contract or subscriber agreement) will be
covered. Without authorization, NEITHER MEDICARE NOR MEDICARE PPO BLUE SAVERRX/VALUERX/
PLUSRX WILL PAY FOR THE SERVICES.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by
or contracted with Medicare PPO Blue SaverRx/ValueRx/PlusRx, he/she may be paid based on my
enrollment in Medicare PPO Blue SaverRx/ValueRx/PlusRx.

Release of Information: By joining this Medicare health plan, I acknowledge that Medicare PPO Blue
SaverRx/ ValueRx/ PlusRx will release my information to Medicare and other plans as is necessary for
treatment, payment, and health care operations. I also acknowledge that Medicare PPO Blue SaverRx/
ValueRx/PlusRx will release my information, including my prescription drug event data to Medicare,
who may release it for research and other purposes which follow all applicable Federal statutes and
regulations. The information on this enrollment form is correct to the best of my knowledge. I understand
that my signature (or the signature of the person authorized to act on my behalf under the laws of the state
where I live) on this application means that I have read and understand the contents of this application.
If signed by an authorized individual (as described above), this signature certifies that:
1) this person is authorized under state law to complete this enrollment and
2) documentation of this authority is available upon request from Medicare.

Your Signature Today’s Date

If you are the authorized representative, you must sign above and provide the following information:

Name Phone Number: ( )

Address Relationship to Enrollee

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. 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.

®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross

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

188153M 55-0171-19 (09/18)



For More Information, or to Enroll:

Call: 1-800-678-2265 (TTY: 711)
October 1 – March 31, 8:00 a.m. - 8:00 p.m. ET
Seven days a week

April 1 – September 30, 8:00 a.m. - 8:00 p.m. ET
Monday through Friday

or
Visit: www.bluecrossma.com/medicare

® Registered Marks of the Blue Cross and Blue Shield Association. © 2018 Blue Cross and Blue
Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

188788M (03/(1001//1198))