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BCBSMA Dental Blue65 SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

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Published by it, 2019-11-15 13:23:21

BCBSMA Dental Blue65 SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

BCBSMA Dental Blue65 SalesKit Book 12/01/2019 Approved by Angela Gagnon 11/22/2019 8:01 AM

Keywords: BCBSMA Dental Blue65 SalesKit Book 12/01/2019

Medicare Dental Plans

2020 DENTAL BLUE® 65

COVERAGE YOU NEED FROM A NAME YOU CAN TRUST

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

(12/01/19)



Dear Prospective Member:

Thank you for requesting information about our Dental Blue® 65 plans. Good oral health is
essential to your overall health. We offer three affordable and comprehensive Dental Blue 65
plans that can help supplement your medical coverage.
With Dental Blue 65, you’ll have access to our extensive network of dentists across the
country, including thousands of dentists in Massachusetts and Rhode Island. All three plans
provide complete coverage for preventive services, as well as varying levels of coverage for
other dental services.

Choose the Best Plan for Your Needs and Budget
We’ve included the following materials to help you get started:
• Dental Blue 65 Overview—Learn more about our dental plans
• Dental Blue 65 Outline of Coverage—Compare the three plans
• Dental Blue 65 Application—Apply for coverage using the enclosed application and

self-addressed envelope

How to Enroll
When you’re ready, you can enroll by:
• Phone—Call us at 1-800-678-2265 (TTY:711), Monday through Friday,

8:00 a.m. to 5:00 p.m. ET.
• Mail—Complete and mail your application to us using the self-addressed envelope
• Fax—Complete your application and fax it to us at 1-617-246-3633

Thank you for your interest in Blue Cross Blue Shield of Massachusetts.
We look forward to serving you.

Sincerely

Gloria Paradiso,
Executive Director, Medicare Sales
Enclosures

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

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).

101 Huntington Avenue, Suite 1300 | Boston, MA 02199-7611 | www.bluecrossma.com

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

198474M 99-0617-20 (09/19)

IN THIS BOOKLET

01 Plan Information
• Discover Something
to Smile About
• Outline of Coverage

02 Disclosures
• Nondiscrimination Notice
• Translation Resources

03 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Dental Blue® 65

2020 DENTAL PLAN COVERAGE
WITH NO SURPRISES

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

Because good oral health is so important to your
well-being, we offer three comprehensive dental plans
for those aged 65 and older, living in Massachusetts.
Regular dental checkups help protect your smile
and prevent problems in the future.

When you complement your medical coverage with one of our
three affordable dental plans, you’ll get:

• 100% coverage for services that • Network access to more than 90 percent
diagnose or prevent tooth decay and of practicing local dentists and more than
other forms of oral disease—services 325,000 provider locations nationwide
you’ll most likely get during a routine
dental checkup or visit • All waiting periods waived, based on
eligibility of having continuous prior
• Regular cleanings and exams 3 times dental coverage
per 12 month period

Can I Use My Current Dentist?

Most likely! If you already have a dentist and you want to know if he or she participates
with Blue Cross Blue Shield of Massachusetts, you may call the dentist, refer to the
most current dental provider directory at bluecrossma.com/medicare, or call
Member Service toll-free at 1-888-741-4340, Monday through Friday from 8:00 a.m.
to 6:00 p.m. ET. (TTY: 711).

REVIEW OUR 2020 DENTAL PLANS OPTIONS

Dental Blue® 65 Preventive*

$22.70/mo. Plan pays 100% of the following: • Periapical X-rays as needed
No waiting
period • One complete initial oral exam, including • Periodic or routine oral exams 3 times
dental history, and charting your teeth per 12 months
No annual and supporting structures (gums, bones)
deductible or to evaluate their condition • Emergency exams
calendar-year
maximum • Full mouth X-rays (7 or more films), or • Study models and casts used in planning
panoramic X-ray with bitewing X-rays, treatment once every 60 months
once every 60 months. Additional bitewing
X-rays once every 6 months

Dental Blue® 65 Basic*

$37.80/mo. Plan pays 100% of preventive services and 50% of the following:
6-month
waiting • Silver and white fillings for each • Adding teeth to existing denture
period** tooth surface every 12 months
• Rebase or reline of dentures, once every
$100 annual • Tooth extractions and biopsies 36 months
deductible
and $1,250 • Periodontal scaling and root planing, • Recementing of crowns, inlays, onlays,
calendar-year once in each quadrant every 24 months and fixed bridgework, once every
maximum 12 months
• Periodontal surgery, once in each
quadrant every 36 months • Bite adjustment, once every 24 months

• Periodontal maintenance, once every • Services to treat root sensitivity
3 months
• General anesthesia when administered in
• Root canals conjunction with covered surgical services

• Repairs of partial or complete dentures, • Emergency dental treatment to relieve
crowns and bridges, once every 12 months acute pain

Dental Blue® 65 Premier*

$68.70/mo. Plan pays 100% of preventive services, 80% of basic services, and 50% of the following:
12-month
waiting • Complete or partial denture, including • Temporary partial dentures to replace
period** services to fabricate and adjust, once any of the six upper or lower front teeth,
every 60 months for each arch but only if they are installed immediately
$50 annual following the loss of teeth and during the
deductible • Fixed bridges, including services to period of healing
and $1,500 fabricate, and adjust, once every 60
calendar-year months per tooth • Crowns once every 60 months for each tooth
maximum
• Dental implant placement • Metallic, porcelain, and white resin inlays,
once every 60 months per tooth
• Replacement of dentures and bridges,
but only when they are installed at least • Replacement of crowns and metallic,
60 months after the initial placement, porcelain, and composite resin inlays/onlays
and only if the existing appliance cannot once every 60 months for each tooth
be made serviceable
• Post and core or crown buildup once every
• Adding teeth to an existing bridge 60 months per tooth

*Covered services. Please see the Outline of Coverage at bluecrossma.com/dentalblue.

**You may be eligible to have all waiting periods waived to allow you to receive minor and major restorative services
right away.

HOW DO I ENROLL?

 Go to bluecrossma.com/medicare
for details on enrollment options.
 Call 1-800-678-2265 (TTY: 711),
Monday through Friday, 8:00 a.m. to 5:00 p.m.

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).

198639M ® Registered Marks of the Blue Cross and Blue Shield Association. (09/19)
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

55-0530-20

Dental Blue® 65

Outline of Coverage

This document is a detailed description and summary
of benefits for Dental Blue 65 Preventive, Dental Blue 65
Basic, and Dental Blue 65 Premier.

Effective January 1, 2020

Eligibility Policy Number: DENT SR (1–1–2012)
Requirements
“Read your subscriber certificate carefully.
• Age 65 or older This disclosure statement is a very brief
summary of your dental plan. The plan
• Resident of Massachusetts itself sets forth the rights and obligations
of both you and the insurance company.
It is, therefore, important that you read
your subscriber certificate carefully.”

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

We know that good oral health is important to you,
and we understand that dental costs can add up.
From diabetes to heart disease and cholesterol
levels, dental care may impact your total health
and wellbeing. Regular dental checkups help
protect your smile, make you look and feel better,
and prevent problems down the road.

Outlined in this document is a detailed description
and summary of benefits for Dental Blue 65
Preventive, Dental Blue 65 Basic, and Dental Blue
65 Premier, offered by Blue Cross Blue Shield of
Massachusetts.

We offer paperless billing for your dental
premiums through eBill.

This easy-to-use tool allows you to view your statement and make
premium payments online. You also have an auto-draft option, where
we set up an automatic withdrawal of premiums directly from your
bank account on each due date. Once you receive an initial paper
invoice, register for eBill at www.bcbsmaebilling.com.

Overview

Your Dentist If You Have to File a Claim

Dental Blue 65 offers access to more than 90 Network dentists will send claims to Blue
percent of practicing local dentists and more Cross Blue Shield of Massachusetts for you.
than 325,000 provider locations nationwide. Just show them your Dental Blue 65 ID card.
Dentists who participate with Blue Cross The payment will be sent directly to your
Blue Shield of Rhode Island and out-of-area dentist.
dentists who participate in our Nationwide
Network of dentists are also available to If you receive care from a non-network
Dental Blue members. dentist, you may have to submit the claim
yourself. If you file, send the Attending
If you already have a dentist and want to Dentist’s Statement form with the original
know if he or she participates with Blue Cross itemized bills. Any benefit payment will
Blue Shield of Massachusetts, you may call be sent to you. You can get a copy of the
the dentist, refer to the most current dental Attending Dentist’s Statement from Member
provider directory, or call Member Service at Service.
the toll-free number on your Dental Blue 65 ID
card. Any claims that you file should be sent to
Blue Cross Blue Shield of Massachusetts,
If you would like help choosing a dentist, P.O. Box 986030, Boston, MA 02298. All
you may call the Physician Selection Service member-submitted claims must be received
at 1-800-821-1388. You may also access within two years of the date of service.
the online dental provider directory at (Coverage is not available for non-network
www.bluecrossma.com. dentists in Massachusetts except for covered
emergency services.)
Coverage Begins
The Blue Cross Blue Shield Grievance
Your coverage will be effective the first of the Program is fully described in the subscriber
month following the month we receive your certificate.
application.
Other Information

Coordination of benefits (COB) applies to plan
members who are covered by another plan
for health care expenses. COB ensures that
payments from all health care plans do not
exceed the total charges billed for covered
services.

Your subscriber certificate has a subrogation
clause. This does not affect the scope of
benefits. This clause allows claim payments
to be retracted when a member recovers
payment for the same charges from a third
party due to liability for injury.

3

Dental Blue 65 Preventive

Monthly Premium Co-insurance, Annual Deductible,
and Annual Maximum
January 1, 2020–December 31, 2020: $22.70
This dental plan provides full benefits based
Services & Benefits on the allowed charge for participating
providers. There are no annual deductibles
Your covered services include: and no annual plan maximums.

• One complete initial oral exam, including Waiting Periods and Pre-existing
initial dental history and charting of the teeth Condition Limitations
and supporting structures
Your dental services will be covered from
• Full mouth X-rays, seven or more films, your effective date of this dental plan without
or panoramic X-ray with bitewing X-rays a waiting period or pre-existing condition
once every 60 months restrictions.

• Bitewing X-rays once every six months Exclusions and Limitations

• Single-tooth X-rays as needed Services limited by frequency include but are
not limited to:
• Study models and casts used in planning
treatment once every 60 months • X-rays
• Exams
• Periodic or routine oral exams 3 times per • Cleanings
12 months
Please review your dental policy for a full
• Emergency exams listing of limitations and exclusions.

• Routine cleaning, scaling, and polishing
of the teeth 3 times per 12 months

4

Dental Blue 65 Basic

Monthly Premium Other Covered Services
• Occlusal adjustment, once each 24 months
January 1, 2020–December 31, 2020: $37.80 • Services to treat root sensitivity
• General anesthesia when administered in
Services & Benefits
conjunction with covered surgical services
Your covered services include: • Emergency dental treatment to relieve

• 100% coverage for all services covered acute pain
under Dental Blue 65 Preventive, plus 50% • Emergency dental treatment to control a dental
coverage for:
condition that requires immediate care to
Restorative Services prevent permanent harm to the member
• Amalgam (silver) fillings (limited to one filling
Co-insurance, Annual Deductible,
for each tooth surface in each 12 months) and Annual Maximum
• Composite resin (tooth color) fillings on
This dental plan provides:
teeth (limited to one filling per tooth surface
in each 12 months) • 100% coverage for all preventative services
• Pin retention for fillings • 50% coverage for services outlined in the

Oral Surgery plan’s Services & Benefits section above
• Tooth extractions, root removal, and biopsies
• Coverage is based on the allowed charge for
Periodontics (Gum and Bone) participating providers.
• Periodontal scaling and root planning, once in
• There is a $100 annual deductible and $1,250
each quadrant each 24 months calendar-year maximum.
• Periodontal surgery (soft-and hard-tissue
Waiting Periods and Pre-existing
surgeries), once in each quadrant each 36 Condition Limitations
months
• Periodontal maintenance following active Your dental services will be covered from
periodontal therapy, once each three months your effective date of this dental plan without
a waiting period or pre-existing condition
Endodontics (Root and Pulp) restrictions for all preventive services. For
• Root canal therapy on permanent teeth, once services that fall outside of preventive, a six-
month waiting period from the effective date is
per lifetime for each tooth required. If you’ve had continuous prior dental
• Retreatment root canal therapy on permanent coverage, you may be eligible to have all waiting
periods waived to allow you to receive minor and
teeth, once in a lifetime for each tooth major restorative services right away.
• Other endodontic surgery intended to treat or
Exclusions and Limitations
remove the dental root
Certain services may be limited or excluded from
Prosthetic Maintenance this plan. These services may include:
• Repair of partial or complete dentures,
• Fillings on tooth surfaces where a sealant
crowns, and bridges, once each 12 months was applied within the prior 12 months
• Adding teeth to existing partial or complete
• Replacement of a filling within 12 months of the
dentures date of prior restoration
• Rebase or reline dentures, once each 36
• A service, supply, procedure, or appliance to
months stabilize teeth when it is due to periodontal
• Recementing of crowns, inlays, onlays, and disease

fixed bridgework, once each 12 months Please review your dental policy for a full listing
of limitations and exclusions.
5

Dental Blue 65 Premier

Monthly Premium Co-insurance, Annual Deductible,
and Annual Maximum
January 1, 2020–December 31, 2020: $68.70
This dental plan provides:
Service & Benefits • 100% coverage for all preventative services
• 80% coverage for minor restorative services,
Your covered services include:
oral surgery, periodontics, endodontics,
• 100% coverage for all services covered under prosthetic maintenance, and other services
Dental Blue 65 Preventive, plus originally covered by Dental Blue 65 Basic
• 50% coverage for major restorative services,
• 80% coverage for all services covered under prosthodontics/tooth replacements, crowns,
Dental Blue 65 Basic, plus inlays, onlays, dental implants and other
services outlined in the plan’s Services &
• 50% coverage for: Benefits section above
• Prosthodontics (Tooth Replacement)
• Complete or partial dentures, including • Benefits are based on the allowed charge for
services to fabricate, measure, fit, and adjust participating providers.
them once each 60 months for each arch
• Fixed bridges, including services to • There is a $50 annual deductible and $1,500
fabricate, measure, fit, and adjust them once calendar-year maximum.
each 60 months per tooth
• Replacement of dentures and bridges, but Waiting Periods and Pre-existing
only when they are installed at least 60 Condition Limitations
months after the initial placement, and only
if the existing appliance cannot be made Your dental services will be covered from your effective
serviceable date of this dental plan without a waiting period or pre-
• Adding teeth to an existing bridge existing condition restrictions for all preventive services.
• Temporary partial dentures to replace any of For services that fall outside of preventive, a 6-month
the six upper or lower front teeth, but only if waiting period from the effective date is required for minor
they are installed immediately following the restorative services, and a 12-month waiting period from
loss of teeth and during the period of healing the effective date is required for major restorative services.

Major Restorative Services If you’ve had continuous prior dental coverage, you may be
(Crowns, Inlays, Onlays) eligible to have all waiting periods waived to allow you to
• Crowns once each 60 months for each tooth receive minor and major restorative services right away
• Metallic, porcelain, and composite resin inlays
Exclusions and Limitations
and onlays once every 60 months per tooth
• Surgical placement of dental implant once Certain services may be limited or excluded from
this plan. These services may include:
per tooth per lifetime
• Replacement of crowns once every 60 months • Fillings on tooth surfaces where a sealant was applied
within the prior 12 months
for each tooth
• Replacement of metallic, porcelain, and • Replacement of a filling within 12 months of the date of
prior restoration
composite resin inlays and onlays once every
60 months • Duplicate dentures or bridges
• Post and core or crown build up once every • Cast restorations, copings, or attachments for installing
60 months per tooth
overdentures, including associated endodontic
procedures such as root canals, precision attachments,
or semiprecision attachments

Please review your dental policy for a full listing of
limitations and exclusions.

6

Renewal and Premium Changes

Continuing Your Dental Coverage Non-Participating Dentists
For covered services furnished by
You have the right to continue this dental plan non-participating dentists, Blue Cross Blue
as long as you pay your premiums for this Shield of Massachusetts calculates your
dental plan on time, you do not make a material benefits based on the usual and customary
misrepresentation to Blue Cross Blue Shield charge for covered services. The term “usual
of Massachusetts, you continue to reside in and customary” means the amount allowed
Massachusetts, and Blue Cross Blue Shield of (also referred to as the “allowed charge”) for
Massachusetts continues to offer this coverage. a service in a geographic area based on the
payment levels usually accepted by dentists in
Right to Change Premium the area for the same or similar service.
The usual and customary charge may
Your dental premium for this dental plan sometimes be less than the dentist’s actual
may change. Blue Cross Blue Shield of charge. If this is the case, you will be
Massachusetts will send you a notice at least responsible for the amount of the dentist’s
60 days before a change is effective. The notice actual charge that is in excess of the usual and
will describe the change and tell you when it is customary charge. Please see your certificate
effective. These changes will apply to all dental to determine what services are covered by
plans of this type, not just your dental plan. non-participating dentists. In Massachusetts.
Blue Cross and Blue Shield will provide dental
Allowed Charge benefits for covered services furnished by a
non-participating dentist in Massachusetts
Blue Cross Blue Shield of Massachusetts when the covered services are emergency
calculates payment of your benefits based on services and a participating dentist is not
the allowed charge. The allowed charge that reasonably available.
Blue Cross Blue Shield of Massachusetts uses
depends on the type of dental provider that Notice of Right to Examine Subscriber
furnishes the covered service to you. Certificate for 10 Days

Participating Dentists If you are a newly enrolled subscriber in this
For covered services furnished by dentists dental plan, you have 10 days from the date
who have a written payment agreement to you received this subscriber certificate to review
furnish dental services to members enrolled in it. If you are not satisfied for any reason, you
a Dental Blue plan, Blue Cross Blue Shield of have the right to return the subscriber certificate
Massachusetts calculates your benefits based within 10 days and have your premium refunded
on the provisions of the participating dentist’s to you.
payment agreement and the participating
dentist’s contracted rate that is in effect at
the time a covered service is furnished. This
contracted rate is referred to as the dentist’s
allowed charge. In most cases, you do not
have to pay the amount of the participating
dentist’s actual charge that is in excess of the
allowed charge. However, there are certain
situations when you will have to pay the
difference between the claim payment and
the participating dentist’s actual charge.

7

Complaints

If you have a complaint, please call Member Service at 1-800-258-2226. (TTY: 711)
If the you are not satisfied, you may call the Massachusetts Division of Insurance at
1-617-521-7777 (Boston) or 1-413-785-5526 (Springfield).

Important: In the event of any inconsistency between this outline of coverage and the
subscriber certificate, the terms of the subscriber certificate will govern.
Limitations and Exclusions. These pages summarize the benefits of your dental care
plan. Your plan description and riders define the full terms and conditions. Should any
questions arise concerning benefits, the plan description and riders will govern. For a
complete list of limitations and exclusions, refer to your plan description and riders.

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).
Complaint forms are available at hhs.gov.

9

Proficiency of Language Assistance Services

Translation Resources
Proficiency of Language Assistance Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available
to you. Call 1-800-200-4255 (TTY: 711).

Spanish/Español: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia
lingüística. Llame al 1-800-200-4255 (TTY: 711).

Portuguese/Português: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos,
grátis. Ligue para 1-800-200-4255 (TTY: 711).

Chinese/ : 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-200-4255
(TTY: 711).

French Creole/Kreyòl Ayisyen: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
disponib gratis pou ou. Rele 1-800-200-4255 (TTY: 711).

Vietnamese/Tiếng Việt: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành
cho bạn. Gọi số 1-800-200-4255 (TTY: 711).

Russian/Русский: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные
услуги перевода. Звоните 1-800-200-4255 (телетайп: 711).

Arabic/‫ﺍﺍﻟﻌﺮﺑﻴﺔ‬:
1-800-200-4255 ‫ ﺍﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈﻥ ﺧﺪﻣﺎﺕ ﺍﻟﻤﺴﺎﻋﺪﺓ ﺍﻟﻠﻐﻮﻳﺔ ﺗﺘﻮﺍﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎﻥ‬،‫ ﺇﺫﺍ ﻛﻨﺖ ﺗﺘﺤﺪﺙ ﺍﻟﻌﺮﺑﻴﺔ‬:‫ﻣﻠﺤﻮﻅﺔ‬
(711 :‫)ﻫﺎﺗﻒ ﺍﻟﺼﻢ ﻭﺍﻟﺒﻜﻢ‬.

Mon-Khmer, Cambodian/ :
1-800-200-4255 (TTY: 711).

French/Français: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont
proposés gratuitement. Appelez le 1-800-200-4255 (ATS: 711).

Italian/Italiano: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di
assistenza linguistica gratuiti. Chiamare il numero 1-800-200-4255 (TTY: 711).

Korean/한국어: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-800-200-4255 (TTY: 711) 번으로 전화해 주십시오.

Greek/λληνικά: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-200-4255 (TTY: 711).

PolishB/lPueolCsrkosis: BUluWe AShGielAd :ofJMeażseslaicmhuóswettisszispaon pInodlespkeund, emntoLżiceesnzsesekoofrzthyesBtalućezCrboeszspałnadtnBelujepSohmielodcAyssociation
językowej. Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

Hindi/ :
1-800-200-4255 (TTY: 711)

Gujarati/ :
1-800-200-4255 (TTY: 711)

11

For more information or help with enrollment, please call
1-800-678-2265

(TTY: 711), Monday through Friday, 8:00 a.m. to 5:00 p.m. ET.

Questions? Call Member Service toll-free at 1-888-741-4340,
Monday through Friday between 8:00 a.m. and 6:00 p.m. ET.

(TTY users can call 711)

For questions about Blue Cross Blue Shield of Massachusetts,
visit www.bluecrossma.com.

Interested in receiving information from Blue Cross Blue Shield of
Massachusetts via email?

Go to www.bluecrossma.com/email to sign up.

® Registered Marks of the Blue Cross and Blue Shield Association. TM Trademarks are the property

of their respective owners. © 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc. 55-0166-20
(09/19)
198640M

02

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).
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.

189008M 55-2067 (8/18)



Translation Resources
TPrroaficniesnlcaytoifoLnangRuaegseoAussrisctaensce 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
Sidpenatnifiicsahc/Eiósnp(aTñTYo:l:7A1T1E).NCIÓN: Si habla español, tiene a su disposición servicios gratuitos

Pdeoratsuigstueensceia/Pconrtuegl iudêiosm: aA.TLElNamÇeÃOal: nSúemfearlao pdoertSuegruvêicsi,osaãloC-llhieentdeisqpuoenifbigiluizraadeons sguratauritjeatmaednete
sideernvitçifiocsacdióenas(TsTisYt:ên7c1i1a).de idiomas. Telefone para os Serviços aos Membros, através do número no
PseourtcuagrutãeosIeD/P(ToTrYtu: g7u1ê1s).: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente

sCehrviniçeosse/d简e 体as中sis文tên: c注ia意de:id如io果ma您s.讲Te中le文fon,e我pa们ra可os向S您er免viç费os提a供os语M言em协b助ros服, 务atr。av请és拨do打n您úmIDero卡n上o 的
号se码u c联ar系tão会ID员(服TT务Y:部71(1)T.TY 号码:711)。

HCahitniaenseC/简re体ole中/K文re:y注òl意A:yis如ye果n您: A讲TA中NS文Y,ON我: 们Si 可ou向p您ale免k费rey提òl供ay语isy言en协, s助èv服is务as。is请tan拨s 打na您n laIDng卡上的
d号is码po联nib系p会ou员o服u 务gra部tis(. RTTeYle 号nim码e:wo71S1è)vis。Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou
HMaailatinatnanCdraenoTleT/YK:r7e1y1ò)l. Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang

Vdiiseptnonaimb epsoeu/ToiuếnggraVtisiệ.tR: LeƯleUnÝim: NeếwuoqSuýèvviịsnMóiaTniếmngnaVniệtk,icsáocudkịcaht vIdụahnỗtititfrkợasnygoônnwnglaữnđ(ưSợècvcisupngoucấp cho
MquaýlavnịtmaniễdnanphTíT. GY:ọ7i c1h1o).Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711).

RViuestnsiaamn/eРsуeс/сTкiиếnйg: ВVНiệИtМ: LАƯНUИÝЕ::NеếсuлиqВuыý vгịоnвóоiрTиiếтеngпоV-iрệtу,сcсáкcиd, Вịcыhмvоụжhеỗтеtrвợоnсgпôоnльnзgоữваđтưьợсяc бcuесnпgлcаấтpныcмhиo
уqсuлýуvгаị мmиiễпnеpрhевí.оGдọчiиcкhаo. ПDоịcзhвоvнụиHтеộiвvоiêтnдеtлheоoбсsлốуtжrêиnваthнẻияIDклcиủеaнqтuоýв vпịо(TнTоYм: е7р1у1,)у. казанному в Вашей
иRдuеsнsтiиaфnи/Ркауцсискоинйно: йВНкаИрМтеАН(тИелЕе: етасйлпи: В7ы11го).ворите по-русски, Вы можете воспользоваться бесплатными
Aусrлaуbгаicм/и‫يبر‬п‫ة‬:ереводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей
иде‫ف‬н‫ت‬т‫ها‬и‫ال‬ф‫ز‬и‫جها‬к)ац‫ك‬и‫ويت‬о‫ ُه‬н‫ة‬н‫ق‬о‫طا‬й‫ى ب‬к‫عل‬ар‫ود‬т‫ج‬е‫ا(لمو‬т‫م‬е‫ق‬л‫لر‬е‫ى ا‬т‫ل‬а‫ع‬й‫ء‬п‫ضا‬:‫ع‬7‫الأ‬1‫ت‬1‫م)ا‬.‫ اتصل بخد‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬
Arabic/‫ةيبر‬:
Mo‫ف‬n‫ت‬-‫ها‬K‫ ال‬h‫از‬m‫)جه‬e‫ك‬r,‫يت‬C‫ ُهو‬a‫ة‬m‫طاق‬b‫ى ب‬o‫عل‬d‫د‬i‫و‬a‫ج‬n‫مو‬/‫ال‬ខ្‫قم‬ែមរ‫ر‬:‫ال‬
ក‫لى‬ា‫ ع‬រ‫اء‬ជ‫ូعض‬ន‫الأ‬ដ‫ំت‬ណ‫ب ឹخدما‬ង‫ل‬៖‫اتص‬ប.្‫ك‬រ‫ل‬ស‫ិسبة‬ន‫الن‬ប‫نًا្ ب‬រ‫جا‬ើអ‫ م‬កន្ ‫وية‬ន‫ិلغ‬យ‫ة ال‬ា‫عد‬យ‫لمسا‬ភ‫ت ا‬ា‫ا‬ស‫دم‬ា‫فر خ‬ខ‫تت្و‬.‫(ف‬មែរ7،‫ة‬1‫ربي‬1‫الع‬:”‫ة‬T‫لغ‬T‫ال‬Y‫لإلذاصكمنواتلبتتكمحد“ث‬ :‫انتباه‬
‫النصي‬
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អកន្ ។ សូមទូរស័ព្ទបៅខ្្កន បសវាសរាជិកតាមបេ្
Mបៅonបេ-Kើ្hរm័ណer្ណស, Cរaាាគmេb់្odួនលៃ iaរ្nរ/សខ្់អមរែ : កន្ កា(TរជTYូន:ដ7ំណ11ឹ)។ង៖ ប្រសិនប្រើអន្កនិយាយភាសា ខ្ែរម
Fបសrenវាcជhំន/Fួយraភnាçសaiាs:ឥAតTគTEិតNថT្IOៃល គNឺអ:ាsចi រvកouបsានpaសrleបzរាfra្រn់អçនក្ais។, dសesូមsទeូរrសvic័ពesបទ្ ៅd’aខs្sនក្ isបtaសncវeាសlinរgាuជistិកiqតuាeមsបoេnt ្
dបៅispបoេnibើ្រle័ណs gណ្សratរuាiគាteេm់្enួនៃល t.រ្Aរpសpe់អleនក្ z (leTTSYe: r7v1ic1e)។adhérents au numéro indiqué sur votre carte d’assuré
(FTrTeYnc: h7/1F1r)a. nçais: ATTENTION : si vous parlez français, des services d’assistance linguistique sont

dItiaslpiaon/ibItleasliagnraot:uAiteTmTEeNntZ.IOApNpEe:lesze lpeaSrlaetrevicitealiadnhoé, rseonntso aduisnpuomnibéirloi pinedr ivqouiésesurvrizviogtreatuciatirtdei das’assisstuernéza
(liTnTgYuis: t7ic1a1.)C. hiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa

I(TtaTlYia: n7/1It1a).liano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza

Klinogrueisatnic/a한. C국h어iam: 주ate의il:S한er국viz어io 를per사i m용e하mb시ri는al n경um우e,ro언rip어ort지ato원su서lla비vo스st를ra s무ch료ed로a id이en용tif하ica실tiva수
(있TT습Y:니71다1.). 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.

KGorereakn/λ/λ한η국νικ어ά: Π주Ρ의ΟΣ:Ο한ΧΗ국: Ε어άν를μιλ사άτ용ε Ε하λλ시ην는ικά,경δι우ατ,ίθε언ντ어αι γ지ια원σας서υπ비ηρ스εσ를ίες무γλ료ωσ로σικ이ής용βο하ήθ실εια수ς,
있δω습ρε니άν다. Κ.αλ귀έσ하τε의τηνIDΥπ카ηρ드εσ에ία Ε있ξυ는πηρ전έτ화ησ번ης호Μ(TεTλώY:ν7σ1τ1ον)를αρ사ιθμ용ό 하τη여ς κά회ρτ원ας μ서έλ비ου스ς σ에ας전(ID화C하ard십) 시오.
G(TrTeYe: k7/1λ1λ).ηνικά: 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.

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 दंे: ्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/ગજુ રાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સવે યાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડ્ડ પર આપેલયા નબં ર 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.

®1647R11eMgB istered Marks of the Blue Cross and Blue Shield Association. © 201855-B14l9u3 (e8/1C6) ross and Blue Shield of

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

189002M 55-2066 (08/18)

03

Enrollment



Dental Blue® 65

APPLICATION FOR DENTAL BLUE 65

Directions You are eligible to apply for a Dental Blue 65
plan if you meet all of the following
• Please print clearly. requirements:
• Carefully read and answer all questions.
• You are a resident of Massachusetts and you
Incomplete applications won’t be accepted. actually live in Massachusetts
Keep one copy of the application for
yourself. • You are age 65 or older
• Don’t send money with this application.
You’ll receive a bill when payment is due. Questions?
You’ll also receive an invitation to sign up
for our eBill option. • The dental premium rate and benefits are explained
• Complete the application, and: in the Outline of Coverage you received with this
» Mail the white copy to: application. If you need more information or
assistance, call us at 1-800-678-2265.
Direct Sales
Blue Cross Blue Shield of Massachusetts • For all other questions, call Dental Blue 65
One Enterprise Drive Member Service at 1-888-741-4340 (TTY: 711).
Quincy, MA 02171-1753
» Or fax to: 1-617-246-3633

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

Please answer all questions.

I am applying for: Dental Blue® 65 Basic Dental Blue® 65 Premier
Dental Blue® 65 Preventive

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 Dental Blue 65 bill sent to an address other than your home address,
complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
Your email address:

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

The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to
enroll me into a dental plan membership. I understand that I should read the subscriber certificate to understand my
benefits and any restrictions that apply to my health care plan. I understand that Blue Cross and Blue Shield may obtain
personal and medical information about me to carry out its business, and that it may use and disclose that information in
accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my
information in “Our Commitment to Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.

Applicant’s Signature: ______________________________________ Date: ___________________________

Will this policy replace an active dental insurance policy? Yes No
If yes, please complete the “Notice to Applicant” form and include it with this application.
Please also indicate below if the policy will replace an existing policy with continuous, uninterrupted coverage for:

6 months of Basic Restorative benefits 12 months of Major Restorative benefits

Notice to Applicant

If you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued
by Blue Cross Blue Shield of Massachusetts, you must sign and return this form with your application.
For your own information and protection, certain facts should be pointed out to you, which could affect
your rights to coverage under the new policy.

Health conditions, Even though some Questions in the It may be to your
which you may of your present health application for the advantage to secure
new policy must be
presently have, may conditions may be answered truthfully the advice of your
not be covered under covered under the and completely; present carrier or
new policy, these otherwise, the validity its agent regarding
the new policy. conditions may be of the policy and the
This could result in subject to certain the proposed
a claim for benefits waiting periods under payment of any replacement of
being denied which the new policy before benefits thereunder your present policy.
have been payable coverage is effective. This is your right
under your present may be voided. under the policy
you have chosen.
policy.

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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

197964M 55-0167-20 (09/19)

Dental Blue® 65

APPLICATION FOR DENTAL BLUE 65

Directions You are eligible to apply for a Dental Blue 65
plan if you meet all of the following
• Please print clearly. requirements:
• Carefully read and answer all questions.
• You are a resident of Massachusetts and you
Incomplete applications won’t be accepted. actually live in Massachusetts
Keep one copy of the application for
yourself. • You are age 65 or older
• Don’t send money with this application.
You’ll receive a bill when payment is due. Questions?
You’ll also receive an invitation to sign up
for our eBill option. • The dental premium rate and benefits are explained
• Complete the application, and: in the Outline of Coverage you received with this
» Mail the white copy to: application. If you need more information or
assistance, call us at 1-800-678-2265.
Direct Sales
Blue Cross Blue Shield of Massachusetts • For all other questions, call Dental Blue 65
One Enterprise Drive Member Service at 1-888-741-4340 (TTY: 711).
Quincy, MA 02171-1753
» Or fax to: 1-617-246-3633

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

Please answer all questions.

I am applying for: Dental Blue® 65 Basic Dental Blue® 65 Premier
Dental Blue® 65 Preventive

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 Dental Blue 65 bill sent to an address other than your home address,
complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
Your email address:

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

The information here is complete and true. I understand that Blue Cross and Blue Shield will rely on this information to
enroll me into a dental plan membership. I understand that I should read the subscriber certificate to understand my
benefits and any restrictions that apply to my health care plan. I understand that Blue Cross and Blue Shield may obtain
personal and medical information about me to carry out its business, and that it may use and disclose that information in
accordance with law. I acknowledge that I may obtain further information about the collection, use, and disclosure of my
information in “Our Commitment to Confidentiality,” Blue Cross and Blue Shield’s notice of privacy practices.

Applicant’s Signature: ______________________________________ Date: ___________________________

Will this policy replace an active dental insurance policy? Yes No
If yes, please complete the “Notice to Applicant” form and include it with this application.
Please also indicate below if the policy will replace an existing policy with continuous, uninterrupted coverage for:

6 months of Basic Restorative benefits 12 months of Major Restorative benefits

Notice to Applicant

If you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued
by Blue Cross Blue Shield of Massachusetts, you must sign and return this form with your application.
For your own information and protection, certain facts should be pointed out to you, which could affect
your rights to coverage under the new policy.

Health conditions, Even though some Questions in the It may be to your
which you may of your present health application for the advantage to secure
new policy must be
presently have, may conditions may be answered truthfully the advice of your
not be covered under covered under the and completely; present carrier or
new policy, these otherwise, the validity its agent regarding
the new policy. conditions may be of the policy and the
This could result in subject to certain the proposed
a claim for benefits waiting periods under payment of any replacement of
being denied which the new policy before benefits thereunder your present policy.
have been payable coverage is effective. This is your right
under your present may be voided. under the policy
you have chosen.
policy.

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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

197964M 55-0167-20 (09/19)



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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

198807M ((1029//0119/)19)


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