2019 MEDEX SalesKit Booklet APPROVED 09/26/2018 12:02 PM by Jazmin Klyce

Medicare Supplement Plans

Coverage you need
From a name you can trust

Medex®´ 2019

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

(10/01/18)



Dear Prospective Member:

Thank you for requesting information about Medex,®´ a family of Medicare supplement plans
from Blue Cross Blue Shield of Massachusetts. Our two plan options, Medex Bronze and
Medex Core, are designed to fill the gaps in Original Medicare and add real value to your health
care coverage.

Our goal is to provide you with information that will help you choose the right plan for you that
fits your needs and budget. We have enclosed the following materials to help you get started:
• Learn about the value of Medex from our Freedom of Choice brochure
• Compare coverage options with a detailed overview of Medex Bronze and Medex Core
• Enroll in Medex using the enclosed application and self-addressed envelope

If you’re ready, you can enroll by telephone, online, by mail, or by fax:
• Telephone—Call us at 1-800-678-2265 (TTY: 711), 8:00 a.m. to 6:00 p.m. ET,

Monday through Friday.
• Online—Visit www.bluecrossma.com/medicare
• Mail—Complete and return the enclosed enrollment form in the self-addressed business

reply envelope provided
• Fax—You may also fax your completed enrollment form to us at 1-617-246-3633

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

Sincerely,

Gloria Paradiso,
Senior 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 1-800-200-4255 (TTY: 711).

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

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

188998M 99-0483-19 (08/18)

In This Booklet

01 Plan Information

• Solutions to Supplement Medicare
• Outline of Medicare Supplement Coverage

02 Resources

• Seminar Information
• It Pays to Stay Blue
• Vision and Hearing Benefits
• GeoBlue Information

03 Disclosures

• Nondiscrimination Notice
• Translation Resources

04 Enrollment

• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Medex®´
Freedom of Choice

Solutions to
Supplement Medicare

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

With Medex from Blue Cross
Blue Shield of Massachusetts,
the choice is yours.
We’ve created plan options for our
members that allow you to choose
what you need from your health plan
and more.

2 Medex Choice Sales: 1-800-678-2265

Table of Contents 2–3
2
Medex 3
The Freedom of Medex
An Introduction to Medex 5–7
5
Medicare 6
What Is Original Medicare? 7
Why Do I Need to Supplement Medicare?
Medicare Coverage 8–14
8–11
Medicare and Medex Together
Medicare Coverage Combined with a Medex Plan 13
Medex Coverage Wellness Programs 14
How Medex Works
14–17
Enrollment in Medex 14
Am I Eligible for Medex? 15
When Do I Enroll? 16
How Do I Enroll? 17
When Will My Coverage Begin?
18–19
Miscellaneous Information 18
Helpful Numbers 19
Premium Rates

www.bluecrossma.com/medicare 1

The Freedom of Medex

Many people who enroll in Original Medicare are surprised
to learn that it doesn’t provide the coverage they expect.
After all, deductibles, co-insurance, and gaps in health
care coverage can amount to thousands of dollars in
expenses a year. That’s why so many Massachusetts
residents turn to Blue Cross Blue Shield of Massachusetts.

Medex, our family of Medicare supplement plans, is designed to add real value and flexibility to
your Medicare solution. Medex helps you save money by lowering your out-of-pocket expenses.
It also fills the gaps in Original Medicare coverage and gives you the power to see any Medicare
provider in the country without a referral.

With Medex, you’ll gain access to benefit features, including:

The versatility of Medex Bronze and The peace of mind of a
worldwide coverage Core members are entitled Blue Cross Blue Shield of
Massachusetts ID card—
to a fitness benefit the most recognized ID
($150 a year) and weight card in health care today
loss benefit ($150 a year)

Please take a moment to review this easy-to-follow booklet. We’ll explain
everything you need to know about Medicare supplement plans and Medex.
If you have any questions about coverage—or if you think Medex is right
for you—call us toll-free at 1-800-678-2265 (TTY: 711). Our office hours
are Monday through Friday, 8:00 a.m. to 6:00 p.m. ET. You can also visit our
website at www.bluecrossma.com/medicare for more information.

2 Medex Choice Sales: 1-800-678-2265

An Introduction to Medex

Medex is a Medicare supplement plan offered by
Blue Cross Blue Shield of Massachusetts. It can be
added to Medicare Part A and B coverage to fill “gaps”
in your Medicare coverage.
As a supplemental insurance plan, Medex helps cover
health care expenses left over after Medicare has
covered its portion of costs.

Medex offers you a choice of two plans with varying coverage levels and
premiums, making it easy to find a plan that meets your unique needs.

Part Keep Medicare d+
A&B Original
Medicare d+ Supplement Medex Bronze
and add… Insurance
Full Supplemental
Coverage

— or —

Medex Core

Enhanced Supplemental
Coverage

Depending on which option you choose, Medex may cover some or virtually all of Medicare cost
sharing amounts, or “gaps,” as well as some services not covered by Medicare. You’ll learn more
about Medicare cost sharing amounts in the next few pages.

We’ll also help you determine which Medex plan is right for you by discussing what each plan
covers and comparing costs.

But let’s begin by exploring what Medicare actually is and how you might benefit from a Medex
supplemental plan.

www.bluecrossma.com/medicare 3

Important: If you haven’t enrolled in Medicare, it is
recommended that you contact your local Social Security
office three months prior to your 65th birthday.

4 Medex Choice Sales: 1-800-678-2265

What Is Original Medicare?

Original Medicare is a federally funded health insurance
plan. It is designed for people age 65 or older and some
disabled people under age 65.

Original Medicare has two parts:

+

Medicare Part A Medicare Part B

(Hospital insurance) pays for inpatient (Medical insurance) pays for outpatient
hospital expenses. hospital charges, doctor visits, and
many other medical services not
Services covered: covered by Part A.

Facility Care Services covered:
• Inpatient hospital care
• Skilled nursing facility care Medical Expenses
• Hospice care
• Home health services • Doctors’ services

• Physical and speech therapy

• Diagnostic tests

• Ambulance trips

• Durable medical equipment

• Diabetic testing supplies

www.bluecrossma.com/medicare 5

Medicare Coverage (Without Supplemental Insurance)

Why Do I Need to Supplement Medicare?

Although Medicare pays a large portion of your medical
expenses, you are responsible for the remaining costs.
Also, Medicare does not cover all medical services in
all situations.

Here are some important things to know about Medicare:

• You may have to pay deductible and co-insurance costs. When Medicare covers a service,
you often must pay for a portion of the cost. Your portion is referred to as a deductible or
co-insurance. Deductibles are the amount you are responsible for before Medicare begins to pay,
and they are subject to change from year to year. After your deductible is paid, you may need to
pay an additional amount—usually 20 percent of the cost for the service, called co-insurance.

• In most cases, Medicare does not cover you outside the United States, even in the event of
an emergency. Please refer to the chart on page 7 for an illustration of Medicare coverage that’s
not supplemented with a Medex plan. The chart highlights Medicare’s benefits, deductible and
co-insurance costs, and some of the services Medicare does not cover.

• Expenses that are not covered by Medicare are often referred to as “gaps.” Medicare
supplement (“Medigap”) plans, such as Medex, help to fill in these coverage gaps. They help
you pay Medicare’s deductible and co-insurance costs, and cover certain services Medicare
doesn’t.

Please refer to the charts on pages 8 through 11 for coverage when Medicare is combined with a Medex plan.

6 Medex Choice Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2018.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Part A Your Cost

Inpatient Hospital Care $1,340 deductible
$335 per day co-insurance
Days 1–60 each benefit period: 100% coverage after you pay the $670 per day co-insurance
$1,340 deductible All costs after 150 days

Days 61–90 each benefit period: 100% coverage after you pay $335 No cost
per day co-insurance $167.50 per day co-insurance
All costs after 100 days
Days 91–150 (60 lifetime reserve days): 100% coverage after you
pay $670 per day co-insurance

Days 150+: no coverage

Skilled Nursing Facility Care

Days 1–20 each benefit period: 100% coverage

Days 21–100 each benefit period: 100% coverage after you pay
$167.50 per day co-insurance

No coverage after 100 days in a benefit period

Medicare Part B Your Cost

Medical Expenses • Ambulance • Doctors’ services
• Diagnostic tests • Durable medical equipment
• Diabetic testing supplies • Physical & speech therapy

Coverage begins after you pay the $183 calendar-year deductible $183 deductible

Medicare covers 80% of the Medicare-approved amount; you pay 20% co-insurance
20% co-insurance
Most outpatient prescription costs
Prescription Drugs
Members may voluntarily purchase Medicare Part D, which covers No cost when Medicare covers the
prescription drugs (unless the drug is covered under Part B) preventive service in full and provider
Routine Services and Preventive Care accepts assignment
100% coverage for specific Medicare preventive services.
A complete listing is found on the Medicare website, All costs
www.medicare.gov
Travel Outside the United States 7
No coverage for medical costs incurred outside the U.S.

www.bluecrossma.com/medicare

Medicare Coverage (Combined with a Medex Plan)

Medicare Medex Core Medex Bronze
(Medicare Supplement (Medicare Supplement 1)
Core) Full coverage of Medicare
deductible and co-insurance
1–60 Coverage for 60 days, after Coverage for Medicare
Days the $1,340 deductible1 daily co-insurance after Full coverage for lifetime
Coverage for 61–90 you pay $1,340 Part A reserve co-insurance, then
61–90 days, after $335 daily deductible an additional 365 days per
Days co-insurance lifetime when Medicare
Hospital Lifetime benefits end
Services Reserve Coverage for an additional Full coverage for lifetime
Days 60 lifetime reserve reserve co-insurance,
days, after $670 daily then an additional 365
co-insurance days per lifetime when
Medicare benefits end

Skilled 1–20 Full coverage for 20 days Covered by Medicare Covered by Medicare
Nursing Days in a Medicare-participating
Facility 21–100 facility Full coverage for Medicare
Days Coverage for days 21–100, No coverage daily co-insurance for days
101+ after $167.50 daily 21–100
Days co-insurance $10 a day for days
No coverage after 100 days No coverage 101–3652 at a Medicare-
participating facility

Physician and Other 80% coverage of approved Coverage of 20% Full coverage of Medicare
Provider Services services, after the $183 co-insurance, after you deductible and co-insurance
Care in the Hospital annual Part B deductible pay $183 annual Part B Full coverage of Medicare
80% coverage of approved deductible deductible and co-insurance
Physician and Other services, after the $183 Coverage of 20% Full coverage of Medicare
Provider Services annual Part B deductible co-insurance, after you deductible and co-insurance
Outpatient Department pay $183 annual Part B
Visits, Office Visits, and deductible
Patient Home Visits
Other Part B Services 80% coverage of approved Coverage of 20%
Ambulance Trips, services, after the $183 co-insurance, after you
Durable Medical annual Part B deductible pay $183 annual Part B
Equipment, Etc. deductible

Note: Although the $183 calendar-year Medicare medical insurance (Part B) deductible appears
more than once in this benefit chart, only one $183 deductible is applicable in a calendar year.

The Medex policy defines the terms and conditions of all the Medex plans in greater detail.
Should any questions arise concerning benefits, the Medex policy will govern.

1. A benefit period begins on the first day you receive services as an inpatient in a hospital and
ends after you have been out of the hospital and have not received skilled care in any other
facility for 60 consecutive days.

2. Bronze coverage also includes $8 a day for days 1–365 at a non-Medicare-participating facility.

8 Medex Choice Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2018.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core
& Medex Bronze
Biologically Inpatient • Coverage for days 1–60 per • Full coverage of the Medicare
Based Mental Admissions benefit period, after the $1,340
Conditions1 in a General inpatient deductible2 deductible and co-insurance3
Hospital or • Full coverage of lifetime reserve
Mental Hospital • Coverage for days 61–90, after
Outpatient $335 daily co-insurance days co-insurance
Visits • Full coverage of up to 365
• Coverage for an additional 60
lifetime reserve days, after $670 additional hospital days in your
daily co-insurance lifetime when Medicare benefits
end4
• Coverage for mental hospital
admissions is limited to 190 days • When covered by Medicare, full
per lifetime coverage of Medicare deductible
and co-insurance with no visit
• Full benefits, less the Part maximum3
B deductible and the Part B
co-insurance • When not covered by Medicare,
full Medex benefits with no visit
maximum

1. Biologically based mental conditions are defined as: schizophrenia; schizoaffective disorder;
major depressive disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-
compulsive disorder; panic disorder; delirium and dementia; affective disorders; eating
disorders; substance abuse; post-traumatic stress disorder (PTSD); autism; and any biologically
based mental disorders that are scientifically recognized and approved by the Massachusetts
Department of Mental Health. Treatment for rape-related mental or emotional disorders is
covered to the same extent as biologically based conditions.

2. A benefit period begins on the first day you receive services as an inpatient in a hospital and
ends after you have been out of the hospital and have not received skilled care in any other
facility for 60 days in a row.

3. For Medex Core, benefits are the same as those described for Medex Bronze, with two
exceptions: the member is responsible for the $1,340 inpatient deductible and $183 annual
Part B deductible, and mental hospital coverage
is limited to 60 days per calendar year.

4. Both days in a general hospital and days in a mental hospital count toward the 365 additional
days per lifetime.

www.bluecrossma.com/medicare 9

Medicare Coverage (Combined with a Medex Plan)

Medicare Medex Core
& Medex Bronze

Inpatient • Coverage for days 1–60 per • Full coverage of the Medicare
Admissions benefit period, after the $1,340 deductible and co-insurance2
in a General inpatient deductible1
Hospital • Full coverage of lifetime reserve
• Coverage for days 61–90, after days co-insurance
$335 daily co-insurance
• Full coverage of up to 365
• Coverage for an additional 60 additional hospital days in your
lifetime reserve days, after $670 lifetime when Medicare benefits
daily co-insurance end3

• Coverage for mental hospital
admissions is limited to 190 days
per lifetime

Non-Biologically Same coverage as general hospital, • Full coverage of Medicare
Based Mental but coverage limited to 190 days deductible and co-insurance2
Conditions per lifetime
(includes drug • Full coverage of lifetime reserve
addiction and Inpatient day co-insurance
alcoholism) Admissions
in a Mental • When Medicare days are used up,
Hospital 120 days per benefit period (at
least 60 days per calendar year),
less any days in a mental hospital
already covered by Medicare
or Medex in that benefit period (or
calendar year)

Outpatient Full benefits, less the Part B • When covered by Medicare,
Visits deductible and the Part B full coverage of Part B deductible
co-insurance and co-insurance with no visit
maximum2

• When not covered by Medicare,
full Medex benefits with no visit
maximum

1. A benefit period begins on the first day you receive services as an inpatient in a hospital and
ends after you have been out of the hospital and have not received skilled care in any other
facility for 60 days in a row.

2. For Medex Core, benefits are the same as those described for Medex Bronze, with two
exceptions: the member is responsible for the $1,340 inpatient deductible and $183 annual
Part B deductible, and mental hospital coverage
is limited to 60 days per calendar year.

3. Both days in a general hospital and days in a mental hospital count toward the 365 additional
days per lifetime.

10 Medex Choice Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2018.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core Medex Bronze
(Medicare Supplement (Medicare Supplement 1)
Core)
Full Coverage
Travel Outside No Coverage Full Coverage (same as in U.S.)
the U.S. (same as in U.S.)
Diabetic Testing For blood glucose
Supplies1 80% coverage of approved For blood glucose monitoring equipment
services, after $183 annual monitoring equipment and supplies covered by
Part B deductible and supplies covered by Medicare:
Medicare:
• Coverage for Medicare
• Coverage for Medicare deductible and
co-insurance co-insurance

For urine-testing materials For urine-testing materials
(not covered by Medicare): (not covered by Medicare):

• 100% coverage of • 100% coverage of
allowed charges allowed charges

Medex Core & Medex Bronze

Fitness Benefit N/A Medex members may receive up to $150 per calendar
year in qualified health club membership fees and exercise
N/A classes
Weight Loss Benefit
Medex members may receive up to $150 per calendar
year when enrolled in a qualified weight-loss program

1. Medicare covers blood glucose materials for all diabetics, whether or not insulin-dependent.
Medicare does not cover urine-testing materials.

This chart does not include all Medicare benefits. Please refer to the Medicare & You handbook
published by the Centers for Medicare and Medicaid Services for more information about
Medicare benefits, or call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048).
You can also visit www.cms.gov for more information.

www.bluecrossma.com/medicare 11

$150EARN UP TO When a member is enrolled
in a qualified fitness or
(per calendar year) weight-loss program.

(See details for qualifying programs)

12 Medex Choice Sales: 1-800-678-2265

Medex Coverage Wellness Programs

Fitness Benefit

• When a member is enrolled in a qualified health club or fitness
facility, they can receive up to $150 per calendar year toward club
membership fees and exercise classes.

Qualifying programs include: Programs that DO NOT qualify:

• Health clubs with a variety of cardiovascular • One-time initiation or termination fees
and strength-training exercise equipment—
e.g., traditional health clubs, YMCAs, YWCAs, • Fees paid for gymnastics, tennis, pool-only
and community fitness centers. facilities, martial arts schools, instructional
dance studios, country clubs or social clubs,
• Fitness classes available at participating sports teams or leagues
Councils on Aging facilities.
• Personal trainer sessions
• Starting in 2019 - A fitness studio with
instructor-led group classes such as yoga, • Fitness equipment or clothing
Pilates, Zumba®´ , kickboxing, indoor cycling/
spinning, and other exercise programs.

Weight-Loss Benefit

• When a member is enrolled in a qualified weight-loss
program, they can receive up to $150 per calendar year
toward program fees.

Qualifying programs include: Programs that DO NOT qualify:
• One-time initiation or termination fees
• Traditional Weight Watchers meetings and • Food, supplements, books, scales,
Weight Watchers At Work program
or exercise equipment
• Hospital based weight-loss programs • Individual nutrition counseling sessions

• Starting in 2019 - Weight Watchers online and (see your health plan coverage)
other non-hospital programs (in-person or
online) that combine healthy eating, exercise,
and coaching sessions with certified health
professionals such as nutritionists, registered
dietitians, or exercise physiologists

www.bluecrossma.com/medicare 13

How Medex Works

With Medex, you show two cards when you receive
medical care: your Medicare card and your Medex card.
Medicare pays first.

Medex plans have many advantages

• You can seek care from any Medicare physician or hospital throughout the United States.
• You don’t need to choose a PCP.
• You don’t need to get referrals for specialty care.
• There are no copayments for physician services.
• You can adjust your Medex coverage at any time during the year. Your coverage in the new plan

will begin the first of the month following receipt of your request to change plans.
• Your Blue Cross Blue Shield of Massachusetts ID card is recognized around the world.

Am I Eligible for Medex?

You don’t need to complete a health care screening to qualify for
Medex coverage.

You are eligible for Medex if you meet the following requirements:

• You live in Massachusetts.
• You are enrolled (or will be enrolling) in both Medicare Part A and Part B.
• You may also be eligible if you are under age 65 and have a disability other than

end-stage renal disease (ESRD).
Note: If you are already covered by both Medicare and Medicaid, you may not
need the additional coverage that Medex would provide. For more information,
contact the Massachusetts Executive Office of Elder Affairs insurance counseling
program at 1-800-882-2003.

14 Medex Choice Sales: 1-800-678-2265

When Do I Enroll?

You can apply for Medex during initial eligibility or
continuous Open Enrollment, and in special situations.

Initial eligibility

You are considered “initially eligible” if one of the situations in the chart below applies to you.

If You Are: You May Apply for Medex:
Within six months of your Medicare Part B effective date
Under 65 Within six months of your 65th birthday
Within six months of your Medicare Part B effective date
Enrolling in Medicare due to a disability other than
end-stage renal disease (ESRD) Within six months of the event

Approaching 65

Enrolling in both parts of Medicare

Over 65

Retiring from an employer-sponsored health plan
and enrolled in Medicare Part B or enrolling in
Medicare Part B

Over or Under 65

Involuntarily losing an employer-sponsored
retiree health plan

Moving out of the service area of a Medicare health
maintenance organization (HMO)

Becoming a resident of Massachusetts

Medex Continuous Open Enrollment

You may apply for Medex coverage at any time. Your coverage will begin the first of the month
following the receipt of the application.

Please note: If you wish to switch from a Medicare Advantage plan to a Medex plan, call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048) to learn how to dis-enroll from your Medicare Advantage plan.

www.bluecrossma.com/medicare 15

How Do I Enroll?

If you want to enroll in Medex, just follow these easy steps:

1. 2. 3.

Choose a Medex plan. The charts Decide if you want to be billed Enroll online, by phone,
in this brochure let you compare monthly or quarterly. You may find by mail, or by fax. See below for
plan coverage and determine the quarterly billing option more details. In addition to your name
which option best suits your convenient if you plan to travel for and address, you will need to
unique needs. more than a few weeks at a time. provide the Medicare number
You must also decide if you want that appears on your Medicare
your premium due on the 1st or card. (If you don’t have your
15th of each month. Medicare card, contact the Social
Security Administration office).

Please note that spouses need to enroll separately. If you receive your health benefits through a group contract
(such as a former employer), please follow that group’s enrollment procedures. Make sure that you keep a copy
for your records.

Enrolling Is Easy

If you’re ready to enroll in Medex, you can enroll by
telephone, online, by mail, or by fax:

• TELEPHONE: Call 1-800-678-2265, Monday through Friday, 8:00 a.m. to 6:00 p.m. ET.
• ONLINE: Visit our website, www.bluecrossma.com/medicare, and click Enroll, then Online.
• MAIL: Complete and return the enclosed enrollment form in the pre-addressed business reply envelope provided.
• FAX: You may also fax your completed enrollment form to us at 1-617-246-3633.

And that’s it! No need to send your premium payment with the application. You will receive a bill
after your application has been processed. If you have any questions about enrolling, please feel
free to call us at 1-800-678-2265.

16 Medex Choice Sales: 1-800-678-2265

When Will My Coverage Begin?

Effective Date of Your Coverage

If you do not yet have Medicare coverage, the effective date of your Medex coverage is
determined by the effective date of your Medicare Part B coverage.

If you already have Medicare coverage, your effective date is determined by the date we receive
your application.

When Your Application Is Received Your Medex Coverage Will Begin
The same day as your Medicare coverage
Before the effective date of your Medicare coverage
The first day of the month following the month
• If you enroll within the first six months your application is received
of your Medicare Part B coverage or

• If you enroll during continuous open enrollment

Please Note: If you haven’t enrolled in Medicare,
contact your local Social Security Administration office
three months prior to your 65th birthday.

www.bluecrossma.com/medicare 17

Helpful Numbers

We understand that health care can be confusing,
particularly when combining plans like Medicare and
Medex. The resources provided below can help you
determine who to call to get the information you need.

Blue Cross Blue Shield of Massachusetts

Blue Cross Blue Shield of Massachusetts associates can answer questions regarding Medex
options, premium rates, applications, timing, enrollment, and other Medex-related issues.
Medex Sales: 1-800-678-2265 TTY: 711

Serving the Health Information Needs of Everyone (SHINE)

SHINE is an independent organization dedicated to helping you understand and compare all
your health plan options. Trained and certified counselors help you determine if you qualify for
any supplemental assistance programs. All services are free of charge.
1-800-AGE-INFO (1-800-243-4636)

Medicare

If you have questions regarding Medicare, or to order a Medicare & You handbook,
call 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) or visit www.cms.gov.

24/7 Nurse Line: 1-888-247-BLUE (2583)

Not sure if you need to see a doctor? Medex members can call a registered nurse 24 hours
a day at the Blue Care Line for immediate assistance with health-related questions.

We think it’s important for you to know...

At the onset of an emergency medical condition that in your judgment requires immediate
attention, you should go to the nearest emergency room. For assistance, call your local
emergency medical service system by dialing 911, or your local emergency telephone number.

18 Medex Choice Sales: 1-800-678-2265

Premium Rates

When you turn 65 and become initially eligible for
Medicare, you may qualify for a discounted Direct Pay
Medex premium rate for up to three years.

If you are eligible for this discount, you will receive a 15 percent discount the first year of
enrollment, a 10 percent discount during the second year of enrollment, and a 5 percent discount
during the third year of enrollment. After the third year, there is no discounted premium rate. Call
1-800-678-2265 to determine if you are eligible for the discount.

-15%First Year -10%Second Year -5%Third Year
Savings Savings Savings

2019 Rates Billed Monthly Billed Quarterly

Medex Core $98.42 $294.45
Medex Bronze $197.74 $591.63

Rates effective January 1, 2019 through December 31, 2019.

Please note: If you obtained Medicare under the age of 65 due to disability, you are not eligible for
the discount.

www.bluecrossma.com/medicare 19

Blue Cross Blue Shield Resources

www.bluecrossma.com/Medicare

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 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 1-800-200-4255 (TTY: 711).

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

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

188571M 42-0430-19 (08/18)

Medex®´

Outline of Medicare
Supplement Coverage

Cover Page: Benefit Plans Medicare Supplement Core Through Choice

The chart on the following page shows the benefits included in each Medicare Supplement
Insurance plan. Every company must make available the “Core” plan. Companies may add
certain benefits to the standard benefits, if approved by the Commissioner. Look at each
company’s materials to find out which benefits, if any, the company has added to the standard
benefits for each plan it offers.

BASIC BENEFITS Included in all plans.
HOSPITALIZATION
Part A co-insurance coverage for the first 90 days per benefit period (not including the
MEDICAL EXPENSES Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage
BLOOD for 365 additional days after Medicare benefits end. This shall include benefits for
biologically based mental disorders.

Part B co-insurance (generally 20% of Medicare-approved expenses) or, in the case
of hospital outpatient department services under a prospective payment system,
applicable copayments.
This shall also include benefits for biologically based mental disorders.

First three pints of blood each year.

For more www.bluecrossma.com/medicare
information:
1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 p.m.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association
1

Medicare Supplement Core Medicare Supplement 1 Medicare Supplement Choice
Medex Core Medex Bronze Medex Choice

STANDARD BENEFITS
Basic Benefits

Hospitalization Hospitalization Hospitalization

For biologically based mental For biologically based mental For biologically based mental

disorders, stays in a licensed mental disorders, stays in a licensed mental disorders, stays in a licensed mental

hospital, less Part A deductibles; for hospital; for other mental disorders: hospital, less Part A deductibles;

other mental disorders: stays in a stays in a licensed mental hospital for a for other mental disorders: stays

licensed mental hospital for at least minimum of 120 days per benefit period in a licensed mental hospital for

60 days per calendar year less days (at least 60 days per calendar year) less at least 60 days per calendar year

covered by Medicare or already days covered by Medicare or already less days covered by Medicare or

covered by plan in that calendar covered by plan in that calendar year for already covered by plan in that

year for the other mental disorders, the other mental disorders. calendar year for the other mental

less Part A deductibles. disorders, less Part A deductibles.

Skilled nursing co-insurance

Part A deductible

Part B deductible

Foreign travel
ADDITIONAL BENEFITS

Fitness program Fitness program Fitness program

Weight loss program Weight loss program Weight loss program
Foreign travel
Part A deductible—100% cover-
age when you select a Choice PCP

Part B deductible—100% coverage
when you select a Choice PCP

Skilled Nursing Facility—
Coverage for days 21–100 when
you select a Choice PCP

RATES
Effective 1/1/19

Billed monthly: $98.42 Billed monthly: $197.74 Billed monthly: $146.23

Billed quarterly: $294.45 Billed quarterly: $591.63 Billed quarterly: $436.68

2

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Blue Cross and Blue Shield of Massachusetts, Inc.

• Medicare Supplement Core—Medex Core (ME 11 DB)
• Medicare Supplement 1—Medex Bronze (ME 2 DB)

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

• Medicare Supplement Choice—Medex Choice
Policy Category: Medicare Supplement Insurance
“NOTICE TO BUYER: This policy may not cover all of the costs associated with medical care incurred
by the buyer during the period of coverage. The buyer is advised to review carefully all policy limitations.”

Premium Information Policy Replacement

We, Blue Cross Blue Shield of Massachusetts, If you are replacing another health insurance
can only raise your premium if we raise policy, do NOT cancel it until you have
the premium for all policies like yours in actually received your new policy and are
Massachusetts, and if approved by the sure you want to keep it. If you cancel your
Commissioner of Insurance. If you choose to present policy and then decide that you do
pay your premium on a monthly or quarterly not want to keep your new policy, it may not
basis, upon your death, we will refund the be possible to get back the coverage of the
unearned portion of the premium paid. If you present policy.
choose to pay your premium on a monthly
or quarterly basis and you cancel your Notice
policy, we will refund the unearned portion
of the premium paid. In the case of death, This policy may not fully cover all of your
the unearned portion of the premium will be medical costs. Blue Cross Blue Shield
refunded on a pro-rata basis. of Massachusetts is not connected
with Medicare. This outline of coverage does
Disclosures not give all the details of Medicare coverage.
Contact your local Social Security office or
Use this outline to compare benefits and consult “Medicare & You” for more details.
premiums among policies.
Complete Answers
Read Your Policy Very Carefully Are Very Important

This is only an outline describing your policy’s When you fill out the application for the new
most important features. The policy is your policy, be sure to answer all the questions
insurance contract. You must read the policy truthfully and completely. The company may
itself to understand all of the rights and duties of cancel your policy and refuse to pay any claims
both yourself and your insurance company. if you leave out or falsify important information.
Review the application carefully before you
Right To Return Policy sign it. Be certain that all information has been
properly recorded.
If you find you are not satisfied with your
policy, you may return it to Blue Cross Blue
Shield of Massachusetts, Medex Member
Services, P.O. Box 9130, North Quincy, MA
02171-9130. If you send the policy back to us
within 30 days after you receive it, we will treat
the policy as if it had never been issued and
return all of your payments.

3

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Massachusetts Summary The Benefits-to-Premium Ratio
for Medex Bronze Is 93.9%.
The Commissioner of Insurance has set
standards for the sale of Medicare Supplement This means that during the anticipated life
Insurance policies. Such policies help you of your policy and others just like it, Blue
pay hospital and doctor bills, and some other Cross Blue Shield of Massachusetts expects
bills, that are not covered in full by Medicare. to pay out $93.90 in claims made by you
Please note that the benefits provided by and other policyholders for every $100 we
Medicare and this Medicare Supplement collect in premiums. The minimum loss ratio
Insurance policy may not cover all of the costs for Blue Cross Blue Shield of Massachusetts
associated with your treatment. It is important policies of this type is 90%. The minimum
that you become familiar with the benefits loss ratio for non-Blue Cross Blue Shield of
provided by Medicare and your Medicare Massachusetts policies of this type is 65%. A
Supplement Insurance policy. This policy higher ratio is to your advantage, as long as it
summary outlines the different coverages you allows the company reasonable return so that
have if, in addition to this policy, you are also the product remains available.
covered by Part A (hospital bills, mainly) and
Part B (doctors’ bills, mainly) of Medicare. The Benefits-to-Premium Ratio
for Medex Core Is 93.9%.
Under Massachusetts General Laws, c.
112, s. 2, no physician who agrees to treat This means that during the anticipated life
a Medicare beneficiary may charge to or of your policy and others just like it, Blue
collect from that beneficiary any amount in Cross Blue Shield of Massachusetts expects
excess of the reasonable charge for that to pay out $93.90 in claims made by you
service as determined by the United States and other policyholders for every $100 we
Secretary of Health and Human Services. collect in premiums. The minimum loss ratio
This prohibition is commonly referred to as for Blue Cross Blue Shield of Massachusetts
the “ban on balance billing.” A physician is policies of this type is 90%. The minimum
allowed to charge you or collect from your loss ratio for non-Blue Cross Blue Shield of
insurer a copayment or co-insurance for Massachusetts policies of this type is 65%. A
Medicare-covered services. However, if your higher ratio is to your advantage, as long as it
physician charges you or attempts to collect allows the company reasonable return so that
from you an amount, which together with the product remains available.
your copayment or co-insurance is greater
than the Medicare-approved amount, The Benefits-to-Premium Ratio
please contact the Board of Registration in for Medex Choice Is 93.9%.
Medicine at (781) 867-8200.
This means that during the anticipated life of
We cannot explain everything here. your policy and others just like it, Blue Cross
Massachusetts law requires that personal Blue Shield of Massachusetts expects to pay
insurance policies be written in easy-to-read out $93.90 in claims made by you and other
language. So, if you have questions about policyholders for every $100 we collect
your coverage that are not answered in this in premiums. The minimum loss ratio for Blue
brochure, read your policy. If you still have Cross Blue Shield of Massachusetts policies
questions, ask your agent or company. You of this type is 90%. A higher ratio is to your
may also wish to get a copy of “Medicare & advantage, as long as it allows the company
You”, a small book put out by Medicare that reasonable return so that the product
describes Medicare benefits. remains available.

4

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Complaints • Write or Fax: The preferred option is for
you to send your grievance in writing
If you have a complaint, call Medex Member to: Member Grievance Program, Blue
Service at 1-800-258-2226. If you are not Cross Blue Shield of Massachusetts, One
satisfied, you may write to The Massachusetts Enterprise Drive, Quincy, MA 02171-2126.
Division of Insurance, 1000 Washington Street, Or, you may fax your grievance to 1-617-
Suite 810, Boston, Massachusetts 02118-6200 246-3616. Blue Cross Blue Shield will let
or call (617) 521-7794 (Boston). you know that your request was received
by sending you a written confirmation
Grievance Program within 15 calendar days.

As a Medex member, you have the right • Email: Or, you may send your grievance
to a review when you disagree with a to the Blue Cross Blue Shield Member
decision made by Blue Cross Blue Shield of Grievance Program internet address
Massachusetts to deny payment for services [email protected]. Blue Cross Blue
that may be eligible for benefits under Medex Shield of Massachusetts will let you know
or if you have a complaint about the care or that your request was received by sending
service that you received from Blue Cross Blue you a confirmation immediately by e-mail.
Shield of Massachusetts or from a provider.
• Telephone: Or, you may call the Blue
Medex Inquiries or Claim Problems Cross Blue Shield of Massachusetts
Member Grievance Program at 1-800-
Most Medex problems or concerns can be 472-2689. When your request is made
handled with just one phone call. For help to by phone, Blue Cross Blue Shield of
resolve a Medex problem or concern, you Massachusetts will send you a written
should first call the Blue Cross Blue Shield account of the grievance within 48 hours of
of Massachusetts customer service office at your phone call.
1-800-258-2226, Monday through Friday, 8:00
a.m. to 6:00 p.m. ET. The TTY toll-free number Once your request is received, Blue Cross Blue
is 711. A customer service representative will Shield of Massachusetts will research the case
work with you. They will help you understand in detail. They will ask for more information
your Medex coverage. Or, they will work if it is needed. Blue Cross Blue Shield of
with you to resolve your Medex problem Massachusetts will let you know in writing of
or concern. They will do this as quickly as the decision or the outcome of the review.
possible.
Note: Medicare has its own policies and
If after speaking with a Blue Cross Blue Shield of procedures for handling appeals and
Massachusetts customer service representative, grievances. If you do not agree with a decision
you still disagree with a decision that is given to by Medicare on the amount that Medicare
you, you may request a review through the Blue has paid on a claim or whether the services
Cross Blue Shield of Massachusetts internal you received are covered by Medicare, you
formal grievance program. have the right to appeal the decision. The
steps you should take to appeal the decision
Internal Formal Grievance Review are explained in your Medicare handbook.
You may also look on the Medicare website
How to Request a Grievance Review: To at www.medicare.gov for more detailed
request a formal review from the Blue Cross information about the Medicare appeals
Blue Shield of Massachusetts internal Member process.
Grievance Program, you (or your authorized
representative) have three options.

5

Medicare Supplement Core: Medex Core

Medicare (Part A) —Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay

Hospitalization* $1,340
(Part A deductible)
Semiprivate room and board, general $0
hospital nursing and miscellaneous services $0
and supplies, and licensed mental hospital $0
stays for biologically based mental disorders All Costs
or other mental disorders prior to the 190-
day Medicare lifetime maximum $1,340
(Part A deductible)
First 60 days of a benefit period All but $1,340 $0 $0

61st through 90th day of a benefit period All but $335 a day $335 a day $0
91st day and after of a benefit period: All but $670 a day
– While using 60 lifetime reserve days $0 $670 a day $0
– Once lifetime reserve days are used: 100% of Medicare All Costs
eligible expenses
• Additional 365 days $0

• Beyond the additional 365 days $0 All but $1,340
$0
Licensed mental hospital stays
not covered by Medicare for biologically
based mental disorders

First 60 days of a benefit period

61st through 90th day of a benefit period $0 100% of Medicare
eligible expenses
91st day and after of a benefit period: $0
– While using 60 lifetime reserve days 100% of Medicare
eligible expenses
– Once lifetime reserve days are used: $0
• Additional 365 days 100% of Medicare
eligible expenses
• Beyond the additional 365 days $0 $0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

6

Medicare Supplement Core: Medex Core (continued)

Medicare (Part A) —Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
$0
Licensed mental hospital stays not covered by All but $1,340 $1,340
Medicare for other mental disorders (Part A deductible)

First 60 days per calendar year less days
covered by Medicare or plan in that calendar year

61st through 120th day of a benefit period $0 100% of Medicare $0
eligible expenses
Days after 60 days per calendar year less days $0
covered by Medicare or plan in that calendar year $0 All Costs

Skilled Nursing Facility Care*

(Participating with Medicare)
You must meet Medicare’s requirements,
including having been in a hospital for at least
three days and entered a Medicare-approved
facility within 30 days after having left the hospital

First 20 days of a benefit period All approved amounts $0 $0

21st through 100th day of a benefit period All but $167.50 $0 Up to $167.50
101st day and after of a benefit period a day $0 a day

$0 All Costs

Blood $0 Three pints $0
First three pints

Additional amounts 100% $0 $0

Hospice Care All but very limited Actual billed $0
co-insurance for charges up to the
Available as long as your doctor certifies outpatient drugs co-insurance
you are terminally ill and you elect to and inpatient amount
receive these services respite care

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core
Benefits”. During this time the hospital is prohibited from billing you for the balance based on any difference between its
billed charges and the amount Medicare would have paid.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

7

Medicare Supplement Core: Medex Core (continued)

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

Services Medicare Pays Plan Pays You Pay
$0 $0 $183 (Part B deductible)
Medical expenses in or out of the hospital
and outpatient hospital treatment, such as
physician’s services, inpatient and outpatient
medical and surgical services and supplies,
physical and speech therapy, diagnostic tests, and
durable medical equipment

First $183 of Medicare-approved amounts**

Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Outpatient treatment for biologically based
mental disorders and other mental health disorders

(for services covered by Medicare)

First $183 of Medicare-approved amounts** $0 $0 $183 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

Outpatient treatment for biologically based $0 100% of $0
expenses
mental disorders and other mental health disorders

(for services not covered by Medicare)

Blood

First 3 pints $0 All Costs $0

Next $183 of Medicare-approved amounts** $0 $0 $183 (Part B deductible)

Remainder of Medicare-approved amounts 80% 20% $0

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

8

Medicare Supplement Core: Medex Core (continued)

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 $183 (Part B deductible)
First $183 of Medicare-approved amounts**
Remainder of Medicare-approved amounts 80% 20% $0
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 $0 $0

Medically necessary skilled-care services 100% $0 $183 (Part B deductible)
and medical supplies 20% $0
Durable medical equipment $0
80%
First $183 of Medicare-approved amounts**

Remainder of Medicare-approved amounts

Other Benefits—Not Covered By Medicare

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

Weight-Loss Program—Not Covered by Medicare $0

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

9

Medicare Supplement 1: Medex Bronze

Medicare (Part A) —Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay

Hospitalization*
Semiprivate room and board, general hospital
nursing and miscellaneous services and supplies,
and licensed mental hospital stays for biologically
based mental disorders or other mental disorders
prior to the 190-day Medicare lifetime maximum

First 60 days of a benefit period All but $1,340 $1,340 $0
61st through 90th day of a benefit period All but $335 a day (Part A deductible) $0

$335 a day

91st day and after of a benefit period:

– While using 60 lifetime reserve days All but $670 a day $670 a day $0

– Once lifetime reserve days are used:

• Additional 365 days $0 100% of Medicare $0
• Beyond the additional 365 days $0 eligible expenses All Costs

$0

Licensed mental hospital stays for
biologically based mental disorders
not covered by Medicare

First 60 days of a benefit period $0 100% of Medicare $0
61st through 90th day of a benefit period $0 eligible expenses $0
91st day and after of a benefit period:
100% of Medicare
eligible expenses

– While using 60 lifetime reserve days $0 100% of Medicare $0
– Once lifetime reserve days are used: eligible expenses
$0
• Additional 365 days $0 100% of Medicare $0
eligible expenses All Costs
• Beyond the additional 365 days
$0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance
amounts. These amounts are subject to change each year.

10

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

Licensed mental hospital stays not covered by
Medicare for other mental disorders

First 120 days per benefit period (at least 60 days per
calendar year) less days covered by Medicare or plan
in that calendar year

First 60 days of a benefit period $0 100% of Medicare $0
eligible expenses

61st through 120th day of a benefit period $0 100% of Medicare $0
eligible expenses

Days after 120 days per benefit period (or 60 days per $0 $0 All Costs
calendar year) less days covered by Medicare or plan
in that calendar year

Skilled Nursing Facility Care*
(Participating with Medicare)
You must meet Medicare’s requirements,
including having been in a hospital for at least three
days and entered a Medicare-approved facility within
30 days after having left the hospital

First 20 days of a benefit period All approved $0 $0
amounts
21st through 100th day of a benefit period Up to $167.50 $0
All but $167.50 a day
101st day through 365th day of a benefit period a day $10 a day Balance
Beyond the 365th day of a benefit period $0 $0 All Costs

$0

(Not participating with Medicare) $0 $8 a day Balance
You must meet Medicare’s requirements, including
having been in a hospital for at
least three days and transferred to the facility
within 30 days after having left the hospital

1st day through 365th day of a benefit period

Beyond the 365th day of a benefit period $0 $0 All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

11

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
Blood

First 3 pints $0 3 pints $0

Additional amounts 100% $0 $0

Hospice Care All but very Actual billed $0

Available as long as your doctor certifies limited charges up
you are terminally ill and you elect to
receive these services co-insurance for to the

outpatient drugs co-insurance amount

and inpatient respite

care

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and
will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core
Benefits”.During this time the hospital is prohibited from billing you for the balance based on any difference between its
billed charges and the amount Medicare would have paid.

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital and
outpatient hospital treatment, such as physician’s
services, inpatient and outpatient medical and surgical

services and supplies, physical and speech therapy,

diagnostic tests, and durable medical equipment

First $183 of Medicare-approved amounts** $0 $183 $0
Remainder of Medicare-approved amounts Generally 80% (Part B deductible) $0

Generally 20%

Outpatient treatment for biologically based mental
disorders and other mental health disorders

(for services covered by Medicare)

First $183 of Medicare-approved amounts** $0 $183 $0
(Part B deductible)
Remainder of Medicare-approved amounts 80% $0
20% $0
Outpatient treatment for biologically based mental $0
disorders and other mental health disorders 100% of expenses

(for services not covered by Medicare)

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

12

Medicare Supplement 1: Medex Bronze (continued)

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

Services Medicare Pays Plan Pays You Pay
Blood
First 3 pints $0 All Costs $0
Next $183 of Medicare-approved amounts**
$0 $183 $0
Remainder of Medicare-approved amounts
Clinical Laboratory Services (Part B deductible)

80% 20% $0

Blood tests for diagnostic services 100% $0 $0
Special Medical Formulas Mandated by Law $0
Covered by Medicare $183 $0
First $183 of Medicare-approved amounts** (Part B deductible)
$0
Remainder of Medicare-approved amounts 80% 20% Balance
Not covered by Medicare $0
All allowed charges

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

13

Medicare Supplement 1: Medex Bronze (continued)

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

First $183 of Medicare-approved amounts** $0 $183 $0
Remainder of Medicare-approved amounts 80% (Part B deductible) $0

20%

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

Other Benefits—Not Covered By Medicare

Services Medicare Pays Plan Pays You Pay

Foreign Travel—Not Covered by Medicare Remainder of $0
Only the services listed above while traveling out- $0
side the United States charges (including

portion normally paid

by Medicare)

Outpatient Prescription Drugs—Not Covered $0 $0 All Costs
by Medicare $0
Fitness Program—Not Covered by Medicare $0 $150 per All charges
calendar year after $150
Weight Loss Program—Not Covered
by Medicare $150 per All charges
calendar year after $150

14

Medicare Supplement Choice: Medex Choice

Medicare (Part A) —Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay
With
Hospitalization* With With Choice With
Semiprivate room and board, general Choice Other PCP Other
hospital nursing and miscellaneous services PCP PCP PCP
and supplies, and licensed mental hospital $0
stays for biologically based mental disorders $0 $1,340
or other mental disorders prior to the $0 (Part A
190-day Medicare lifetime maximum $0 Deductible)
All Costs $0
First 60 days of a benefit period All but $1,340 $1,340 $0
$0 $0
61st through 90th day of a benefit period All but $335 a day $335 a day
91st day and after of a benefit period: $0 $0
– While using 60 lifetime reserve days All but $670 a day $670 a day All Costs
– Once lifetime reserve days are used: $0
$0 100% of Medicare $1,340
• Additional 365 days eligible expenses $0 (Part A
All Costs Deductible)
• Beyond the additional 365 days $0 $0 $0
Licensed mental hospital stays
not covered by Medicare for biologically $0 100% of All but
based mental disorders Medicare $1,340
First 60 days of a benefit period eligible
expenses
61st through 90th day of a benefit period
$0 100% of Medicare
91st day and after of a benefit period: eligible expenses
– While using 60 lifetime reserve days
$0 100% of Medicare
– Once lifetime reserve days are used: eligible expenses
• Additional 365 days
$0 100% of Medicare
• Beyond the additional 365 days eligible expenses

$0 $0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you
have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.

These amounts are subject to change each year. 15

Medicare Supplement Choice: Medex Choice (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
With Choice PCP
Licensed mental hospital stays not covered by With Choice PCP
Medicare for other mental disorders

First 120 days per benefit period (at least 60 days
per calendar year) less days covered by Medicare
or plan in that calendar year

First 60 days of a benefit period $0 100% of Medicare- $0
eligible expenses $0
61st through 120th day of a benefit period $0 100% of Medicare All Costs
eligible expenses
Days after 120 days per benefit period (or 60 days $0 $0 With Other PCP
per calendar year) less days covered by Medicare
or plan in that calendar year With Other PCP $1,340
(Part A deductible)
Licensed mental hospital stays not covered by
Medicare for other mental disorders $0

First 60 days per calendar year less days $0 All but $1,340 All Costs
covered by Medicare or plan in that $0
calendar year 100% of Medicare
eligible expenses
61st day and after of a benefit period
$0
Days after 60 days per calendar year $0
less days covered by Medicare or plan
in that calendar year With With With With
Choice Other Choice Other
Skilled Nursing Facility Care* PCP PCP PCP PCP
(Participating with Medicare)
You must meet Medicare’s requirements, includ-
ing having been in a hospital for at least three
days and entered a Medicare-approved facility
within 30 days after having left the hospital

First 20 days of a benefit period All approved $0 $0 $0 $0
21st through 100th day of a benefit period amounts $0
$167.50 $0 Up to
101st day and after of a benefit period All but $167.50 per day Balance $167.50 a
a day day

$0 $10 a day $0 All Costs

Beyond the 365th day of a benefit period $0 $0 $0 All Costs All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you
have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.

These amounts are subject to change each year. 16

Medicare Supplement Choice: Medex Choice (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
With
(Not participating with Medicare) With With Choice With
You must meet Medicare’s requirements, includ- Choice Other PCP Other
ing having been in a hospital for at least three PCP PCP PCP
days and transferred to the facility within 30 days Balance
after having left the hospital $8 a day $0 All costs All Costs
All Costs
1st day through 365th day of a benefit period $0 $0

Beyond the 365th day of a benefit period $0 $0 $0

Blood

First three pints $0 Three pints

Additional amounts 100% $0 $0

Hospice Care All but very Actual billed $0

Available as long as your doctor certifies limited charges up to the

you are terminally ill and you elect to co-insurance for co-insurance amount

receive these services outpatient drugs

and inpatient

respite care

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and

will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core

Benefits”. During this time the hospital is prohibited from billing you for the balance based on any difference between its

billed charges and the amount Medicare would have paid.

The Deductible and Co-insurance amounts listed above reflect the 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

17

Medicare Supplement Choice: Medex Choice (continued)

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital With With With With
and outpatient hospital treatment, such as Choice Other Choice Other
physician’s services, inpatient and outpatient PCP PCP PCP PCP

medical and surgical services and supplies,

physical and speech therapy, diagnostic

tests, and durable medical equipment

First $183 of Medicare-approved amounts** $0 $183 $0 $0 $183 (Part B
Remainder of Medicare-approved amounts Generally 80% Generally 20% deductible)

$0 $0

Outpatient treatment for biologically based
mental disorders and other mental health disor-
ders (for services covered by Medicare)

First $183 of Medicare-approved amounts** $0 $183 $0 $0 $183 (Part B
Remainder of Medicare-approved amounts 80% deductible)

20% 20% $0 $0

Outpatient treatment for biologically based $0 100% of expenses $0 $0
mental disorders and other mental health
disorders (for services not covered by Medicare)

Blood

First 3 pints $0 All Costs All Costs $0 $0
Next $183 of Medicare-approved amounts** $0
$183 $0 $0 $183 (Part B
Remainder of Medicare-approved amounts 80% deductible)
20% 20% $0 $0

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

18

Medicare Supplement Choice: Medex Choice (continued)

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

Services Medicare Pays Plan Pays You Pay
Clinical Laboratory Services
With With With With
Choice Other Choice Other
PCP PCP PCP PCP

Blood tests for diagnostic services 100% $0 $0 $0 $0

Special Medical Formulas Mandated by Law

Covered by Medicare $0 $183 $0 $0 $183 (Part B
First $183 of Medicare-approved amounts** deductible)
20% 20%
Remainder of Medicare-approved amounts 80% All allowed charges $0 $0
Not covered by Medicare $0
Balance

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay

Home Health Care— With With With With
Medicare-Approved Services Choice Other Choice Other
PCP PCP PCP PCP
Medically necessary skilled care services 100%
and medical supplies $0 $0 $0 $0 $0

Durable medical equipment $183 $0 $0 $183 (Part B
20% 20% deductible)
First $183 of Medicare-approved amounts**
$0 $0
Remainder of Medicare-approved amounts 80%

Other Benefits—Not Covered By Medicare

Services Medicare Plan Pays You Pay
Pays
Outpatient Prescription Drugs— $0 $0 All costs
Not Covered by Medicare
$0 $150 per calendar year All charges
Fitness Program—Not Covered by Medicare after $150
All charges
Weight Loss Program—Not Covered by Medicare $0 $150 per calendar year after $150

**Once you have been billed $183 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 2018 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.
19

Blue Cross Blue Shield Resources

www.bluecrossma.com/Medicare
Medicare Plan Sales: 1-800-678-2265

Member Service: 1-800-258-2226 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 p.m. ET.

Blue Cross Blue Shield of Massachusetts complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-258-2226 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-258-2226 (TTY: 711).

®, SM Registered Marks and Service 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. © 2018 Blue Cross and Blue Shield
of Massachusetts, Inc.

188555 32-3000-19 (08/18)