BCBSMA Medex Core Sapphire Sales Kit Book November 2022 Approved By Lindsey Rinaldi 11/07/2022 4:35 PM

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

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

Medicare (Parts A & B)

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

Remainder of Medicare-approved amounts

Other Benefits—Not Covered by Medicare

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

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

$0 charges (including
portion normally

paid by Medicare)

**Once you have been billed $233 of Medicare-approved amounts for covered services (which are noted with a double asterisk),
your Part B deductible will have been met for the calendar year.

The deductible and co-insurance amounts listed above reflect the 2022 Medicare deductible and co-insurance amounts.
These amounts are subject to change each year.

Blue Cross Blue Shield of Massachusetts 18

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

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks
of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield
of Massachusetts HMO Blue, Inc. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc.,

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

001615505 32-3000-23 (9/22)

02

Resources



IT’S MEDICARE OPEN ENROLLMENT TIME:
SIGN UP FOR A SEMINAR TODAY!

Thinking about switching plans? Join us for an upcoming Medicare seminar
to learn about your options and get answers to your questions.

ONLINE SEMINARS

We also offer a number of online seminars. To view the full list or to register
scan the QR code or visit bluecrossma.com/seminar.

Seminar Type Date Time Location

Medicare Plan Options Monday, October 17, 2022 10:00 a.m. - 12:00 p.m. DoubleTree by Hilton
Medicare Plan Options Tuesday, October 18, 2022 10:00 a.m. - 12:00 p.m. 5400 Computer Drive, Westborough
Medicare Plan Options Wednesday, October 19, 2022 2:00 p.m. - 4:00 p.m.
Medicare Plan Options Wednesday, October 19, 2022 2:00 p.m. - 4:00 p.m. enVision Hotel
Medicare Plan Options Saturday, October 22, 2022 10:00 a.m. - 12:00 p.m. 31 Hampshire Street, Mansfield
Medicare Plan Options Monday, October 24, 2022 10:00 a.m. - 12:00 p.m.
Medicare Plan Options Tuesday, October 25, 2022 10:00 a.m. - 12:00 p.m. Northampton Country Club
Medicare Plan Options Tuesday, October 25, 2022 10:00 a.m. - 12:00 p.m. 135 Main Street, Leeds
Medicare Plan Options Wednesday, October 26, 2022 2:00 p.m. - 4:00 p.m.
Medicare Plan Options Wednesday, October 26, 2022 2:00 p.m. - 4:00 p.m. Marriott
Medicare Plan Options Friday, October 28, 2022 10:00 a.m. - 12:00 p.m. 8A Centennial Drive, Peabody

Medicare Plan Options Monday, October 31, 2022 10:00 a.m. - 12:00 p.m. Lombardo’s
Medicare Plan Options Tuesday, November 1, 2022 10:00 a.m. - 12:00 p.m. 6 Billings Street, Randolph
Medicare Plan Options Wednesday, November 2, 2022 2:00 p.m. - 4:00 p.m.
Medicare Plan Options Thursday, November 3, 2022 10:00 a.m. - 12:00 p.m. Marriott
Medicare Plan Options Thursday, November 3, 2022 10:00 a.m. - 12:00 p.m. One Burlington Mall Road, Burlington
Medicare Plan Options Friday, November 4, 2022 10:00 a.m. - 12:00 p.m.
Medicare Plan Options Monday, November 7, 2022 10:00 a.m. - 12:00 p.m. John Carver Inn & Spa
25 Summer Street, Plymouth

Clarion Hotel
700 Myles Standish Blvd, Taunton

Spinelli’s Function Facility
Route One South, Lynnfield

Beechwood Hotel
363 Plantation Street, Worcester

Blue Cross Blue Shield of Massachusetts
101 Huntington Avenue,
Suite 1300, 3rd Floor, Boston

Marriott
One Burlington Mall Road, Burlington

La Quinta Inn & Suites by Wyndham
100 Congress Street, Springfield

Lombardo’s
6 Billings Street, Randolph

Holiday Inn
55 Ariadne Road, Dedham

Northampton Country Club
135 Main Street, Leeds

Spinelli’s Function Facility
Route One South, Lynnfield

Hawthorne Hotel
18 Washington Square W, Salem

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

Seminar Type Date Time Location

Medicare Plan Options Thursday, November 10, 2022 10:00 a.m. - 12:00 p.m. Beechwood Hotel
Medicare Plan Options Monday, November 14, 2022 10:00 a.m. - 12:00 p.m. 363 Plantation Street, Worcester
Medicare Plan Options Wednesday, November 16, 2022 2:00 p.m. - 4:00 p.m.
Medicare Plan Options Thursday, November 17, 2022 10:00 a.m. - 12:00 p.m. enVision Hotel
Medicare Plan Options Friday, November 18, 2022 10:00 a.m. - 12:00 p.m. 31 Hampshire Street, Mansfield
Medicare Plan Options Saturday, November 19, 2022 10:00 a.m. - 12:00 p.m.
Medicare Plan Options Tuesday, November 22, 2022 10:00 a.m. - 12:00 p.m. Marriott
Medicare Plan Options Tuesday, November 22, 2022 10:00 a.m. - 12:00 p.m. One Burlington Mall Road, Burlington
Medicare Plan Options Monday, November 28, 2022 10:00 a.m. - 12:00 p.m.
Medicare Plan Options Wednesday, November 30, 2022 2:00 p.m. - 4:00 p.m. DoubleTree by Hilton
5400 Computer Drive, Westborough
Medicare Plan Options Thursday, December 1, 2022 10:00 a.m. - 12:00 p.m.
Medicare Plan Options Thursday, December 1, 2022 10:00 a.m. - 12:00 p.m. Holiday Inn
Medicare Plan Options Friday, December 2, 2022 10:00 a.m. - 12:00 p.m. 55 Ariadne Road, Dedham
Medicare Plan Options Monday, December 5, 2022 10:00 a.m. - 12:00 p.m.
Clarion Hotel
Medicare Plan Options Monday, December 5, 2022 10:00 a.m. - 12:00 p.m. 700 Myles Standish Blvd, Taunton
Medicare Plan Options Tuesday, December 6, 2022 10:00 a.m. - 12:00 p.m.
DoubleTree by Hilton
99 Erdman Way, Leominster

La Quinta Inn & Suites by Wyndham
100 Congress Street, Springfield

Marriott
8A Centennial Drive, Peabody

Blue Cross Blue Shield of Massachusetts
101 Huntington Avenue,
Suite 1300, 3rd Floor, Boston

Marriott
One Burlington Mall Road, Burlington

Beechwood Hotel
363 Plantation Street, Worcester

La Quinta Inn & Suites by Wyndham
100 Congress Street, Springfield

Blue Cross Blue Shield of Massachusetts
101 Huntington Avenue,
Suite 1300, 3rd Floor, Boston

Hawthorne Hotel
18 Washington Square W, Salem

Lombardo’s
6 Billings Street, Randolph

*A Blue Cross Blue Shield of Massachusetts representative will present Medicare HMO, PPO, PDP,
and Medicare Supplement plan options and benefits. Visit the website below to view the agenda.

They can answer your questions and assist with enrollment when you’re ready.

Not seeing a date that works for you? NEED HELP SIGNING UP?

There are plenty more to choose from. For assistance signing up for a seminar, or for
Check out our full list of events at accommodations for persons with special needs, call
bluecrossma.com/seminar or scan 1-800-262-BLUE (2583) (TTY: 711) 7:00 a.m. – 12:00
the QR Code. midnight, seven days a week (excluding holidays).

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross
Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue
Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont
are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services
(CMS) and are the risk-bearing entities for Blue MedicareRx plans. The joint enterprise is a Medicare-approved Part D
sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal. ® Registered Marks of the Blue Cross and
Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and
Blue Shield of Massachusetts HMO Blue, Inc. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc. or Blue Cross
and Blue Shield of Massachusetts HMO Blue, Inc.
001737204 Y0014_22171_M 99-0645-23 (8/23)

Medex®´ Core, Medex®´ Sapphire

IT PAYS TO STAY BLUE

If you’re 65 or older and eligible for Medicare for the first time, sticking with us
could qualify you for these savings on your premium when you enroll in Medex®´:

15% 10% 5%

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

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

How These Savings Work

Plan Full Rate* First Year: Second Year: Third Year:
15% Discount* 10% Discount* 5% Discount*
$110.98
Medex Core $116.82 $99.30 $105.14 $183.00
Medex Sapphire $192.63 $163.74 $173.37

*Rates effective January 1, 2023 to December 31, 2023

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

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



Learn More

For more information, visit bluecrossma.com/medicare,
or call us at 1-800-678-2265 (TTY: 711),

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

Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract.
Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

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

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

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

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

and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
© 2022 Blue Cross and Blue Shield of Massachusetts, Inc.

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

001633997 55-2398-23 (9/22)

Medex®´ Core, Medex®´ Sapphire

VISION AND
HEARING
BENEFITS

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

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

COMPLETE YOUR COVERAGE

Glasses and hearing aids aren’t covered by Medicare. That’s why our Medex®´
Vision and Hearing benefit plan offers the coverage you’re missing. Plus, from
January 1, 2023 to December 31, 2023, it’s just $2.66 per month. This amount will
be added to your direct-billed Medex premium. With the Medex Vision
and Hearing plan, you’ll get the following benefits:

Vision Care Benefits Hearing Care Benefits

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

HOW TO GET REIMBURSED

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

 

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

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

How do I apply?

 The easiest way to enroll is by phone.

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

 Enroll by mail or fax:

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

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

÷ Medicare Plan Sales:

 1-800-678-2265 (TTY: 711)
8:00 a.m. to 5:00 p.m. ET, Monday through Friday
FOR MORE INFORMATION, bluecrossma.com/Medicare
OR TO ENROLL:

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços
linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).

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

and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
®´´ Registered Marks are the property of their respective owners.
© 2022 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

001633309 55-0435-23 (9/22)

Offered through the Global Citizens Association, Washington, D.C.

What is GeoBlue?

GeoBlue is a provider of health insurance for short-term and
frequent leisure, study, mission, marine and business travel.

Why should I choose a GeoBlue Plan?
All GeoBlue products comprehensive benefits, unrivaled technology and unsurpassed protection.

What short-term plan options are available?

Single-trip plans up to 182 days in length

GeoBlue Voyager - Up to $1,000,000 medical/$500,000 evacuation
• Choice of medical limits and deductibles
• Coverage of COVID-19 testing and treatment, at no additional cost, for everyone 95 years or younger
• Pre-existing condition coverage option
• Two levels of coverage: Essential and Choice
• Primary U.S. health plan required for Choice option
• Groups of 5 or more travelers may be enrolled as a group

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

GeoBlue Trekker - Up to $250,000 medical/$500,000 evacuation
• Choice of medical limits
• Pre-existing conditions covered
• 364 day plan (70 days max. per trip)
• Two levels of coverage are available: Essential and Choice
• Primary U.S. health plan required for both Choice and Essential options

What long-term plan options are available?

Global living plans for assignments or trips lasting 6 months or longer. Coverage of COVID-19 testing
and treatment, at no additional cost.

GeoBlue Xplorer - Primary health insurance for global living. Unlimited medical maximum,
evacuation, preventive care, pre-existing conditions covered with creditable coverage and more

• Premier: Worldwide coverage, including the U.S.

• Essential: Worldwide coverage, excluding the U.S., offers 50% savings Other questions?

• Essential w/ Basic U.S. Benefits: Worldwide coverage, excluding the U.S.,
except for accident and sickness coverage during 3 visits to the U.S. per year,

each trip lasting up to 21 days BCBSMA Call Center
888-366-3212
GeoBlue Navigator - A customized version of GeoBlue Xplorer geared for the
needs of career missionaries, yacht crew members, students and faculty

GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an
independent licensee of the Blue Cross and Blue Shield Association. GeoBlue is the administrator of coverage provided under insurance policies
issued by 4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association.

4ELI-GBHPSPOT0620



03

Disclosures



NONDISCRIMINATION NOTICE

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

Blue Cross Blue Shield of Massachusetts provides:

• Free aids and services to people with disabilities to communicate effectively
with us, such as qualified sign language interpreters and written information
in other formats (large print or other formats).

• Free language services to people whose primary language is not English,
such as qualified interpreters and information written in other languages.

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

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

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

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

Complaint forms are available at hhs.gov.

001614756 Blue Cross Blue Shield of Massachusetts is an Independent Licensee
of the Blue Cross and Blue Shield Association.
55-2067 (9/22)



TRANSLATION RESOURCES

Proficiency of Language Assistance Services

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/简体中文: 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) 。

Haitian 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 (TTY: 711).

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

Mon-Khmer, Cambodian/ខ្មែរ: ប្រយ័ត្ន៖ ប សើ ិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយ
មនិ គតិ ឈ្ន លួ គអឺ ាចមានសរំ ា ់ ំបរអើ ្នក។ ចូ រ ទូរស័ព្ទ 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 (TTY: 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: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-800-200-4255 (TTY: 711)번으로 전화해 주십시오.

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

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
BZaludezwCorńopsosdBnluuemeSrh1ie-8ld00o-2f0M0-a4s2s5a5c(ThTuYs:e7t1t1s).is an Independent Licensee
of the Blue Cross and Blue Shield Association
Hindi/ह दंि ी: ध्यान दंे: यदद आप ह िंदी बोलते हंै तो आपके दलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हंै। 1-800-
200-4255 (TTY: 711) पर कॉल करंे ।�

있습니다. 1-800-200-4255 (TTY: 711)번으로 전화해 주십시오.

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

Polish/Polski: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.
Zadzwoń pod numer 1-800-200-4255 (TTY: 711).

Hindi/ह दंि ी: ध्यान दंे: यदद आप ह िंदी बोलते हंै तो आपके दलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-
200-4255 (TTY: 711) पर कॉल करंे ।�
�

Gujarati/ગજુ રાતી: સચુ ના: જો તમે ગજુ રાતી બોલતા હો, તો નન:શલુ ્ક ભાષા સહાય સવે ાઓ તમારા માટે
ઉપલબ્ધ છે. ફોન કરો 1-800-200-4255 (TTY: 711).

Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo
ng tulong sa wika nang walang bayad. Tumawag sa 1-800-200-4255 (TTY: 711).

Japanese/日本語: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-
800-200-4255 (TTY: 711）まで、お電話にてご連絡ください。

German/Deutsch: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-200-4255 (TTY: 711).

Lao/ພາສາລາວ: ໂປດຊາບ: ຖ້ າວ່ າ ທ່ ານເວ້ າພາສາ ລາວ, ການບໍ ິລການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, ໂດຍບໍ່ ເສັ ຽຄ່ າ
, ແມ່ ນີມພ້ ອມໃຫ້ ທ່ ານ. ໂທຣ 1-800-200-4255 (TTY: 711)

Navajo/Diné Bizaad: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee
1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-200-4255 (TTY: 711.)

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2022 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross
and Blue Shield of Massachusetts HMO Blue, Inc.
001615801 55-2066-23 (9/22)

04

Enrollment



Medex®´ Core, Medex®´ Sapphire

APPLICATION FOR DIRECT BILLED MEDEX®´

Directions You’re eligible to apply for
a Medex plan if you meet all
• Please print clearly. of the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications will not be and you actually live in Massachusetts.
accepted. Please keep a copy of the
application for your records. • You’re eligible for Medicare Part A
• Send us your application after you receive and Medicare Part B and enrolled
your red, white, and blue Medicare card. in Medicare Part B.
• Don’t send money with this application.
You’ll receive a bill when payment is due. • If you’re under age 65, you qualify
• Please complete and return to: for Medicare coverage because
of disability.
Blue Cross Blue Shield of Massachusetts
Enrollment Department Note: If you’re covered by Medicaid,
P.O. Box 55011 you may or may not be eligible to
Boston, MA 02205 enroll in Direct Billed Medex. See the
• Or, fax the application to 1-617-246-3633. “Important Information” section of this
• To enroll by phone, call 1-800-678-2265. application form.
• Medex premium rates and benefits are
explained in the booklet you received
with this application. If you need more
information or assistance, call us at
1-800-678-2265.
• For all other questions, call:
Medex Member Service:
1-800-258-2226 TTY: 711

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

Please answer all questions.

Check the Medex plan of your choice: Medex Sapphire (Medicare Supplement 1A)
Medex Core (Medicare Supplement Core) Medex Sapphire with Vision and Hearing Benefit
Medex Core with Vision and Hearing Benefit

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
Male Female (—M —M /—D —D /—Y —Y —Y —Y )
Non-Binary () –

Your permanent home address:
Number and Street

City: State: ZIP Code:

If you want your Medex bill sent to an address
other than your home address, complete the following section.

Your billing address only:
Number and Street

City: State: ZIP Code:

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

Medicare Number:

Medicare Part A (Hospital Insurance) Effective Date:

Medicare Part B (Medical Insurance) Effective Date:

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

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

Important Information

Please read the below section, then answer questions 1 through 5.

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

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

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

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying
you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights

to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans.
Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.

To the best of your knowledge, [Mark Yes or No below with an “X”]

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

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

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

(d) Did you drop a Medicare supplemental policy
to enroll in the Medicare plan? Yes No

(b) What are your dates of coverage under the other
policy? Start ___/___/___ End ___/___/___

(If you’re still covered under the other policy,

leave “End” blank.)

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

Applicant’s Signature: Date:

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color, national origin,

age, disability, sex, sexual orientation, or gender identity.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos

de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços

linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks
of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield
of Massachusetts HMO Blue, Inc. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc.,

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

001634020 55-2396-23 (8/22)

Medex®´ Core, Medex®´ Sapphire

APPLICATION FOR DIRECT BILLED MEDEX®´

Directions You’re eligible to apply for
a Medex plan if you meet all
• Please print clearly. of the following requirements:
• Carefully read and answer all questions.
• You’re a resident of Massachusetts
Incomplete applications will not be and you actually live in Massachusetts.
accepted. Please keep a copy of the
application for your records. • You’re eligible for Medicare Part A
• Send us your application after you receive and Medicare Part B and enrolled
your red, white, and blue Medicare card. in Medicare Part B.
• Don’t send money with this application.
You’ll receive a bill when payment is due. • If you’re under age 65, you qualify
• Please complete and return to: for Medicare coverage because
of disability.
Blue Cross Blue Shield of Massachusetts
Enrollment Department Note: If you’re covered by Medicaid,
P.O. Box 55011 you may or may not be eligible to
Boston, MA 02205 enroll in Direct Billed Medex. See the
• Or, fax the application to 1-617-246-3633. “Important Information” section of this
• To enroll by phone, call 1-800-678-2265. application form.
• Medex premium rates and benefits are
explained in the booklet you received
with this application. If you need more
information or assistance, call us at
1-800-678-2265.
• For all other questions, call:
Medex Member Service:
1-800-258-2226 TTY: 711

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

Please answer all questions.

Check the Medex plan of your choice: Medex Sapphire (Medicare Supplement 1A)
Medex Core (Medicare Supplement Core) Medex Sapphire with Vision and Hearing Benefit
Medex Core with Vision and Hearing Benefit

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
Male Female (—M —M /—D —D /—Y —Y —Y —Y )
Non-Binary () –

Your permanent home address:
Number and Street

City: State: ZIP Code:

If you want your Medex bill sent to an address
other than your home address, complete the following section.

Your billing address only:
Number and Street

City: State: ZIP Code:

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

Medicare Number:

Medicare Part A (Hospital Insurance) Effective Date:

Medicare Part B (Medical Insurance) Effective Date:

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

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

Important Information

Please read the below section, then answer questions 1 through 5.

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

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

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

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying
you were eligible for guaranteed issue of a Medicare supplemental insurance policy, or that you had certain rights

to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare supplemental plans.
Please include a copy of the notice from your prior insurer with your application. PLEASE ANSWER ALL QUESTIONS.

To the best of your knowledge, [Mark Yes or No below with an “X”]

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

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

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

(d) Did you drop a Medicare supplemental policy
to enroll in the Medicare plan? Yes No

(b) What are your dates of coverage under the other
policy? Start ___/___/___ End ___/___/___

(If you’re still covered under the other policy,

leave “End” blank.)

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

Applicant’s Signature: Date:

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color, national origin,

age, disability, sex, sexual orientation, or gender identity.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos

de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços

linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks
of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield
of Massachusetts HMO Blue, Inc. © 2022 Blue Cross and Blue Shield of Massachusetts, Inc.,

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

001634020 55-2396-23 (8/22)



 Medicare Plan Sales:

FOR MORE INFORMATION, 1-800-678-2265 (TTY: 711)
OR TO ENROLL: 8:00 a.m. to 5:00 p.m. ET, Monday through Friday
bluecrossma.com/Medicare

Blue Cross Blue Shield of Massachusetts complies with applicable federal
civil rights laws and does not discriminate on the basis of race, color,

national origin, age, disability, sex, sexual orientation, or gender identity.

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia lingüística. Llame al 1-800-678-2265 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços
linguísticos, grátis. Ligue para 1-800-678-2265 (TTY: 711).

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

and Blue Shield of Massachusetts HMO Blue, Inc. © 2022 Blue Cross and Blue Shield
of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

001607659 99-0681-23 (9/22)