BCBSMA 2020 Medex Core Sapphire Bronze SalesKit Book 11/01/2019 Approved by Angela Gagnon 10/22/2019 8:27 AM

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

Services Medicare Pays Plan Pays You Pay
$0
Clinical Laboratory Services 100% $0
Blood tests for diagnostic services
Special Medical Formulas Mandated by Law $0 $0 $185
Covered by Medicare (Part B deductible)

First $185 of Medicare-approved amounts** 80% 20% $0

Remainder of Medicare-approved amounts $0 All allowed charges Balance
Not covered by Medicare

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay

Home Health Care—Medicare-Approved Services 100% $0 $0

Medically necessary skilled care services $0 $185
and medical supplies 20% (Part B deductible)
$0
Durable medical equipment

First $185 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

Other Benefits—Not Covered By Medicare

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

**Once you have been billed $185 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 2019 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: 1-800-678-226
Member Service: 1-800-258-2226 (TTY: 711)

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

Blue Cross Blue Shield of Massachusetts complies with applicable Federal civil rights laws
and does not discriminate on the basis of race, color, national origin, age, disability, 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).

198546M ®, 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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc.

32-3000-20 (09/19)

02

Resources



Join us for a FREE informational
meeting in your neighborhood.

When Medicare seems overwhelming or confusing, we’ll be there to make it easier.

Get answers to your questions about Medicare coverage, and hear
what other people who share your concerns are asking us, at one of our
informational meetings.

Get a detailed look at how Medicare works, and all of our extensive plan options, including
Medicare Advantage plans (HMO & PPO), Medicare Supplement plans (Medigap), and Prescription
Drug Plans (PDP).

Reserve your seat at the location nearest you.

RESERVE We’re always adding and updating seminars. Visit our website
NOW at bluecrossma.com/seminars to see the latest list.

1-800-262-BLUE (2583) bluecrossma.com/seminar

(TTY/TDD: 711) 7:00 a.m.–12:00 a.m., You can also make your reservation online
Seven days a week (excluding holidays) anytime, 24 hours a day, seven days a week

Y0014_19126_C
S2893_1994_C

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

Reserve your seat at the location nearest you.

RESERVE We’re always adding and updating seminars. Visit our website
NOW at bluecrossma.com/seminars to see the latest list.

All Medicare Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works, and all the coverage options available to fit your budget and lifestyle. This seminar will review
supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Chelmsford 11/1/2019 10:30 AM - 12:30 PM Radisson 10 Independence Drive

Milford 11/4/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 11 Beaver Street

Hyannis 11/4/2019 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue

Peabody 11/5/2019 10:30 AM - 12:30 PM Marriott 8A Centennial Drive

Middleboro 11/6/2019 10:30 AM - 12:30 PM Lorenzo's Italian Restaurant 500 West Grove Street

Worcester 11/7/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Fall River 11/7/2019 10:30 AM - 12:30 PM McGovern's Family Restaurant 310 Shove Street

Taunton 11/8/2019 10:30 AM - 12:30 PM Holiday Inn 700 Myles Standish Blvd

Burlington 11/9/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road

Springfield 11/11/2019 10:30 AM - 12:30 PM La Quinta Inn & Suites 100 Congress Street

Leominster 11/11/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Salem 11/12/2019 10:30 AM - 12:30 PM Hawthorne Hotel 18 Washington Square West

Natick 11/13/2019 10:30 AM - 12:30 PM Crowne Plaza 1360 Worcester Street

Westborough 11/13/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 5400 Computer Drive

Worcester 11/14/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Hadley 11/15/2019 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street

New Bedford 11/18/2019 10:30 AM - 12:30 PM Fairfield Inn & Suites 185 MacArthur Drive

Boston 11/19/2019 10:30 AM - 12:30 PM Blue Cross Blue Shield 101 Huntington Avenue,
of Massachusetts Suite 1300, 3rd Floor

continued

All Medicare Plan Options

By registering for one of the seminars below, you’ll gain a better understanding of how Medicare
works, and all the coverage options available to fit your budget and lifestyle. This seminar will review
supplemental plans, prescription drug plans, and Medicare Advantage plans.

City/Town: Date: Time: Location: Address:

Milford 11/19/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 11 Beaver Street

Lynnfield 11/20/2019 10:30 AM - 12:30 PM Spinelli's Function Facility Route One South

Leominster 11/20/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Tewksbury 11/21/2019 10:30 AM - 12:30 PM Holiday Inn 4 Highwood Drive

Worcester 11/22/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Hyannis 11/22/2019 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue

Hadley 11/25/2019 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street

Natick 11/26/2019 10:30 AM - 12:30 PM Crowne Plaza 1360 Worcester Street

Gardner 11/27/2019 10:30 AM - 12:30 PM Colonial Hotel 625 Betty Spring Road

Worcester 12/2/2019 10:30 AM - 12:30 PM Beechwood Hotel 363 Plantation Street

Leominster 12/3/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Burlington 12/3/2019 10:30 AM - 12:30 PM Marriott One Burlington Mall Road

Peabody 12/4/2019 10:30 AM - 12:30 PM Marriott 8A Centennial Drive

Rockland 12/5/2019 10:30 AM - 12:30 PM DoubleTree by Hilton 929 Hingham Street

Waltham 12/6/2019 10:30 AM - 12:30 PM Embassy Suites 550 Winter Street

For accommodations of persons with special needs at meetings, please call 1-800-262-BLUE
(2583) (TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., seven days a week.
A Blue Cross Blue Shield of Massachusetts representative will be present to discuss our
Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits, answer your
questions, and explain how to enroll. Blue Cross Blue Shield of Massachusetts is an HMO and
PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts
depends on contract renewal.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are
the legal entities which have contracted as a joint enterprise with the Centers for Medicare
& Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx plans.
The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx
(PDP) depends on contract renewal.

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).

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

199695M 99-0645 (10/19)

Medex®´ Core | Medex®´ Sapphire | Medex®´ Bronze

IT PAYS TO STAY BLUE

If you are 65 or older and becoming eligible for Medicare
for the first time, you may qualify for a discount on your premium.

If you qualify, enroll now to save 15 percent on your Medex monthly plan premium
for the first year, 10 percent the second year, and 5 percent the third year.

Plan Full Rate* First Year: Second Year: Third Year:
15% Discount* 10% Discount* 5% Discount*
$98.90
Medex Core $104.10 $88.49 $93.69 $169.07
$198.75
Medex Sapphire $177.97 $151.28 $160.17

Medex Bronze $209.21 $177.83 $188.29

* Rates effective January 1, 2020 to December 31, 2020

Member Perks and Wellness Benefits

Now there are even more reasons to get and stay healthy. These discounts
and services make healthy living easier—and more affordable—than ever.

• Fitness and weight loss benefits are included in direct-billed Medex Core,
Medex Sapphire, and Medex Bronze plans. Members are entitled to a fitness benefit
($150 a year) and a weight loss benefit ($150 a year).

• Add a vision and hearing benefit package to your Medex Core, Medex Sapphire,
or Medex Bronze plan. Call the number below for more details.

• Complement your coverage with a dental plan from Blue Cross that fits your
specific needs. Call us at the number below for more information.

• Pay your premiums online with eBill.

For more www.bluecrossma.com/medicare
information:
1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 5:00 p.m.

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 1-800-258-2226 (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., © 2019 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, In.

198641M 99-0290-20 (09/19)

Medex®´ Core
Medex®´ Sapphire

Medex®´ Bronze

VISION AND HEARING BENEFITS

If you have a direct-billed Medex Core, Medex Sapphire, or
Medex Bronze plan, here’s an easy way to help cover your vision
and hearing expenses, while limiting your out-of-pocket costs.

Good eyesight and hearing are so important to your quality of life, but glasses and hearing
aids aren’t covered by Medicare. The Medex Vision and Hearing benefit plan covers these
benefits so you can more easily afford the glasses and hearing aids you need—all for one
low price of $2.45/month.

 What additional vision care  What additional hearing care
services benefits will I get? benefits will I get?

With the Medex Vision and Hearing plan, With the Medex Vision and Hearing plan, you’ll
you’ll receive the following vision care services: get the following routine hearing care services:

• Routine vision exams: Covers one routine • Routine hearing exams: Reimbursement for
vision exam every calendar year to one routine hearing exam every two calendar
determine if you need corrective lenses. years, when the exam is furnished by a Blue
Any Blue Cross and Blue Shield participating Cross and Blue Shield participating physician
physician or optometrist, or any licensed or audiologist, or any licensed physician
ophthalmologist or optometrist outside outside of Massachusetts.
of Massachusetts can perform your exam.
• Hearing aids: Reimbursement for up to
• Eyeglasses or contact lenses: Covers up $200 every two calendar years for one
to $150 every calendar year for one set of hearing aid (or one set of binaural hearing
frames and prescription lenses or contact aids) from a licensed hearing aid dealer.
lenses (in place of eyeglasses) from any This $200 benefit payment includes costs
licensed vision care supplier. This $150 for: dispensing fees, acquisition costs,
benefit payment includes costs for batteries, and hearing aid repairs.
measurement, fitting, and adjustments.
Note: No coverage is provided for costs to replace lost
Note: No coverage is provided for amounts more than hearing aids, unless you have gone more than two calendar
$150 every calendar year; non-prescription lenses; years without receiving a hearing aid benefit.
sunglasses that do not require a prescription; safety glasses;
replacement of lost or broken frames or lenses; and special
procedures, such as vision training and subnormal vision aids
and similar procedures and devices.

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

Is it easy to get reimbursed for vision How much does the Medex Vision
and hearing care services? and Hearing plan cost?

Yes. At the time you buy your glasses, contacts, Effective January 1, 2020 to December 31,
or hearing aid(s), or at a later date, the provider 2020, the additional benefit coverage cost is
may ask you to pay all charges. If this happens, $2.45 per month. This amount will be added
you will need to file a claim with Blue Cross to your direct-billed Medex premium.
Blue Shield of Massachusetts for repayment
of these covered services. Simply complete
a Medex Subscriber Claim From and send it
with your original itemized bill(s). If you need a
claim form or would like help completing your
form, call Member Service at 1-800-258-2226,
TTY: 711, Monday through Friday, 8:00 a.m.
to 5:00 p.m. ET.

How do I apply?

 The easiest way to enroll is by phone.
Phone: 1-800-678-2265, TTY: 711
Monday–Friday | 8 a.m.– 5 p.m.

 To enroll by mail, please complete the application for Direct-Billed Medex and return it to:
Direct Sales
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-1753

Or fax the application to 1-617-246-3633.

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

198473M 55-0435-20 (09/19)

What is GeoBlue?

GeoBlue is a provider of health insurance for short-term travel.

Why Should I choose a GeoBlue Plan?

With GeoBlue you’ll receive valuable benefits like:

• Additional coverage wherever and whenever you travel (i.e. medical evacuation coverage)
• Hassle-free access to care, meaning no claim forms for you to deal with if you see a contracted provider
• Concierge-level member service 24/7/365
• Access to a trusted network of providers and hospitals

What short-term plan options are available?

Single-trip plans up to 180 days in length

GeoBlue Voyager - Up to $1,000,000 medical/$500,000 evacuation
• Choice of medical limits and deductibles
• Pre-existing condition coverage option
• For trips over 180 days, one policy extension is available
• Two levels of coverage: Essential and Choice

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

GeoBlue Trekker: - Up to $250,000 medical/$500,000 evacuation
• Choice of medical limits
• Pre-existing conditions covered
• 364 day policy (70 days max. per trip)
• Two levels of coverage are available: Essential and Choice

Other Questions?

For more information: Call 1-888-731-2195

GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association.
Made available in cooperation with Blue Cross and Blue Shield companies in select service areas.



03

Disclosures



Nondiscrimination Notice

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

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

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

If you need these services, call Member Service at the number on your ID card.
If you believe that Blue Cross Blue Shield of Massachusetts has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual
orientation, or gender identity, you can file a grievance with the Civil Rights Coordinator by mail at
Civil Rights Coordinator, Blue Cross Blue Shield of Massachusetts, One Enterprise Drive, Quincy, MA
02171-2126; phone at 1-800-472-2689 (TTY: 711); fax at 1-617-246-3616; or email
at [email protected].
If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights online at ocrportal.hhs.gov; by mail at U.S. Department of Health and Human
Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC 20201;
by phone at 1-800-368-1019 or 1-800-537-7697 (TDD).
Complaint forms are available at hhs.gov.

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

189008M 55-2067 (8/18)



Blue MedicareRxSM (PDP) complies with applicable Federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, or sex. Blue MedicareRx does not exclude people or treat
them differently because of race, color, national origin, age, disability, or sex.

Blue MedicareRx:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other
formats)

• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages

If you need these services, call the number on the back of your Member ID Card. TTY/TDD users should call
711.

If you believe that Blue MedicareRx has failed to provide these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Blue MedicareRx (PDP)
Grievance Department Coordinator
P.O. Box 30016
Pittsburgh, PA 15222-0330

Phone: 1-866-884-9478
Fax: 1-866-217-3353

You can file a grievance in person, by mail, or fax. If you need help filing a grievance, Blue MedicareRx
Grievance Department 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, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ENGLISH KOREAN
ATTENTION: If you speak English, language 알림: 한국어를 하시는 경우 무료 통역 서비스가
assistance services, free of charge, are available to you. 준비되어 있습니다. 회원 카드 뒷면에 표시된
Call the number on the back of your Member ID Card. 전화번호(TTY: 711)로 연락주시기 바랍니다.
TTY: 711.

ARABIC M្របយOត័ N៖� -្KរបសHិនMេបEអើ R�កន,យិ C‌AយMភាសBា㏸OែខD�រ IេសANវ‌ជនំ យួ ែផ�កភាសា㏸េដ‌យមនិ គតិ ឈល�
‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ‬:‫ﻣﻠﺤﻮظﺔ‬
‫ اﺗﺼﻞ ﺑﺎﻟﺮﻗﻢ اﻟﻤﺒﯿﻦ ﻋﻠﻰ ظﮭﺮ ﺑﻄﺎﻗﺔ اﻟﻌﻀﻮﯾﺔ‬.‫ﺗﺘﻮﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن‬

.711 :‫ ﻟﻠﺼﻢ واﻟﺒﻜﻢ‬.‫ اﻟﺨﺎﺻﺔ ﺑﻚ‬គឣឺ ‍ចរកបានសំរ‌ប់អ�ក។

CHINESE ចូរទរូ សព័ �េ�េលខេ�ខាងខ�ងៃនបណ័ �សមា� ល់ខន� សមាជកិ របសអ់ ក� ។ TTY:
小贴士：如果您说中文，欢迎使用免费语言协助服
务。请拨打您会员身份证上的电话号码。（TTY： 711។
711)。
POLISH
FRENCH UWAGA: Dla osób mówiących po polsku dostępna jest
ATTENTION : Si vous parlez français, des services bezpłatna pomoc językowa. Zadzwoń pod numer podany
gratuits d’interprétation sont à votre disposition. na odwrocie Twojej Członkowskiej karty ident. Tel. tekst.:
Veuillez appeler le numéro figurant au verso de votre 711.
Carte de membre. TTY: 711.
PORTUGUESE
FRENCH CREOLE ATENÇÃO: Se fala português, estão disponíveis serviços
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd gratuitos de assistência linguística na sua língua. Telefone
pou lang ki disponib gratis pou ou. Rele nimewo ki sou para o número no verso do seu Cartão de Identificação de
do Kat ID Manm ou an. TTY: 711. Membro. TTY: 711.

GREEK RUSSIAN
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, υπάρχει διαθέσιμη ВНИМАНИЕ: Если вы говорите на русском языке, вам
υπηρεσία γλωσσικής υποστήριξης, η οποία παρέχεται будут бесплатно предоставлены услуги переводчика.
δωρεάν. Καλέστε τον αριθμό στο πίσω μέρος της Звоните по телефону, указанному на обороте вашей
κάρτας μέλους (Αριθμός για άτομα με προβλήματα идентификационной карты участника. Телетайп: 711.
ακοής/ομιλίας: 711).
SPANISH
HINDI ATENCIÓN: Si usted habla español, tenemos servicios de
ध्यान द�िजए : अगर आप �हदं � बोलते ह� तो आपके �लए asistencia lingüística disponibles para usted sin costo
alguno. Llame al número que aparece al reverso de su
tarjeta de membresía. TTY: 711.

भाषा सहायता सेवाएं मफु ्त उपलब्ध ह�। आपके सदस्य ID TAGALOG
काड्र के पीछे �दए गए नम्बर पर कॉल कर�। TTY: 711. Pansinin: Kung nagsasalita ka ng Tagalog, mga serbisyo
ng tulong sa wika, nang walang bayad, ay magagamit sa
ITALIAN iyo. Tawagan ang numero sa likod ng iyong ID card ng
ATTENZIONE: Se lei parla italiano, sono disponibili Miyembro. TTY: 711.
servizi gratuiti di assistenza linguistica nella sua lingua.
Chiami il numero che si trova sul retro della sua tessera VIETNAMESE
(Member ID Card). TTY: 711.
LƯU Ý: Nếu quý vị nói tiếng Việt, thì có sẵn các dịch vụ
S2893_1709 hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Hãy gọi tới số
ở mặt sau Thẻ ID Thành Viên của quý vị. TTY: 711.

NDN-20

04

Enrollment



Medex®´

APPLICATION FOR
DIRECT BILLED MEDEX®´

Directions You are eligible to apply
for a Medex plan if you meet all
• Please print clearly. of the following requirements:
• Please carefully read and answer
• You are a resident of Massachusetts
all questions. Incomplete applications and you actually live in Massachusetts.
will not be accepted. Please keep a copy
of the application for your records. • You are eligible for Medicare Part A
• Please do not send us your application and Medicare Part B and enrolled
until you have received your red, white, in Medicare Part B.
and blue Medicare card.
• Do not send money with this application. • If you are under age 65, you qualify
You will receive a bill when payment is due. for Medicare coverage because
• Please complete and return to: of disability except for end-stage
renal disease.
Direct Sales
Blue Cross Blue Shield Notes:
of Massachusetts
One Enterprise Drive • Medex Bronze shall, on or after January 1,
Quincy, MA 02171-1753 2020, only be offered to eligible persons
who: (a) have attained 65 years of age
• Or fax the application to 1-617-246-3633 before January 1, 2020; or (b) first became
• To enroll by phone, please call eligible for Medicare due to age, disability
or end-stage renal disease, before January 1,
1-800-678-2265. 2020. Those who are otherwise eligible for
• Medex premium rates and benefits are Medicare Part A and B and who are enrolled
in Medicare Part B, but who are not eligible
explained in the booklet you received to purchase Medex Bronze, shall be eligible
with this application. If you need more to purchase all other Direct Billed Medex
information or assistance, call us at plans that are currently offered.
1-800-678-2265.
• For all other questions, contact: • If you are covered by Medicaid, you may
or may not be eligible to enroll in Direct
Medex Member Service: Billed Medex. See paragraph (g) of the
1-800-258-2226 TTY: 711 “Important Information” section of this
application form.

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

Please answer all questions. Medex Core with Vision and Hearing Benefit
Medex Sapphire with Vision and Hearing Benefit
Check the Medex Plan of your choice: Medex Bronze with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core)
Medex Sapphire (Medicare Supplement 1A)
Medex Bronze (Medicare Supplement 1)

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender Your complete date of birth: Your telephone number:
Male
Female () –

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
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 ______________

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 are 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 “Important Information” section. Then answer questions 1 through 5.

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

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

(f) If you are eligible for, and have enrolled in a Medicare
supplemental insurance policy by reason of disability and

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, [Please mark Yes or No below with an “X”]

1. (a) Did you turn age 65 in the last 6 months? 2. Are you covered for medical assistance through the
Yes No state Medicaid program? [NOTE TO APPLICANT:
If you are participating in a “Spend-Down Program”
(b) Did you enroll in Medicare Part B in the last 6 and have not met your “Share of Cost,” please answer
months? Yes No NO to this question.] Yes No If yes,

(c) If yes, what is the effective (a) Will Medicaid pay your premiums for this Medicare
date?_______________ 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 policy
than original Medicare within the past 63 days in force? Yes No
(for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), fill in your start and end (b) If so, with what company, and what plan do
dates below. If you are still covered under this plan, you have?
leave “END” blank. Start __/__/__ End __/__/__
(c) If so, do you intend to replace your current Medicare
(b) If you are still covered under the Medicare plan, 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 (For example, an employer, union, or individual plan)
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 are 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, 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).

198547M ®, 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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc.

55-0936-20 (09/19)

Medex®´

APPLICATION FOR
DIRECT BILLED MEDEX®´

Directions You are eligible to apply
for a Medex plan if you meet all
• Please print clearly. of the following requirements:
• Please carefully read and answer
• You are a resident of Massachusetts
all questions. Incomplete applications and you actually live in Massachusetts.
will not be accepted. Please keep a copy
of the application for your records. • You are eligible for Medicare Part A
• Please do not send us your application and Medicare Part B and enrolled
until you have received your red, white, in Medicare Part B.
and blue Medicare card.
• Do not send money with this application. • If you are under age 65, you qualify
You will receive a bill when payment is due. for Medicare coverage because
• Please complete and return to: of disability except for end-stage
renal disease.
Direct Sales
Blue Cross Blue Shield Notes:
of Massachusetts
One Enterprise Drive • Medex Bronze shall, on or after January 1,
Quincy, MA 02171-1753 2020, only be offered to eligible persons
who: (a) have attained 65 years of age
• Or fax the application to 1-617-246-3633 before January 1, 2020; or (b) first became
• To enroll by phone, please call eligible for Medicare due to age, disability
or end-stage renal disease, before January 1,
1-800-678-2265. 2020. Those who are otherwise eligible for
• Medex premium rates and benefits are Medicare Part A and B and who are enrolled
in Medicare Part B, but who are not eligible
explained in the booklet you received to purchase Medex Bronze, shall be eligible
with this application. If you need more to purchase all other Direct Billed Medex
information or assistance, call us at plans that are currently offered.
1-800-678-2265.
• For all other questions, contact: • If you are covered by Medicaid, you may
or may not be eligible to enroll in Direct
Medex Member Service: Billed Medex. See paragraph (g) of the
1-800-258-2226 TTY: 711 “Important Information” section of this
application form.

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

Please answer all questions. Medex Core with Vision and Hearing Benefit
Medex Sapphire with Vision and Hearing Benefit
Check the Medex Plan of your choice: Medex Bronze with Vision and Hearing Benefit
Medex Core (Medicare Supplement Core)
Medex Sapphire (Medicare Supplement 1A)
Medex Bronze (Medicare Supplement 1)

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

Your gender Your complete date of birth: Your telephone number:
Male
Female () –

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
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 ______________

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 are 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 “Important Information” section. Then answer questions 1 through 5.

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

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

(f) If you are eligible for, and have enrolled in a Medicare
supplemental insurance policy by reason of disability and

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, [Please mark Yes or No below with an “X”]

1. (a) Did you turn age 65 in the last 6 months? 2. Are you covered for medical assistance through the
Yes No state Medicaid program? [NOTE TO APPLICANT:
If you are participating in a “Spend-Down Program”
(b) Did you enroll in Medicare Part B in the last 6 and have not met your “Share of Cost,” please answer
months? Yes No NO to this question.] Yes No If yes,

(c) If yes, what is the effective (a) Will Medicaid pay your premiums for this Medicare
date?_______________ 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 policy
than original Medicare within the past 63 days in force? Yes No
(for example, a Medicare Advantage plan, or a
Medicare HMO or PPO), fill in your start and end (b) If so, with what company, and what plan do
dates below. If you are still covered under this plan, you have?
leave “END” blank. Start __/__/__ End __/__/__
(c) If so, do you intend to replace your current Medicare
(b) If you are still covered under the Medicare plan, 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 (For example, an employer, union, or individual plan)
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 are 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, 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).

198547M ®, 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.
© 2019 Blue Cross and Blue Shield of Massachusetts, Inc.

55-0936-20 (09/19)



FOR MORE INFORMATION, OR TO ENROLL:

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

bluecrossma.com/Medicare

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

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

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

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

and Blue Shield of Massachusetts HMO Blue, Inc.

198636M ((1019//0119/)19)