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BCBSMA Medex Core Sapphire SalesKit Book 02/01/2020 Approved by Angela Gagnon 01/24/2020 at 11:18 AM

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BCBSMA Medex Core Sapphire SalesKit Book 02/01/2020 Approved by Angela Gagnon 01/24/2020 at 11:18 AM

BCBSMA Medex Core Sapphire SalesKit Book 02/01/2020 Approved by Angela Gagnon 01/24/2020 at 11:18 AM

Keywords: BCBSMA Medex Core Sapphire SalesKit Book 02/01/2020

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

Services Medicare Pays Plan Pays You Pay
$0
Clinical Laboratory Services $0
$0
Blood tests for diagnostic services 100% 20% $198
All allowed charges (Part B deductible)
Special Medical Formulas Mandated by Law $0
Balance
Covered by Medicare

First $198 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%
Not covered by Medicare $0

Medicare (Parts A & B) Medicare Pays Plan Pays You Pay
100% $0
Services $0
$0
Home Health Care—Medicare-Approved Services 20% $198
Medically necessary skilled care services (Part B deductible)
and medical supplies $0
Durable medical equipment

First $198 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

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

**Once you have been billed $198 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 2020 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-2 ®, 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 (11/19)

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

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 01/29/2020 10:30 AM - 12:30 PM Radisson 10 Independence Drive

Burlington 01/30/2020 10:30 AM - 12:30 PM Marriott One Burlington Mall Road

Hyannis 02/04/2020 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue

Leominster 02/06/2020 10:30 AM - 12:30 PM DoubleTree by Hilton 99 Erdman Way

Brockton 02/12/2020 10:30 AM - 12:30 PM Holiday Inn Express 405 Westgate Drive

Chelmsford 02/13/2020 10:30 AM - 12:30 PM Radisson 10 Independence Drive

Brookline 02/20/2020 10:30 AM - 12:30 PM Courtyard by Marriott 40 Webster Street

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

Y0014_19126_C S2893_1994_C

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:

Randolph 02/26/2020 10:30 AM - 12:30 PM Lombardo’s 6 Billings Street
Blue Cross Blue Shield 101 Huntington Avenue,
Boston 02/27/2020 10:30 AM - 12:30 PM of Massachusetts Suite 1300, 3rd Floor
Spinelli’s Function Facility Route One South
Lynnfield 03/03/2020 10:30 AM - 12:30 PM Holiday Inn 700 Myles Standish Blvd
Taunton 03/04/2020 10:30 AM - 12:30 PM The Verve Hotel/Crowne Plaza 1360 Worcester Street
Natick 03/10/2020 10:30 AM - 12:30 PM Marriott 8A Centennial Drive
Peabody 03/12/2020 10:30 AM - 12:30 PM Blue Cross Blue Shield 101 Huntington Avenue,
of Massachusetts Suite 1300, 3rd Floor
Boston 03/19/2020 10:30 AM - 12:30 PM Marriott One Burlington Mall Road
Rachel’s Lakeside 950 State Road
Burlington 03/24/2020 10:30 AM - 12:30 PM Resort and Conference Center 35 Scudder Avenue
Dartmouth 03/26/2020 10:30 AM - 12:30 PM Marriott 8A Centennial Drive
Hyannis 04/02/2020 10:30 AM - 12:30 PM Holiday Inn 55 Ariadne Road
Peabody 04/07/2020 10:30 AM - 12:30 PM Courtyard by Marriott 40 Webster Street
Dedham 04/09/2020 10:30 AM - 12:30 PM The Publick House 277 Main Street
Brookline 04/14/2020 10:30 AM - 12:30 PM Blue Cross Blue Shield 101 Huntington Avenue,
Sturbridge 04/16/2020 10:30 AM - 12:30 PM of Massachusetts Suite 1300, 3rd Floor
La Quinta Inn & Suites 100 Congress Street
Boston 04/21/2020 10:30 AM - 12:30 PM Hadley Farms Meeting House 41 Russell Street

Springfield 04/23/2020 10:30 AM - 12:30 PM
Hadley 04/29/2020 10:30 AM - 12:30 PM

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. © 2020 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000289879 99-0645 (01/20)

Medex®´ Core | Medex®´ Sapphire

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*
$169.07
Medex Sapphire $177.97 $151.28 $160.17 $98.90

Medex Core $104.10 $88.49 $93.69

* 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 Sapphire
and Medex Core 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
or Medex Sapphire 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 1-800-200-4255 (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. ®´, 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.

198802M 55-2398-20 (08/19)

Medex®´ Core
Medex®´ Sapphire

VISION AND HEARING BENEFITS

If you have a direct-billed Medex Core or Medex Sapphire
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, you’ll With the Medex Vision and Hearing plan, 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 determine one routine hearing exam every two calendar
if you need corrective lenses. Any Blue Cross years, when the exam is furnished by a Blue
and Blue Shield participating physician or Cross and Blue Shield participating physician
optometrist, or any licensed ophthalmologist or audiologist, or any licensed physician
or optometrist outside of Massachusetts can outside of Massachusetts.
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 $150 hearing aids, unless you have gone more than two calendar
every calendar year; non-prescription lenses; sunglasses that years without receiving a hearing aid benefit
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 Form 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 6:00 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.

198914M 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.



02

Disclosures



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

KGorereakn/λ/λ한η국νικ어ά: Π주Ρ의ΟΣ:Ο한ΧΗ국: Ε어άν를μιλ사άτ용ε Ε하λλ시ην는ικά,경δι우ατ,ίθε언ντ어αι γ지ια원σας서υπ비ηρ스εσ를ίες무γλ료ωσ로σικ이ής용βο하ήθ실εια수ς,
있δω습ρε니άν다. Κ.αλ귀έσ하τε의τηνIDΥπ카ηρ드εσ에ία Ε있ξυ는πηρ전έτ화ησ번ης호Μ(TεTλώY:ν7σ1τ1ον)를αρ사ιθμ용ό 하τη여ς κά회ρτ원ας μ서έλ비ου스ς σ에ας전(ID화C하ard십) 시오.
G(TrTeYe: k7/1λ1λ).ηνικά: ΠΡΟΣΟΧΗ: Εάν μιλάτε Ελληνικά, διατίθενται για σας υπηρεσίες γλωσσικής βοήθειας,
δωρεάν. Καλέστε την Υπηρεσία Εξυπηρέτησης Μελών στον αριθμό της κάρτας μέλους σας (ID Card)
(TTY: 711).

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

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

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

Polish/Polski: UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy
językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze
(TTY: 711).

Hindi/हिदं ी: ध्यान दंे: ्दद आप दिनददी बोलते िंै, तो भयाषया सिया्तया सेवयाएँ, आप कके रलंे ल(टएदी.टनदीन.व:शयाईुल.:क711).
उपलब्ध िंै। सदस् सेवयाओं को आपके आई.डी. कयाड्ड पर ददए गए नबं र पर कॉल

Gujarati/ગજુ રાતી: ધ્યાન આપો: જો તમે ગુજરયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સવે યાઓ વવનયા મૂલ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડ્ડ પર આપેલયા નબં ર પર Member Service ને કૉલ કરો (TTY: 711).

Tagalog/Tagalog: PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na

mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong
nasa iyong ID Card (TTY: 711).

Japanese/日本語: お知らせ:日本語をお話しになる方は無料の言語アシスタンスサービスをご
利用いただけます。IDカードに記載の電話番号を使用してメンバーサービスまでお電話ください
(TTY: 711)。

German/Deutsch: ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche

Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an
(TTY: 711).

Persian/‫پارسیان‬:
‫ با شمار تلفن مندرج بر روی کارت شناسایی‬.‫ خدمات کمک زبانی ب صورت رایگان در اختیار شما قرار می گیرد‬،‫ اگر زبان شما فارسی است‬:‫توج‬

.(TTY: 711) ‫خود با بخش «خدمات اعضا» تماس بگیر ید‬
Lao/ພາສາລາວ: ໍຂ້ ຄວນໃສ່ ໃຈ: ຖ້ າເົຈ້ າເົວ້ າພາສາລາວໄດ້ , ີມການໍບິລການຊ່ ວຍເືຫຼ ອດ້ ານພາສາໃຫ້ ທ່ ານໂດຍ
່ໍບເສຍຄ່ າ. ໂທຫາຝ່ າຍໍບິລການສະມາິຊກ່ີທໝາຍເລກໂທລະສັ ບຢູ່ ໃນບັ ດຂອງທ່ ານ (TTY: 711).
Navajo/Diné Bizaad: BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47
t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’
b44sh bee hod77lnih (TTY: 711).

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross
and Blue Shield Association. © 2016 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

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

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

189002M 55-2066 (08/18)

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)



03

Enrollment



Medex®´ Core
Medex®´ Sapphire

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 Note:
of Massachusetts
One Enterprise Drive • If you are covered by Medicaid, you may
Quincy, MA 02171-1753 or may not be eligible to enroll in Direct
Billed Medex. See paragraph (g) of the
• Or fax the application to 1-617-246-3633 “Important Information” section of this
• To enroll by phone, please call application form.

1-800-678-2265.
• 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, contact:

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

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 and 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 90 provide advice concerning your purchase of Medicare
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 Elder
policy was suspended, the reinstituted policy will not Affairs insurance counseling program at 1-800-243-4636
have outpatient prescription drug coverage, as you (TTY: 1-800-872-0166) or write to that office at the
will be enrolled in the most comparable plan without following address for more information: One Ashburton
outpatient prescription drug coverage. 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

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 and have not met your “Share of Cost,” please
6 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 are 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 are 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 (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).

198804M ®, 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.

55-2396-20 (09/19)

Medex®´ Core
Medex®´ Sapphire

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 Note:
of Massachusetts
One Enterprise Drive • If you are covered by Medicaid, you may
Quincy, MA 02171-1753 or may not be eligible to enroll in Direct
Billed Medex. See paragraph (g) of the
• Or fax the application to 1-617-246-3633 “Important Information” section of this
• To enroll by phone, please call application form.

1-800-678-2265.
• 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, contact:

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

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 and 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 90 provide advice concerning your purchase of Medicare
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 Elder
policy was suspended, the reinstituted policy will not Affairs insurance counseling program at 1-800-243-4636
have outpatient prescription drug coverage, as you (TTY: 1-800-872-0166) or write to that office at the
will be enrolled in the most comparable plan without following address for more information: One Ashburton
outpatient prescription drug coverage. 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

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 and have not met your “Share of Cost,” please
6 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 are 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 are 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 (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).

198804M ®, 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.

55-2396-20 (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).

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