BCBSMA Dental Blue65 SalesKit Book 05/01/2021 Approved By Danielle Roy 4/21/2021 2:09 PM

Medicare Dental Plans

2021 DENTAL BLUE® 65

COVERAGE YOU NEED FROM A NAME YOU CAN TRUST

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

(05/01/21)



101 Huntington Avenue
Suite 1300
Boston, MA 02199-7611
bluecrossma.org

Dear Prospective Member:
Thank you for your interest in our Dental Blue® 65 plans. Maintaining a healthy smile can
contribute to your overall health, so we offer affordable and comprehensive Dental Blue 65
plans that can supplement your Medicare coverage.
With Dental Blue 65, you’ll have access to our extensive network of dentists across the
country, including thousands of dentists in Massachusetts and Rhode Island. All three plans
provide complete coverage for preventive services, as well as varying levels of coverage for
other dental services.

We’ve included the following materials to help you find the plan that fits your needs:

 

Dental Blue 65 Overview: Dental Blue 65 Dental Blue 65 Application:
Learn more about Outline of Coverage: Apply for coverage using
our dental plans. Compare the three plans.
the enclosed application and
self-addressed envelope.

If you have any questions, we’re here to help.
Sincerely,

Gloria Paradiso Online: bluecrossma.com/medicare
Executive Director, Medicare Sales
Enclosures By mail: Complete the enclosed enrollment form
and mail in the self-addressed envelope.
Ready to Enroll?
By fax: Complete the enclosed enrollment
By phone: 1-800-678-2265 (TTY: 711) form and fax to 1-617-246-8506.
Monday through Friday,
8:00 a.m. to 5:00 p.m. ET.

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

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

sexual orientation, or gender identity.

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. © 2020 Blue Cross and Blue Shield
of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000405903 99-0617-21 (9/20)

IN THIS BOOKLET

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

02 Disclosures
• Nondiscrimination Notice
• Translation Resources

03 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Dental Blue® 65

2021 DENTAL PLAN COVERAGE
WITH NO SURPRISES

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

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

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

• 100% coverage for services that • Network access to more than 90 percent
diagnose or prevent tooth decay and of practicing local dentists and more than
other forms of oral disease—services 350,000 provider locations nationwide
you’ll most likely get during a routine
dental checkup or visit • All waiting periods waived, based on
eligibility of having continuous prior
• Regular cleanings and exams 3 times dental coverage
per 12 month period

New for 2021: Enhanced Dental Benefits

Effective January 1, 2021, Dental Blue 65 plans now include Enhanced Dental Benefits
for at-risk members with qualifying medical conditions. Eligible members receive additional
condition-specific support including full coverage for preventive and periodontal services*
that have been connected to improved overall health.

Can I Use My Current Dentist?

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

*Available on plans that offer periodontal benefits; standard waiting periods apply.

REVIEW OUR 2021 DENTAL PLANS OPTIONS

Dental Blue® 65 Preventive*

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

Dental Blue® 65 Basic*

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

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

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

Dental Blue® 65 Premier*

$68.70/mo. Plan pays 100% of preventive services, 80% of basic services, and 50%
6-month of the following major services:
waiting period
for basic • Complete or partial denture, including • Temporary partial dentures to replace
services services to fabricate and adjust, once any of the six upper or lower front teeth,
every 60 months for each arch but only if they are installed immediately
12-month following the loss of teeth and during the
waiting period • Fixed bridges, including services to period of healing
for major fabricate, and adjust, once every 60
services months per tooth • Crowns once every 60 months for each tooth

$50 annual • Dental implant placement • Metallic, porcelain, and white resin inlays,
deductible once every 60 months per tooth
and $1,500 • Replacement of dentures and bridges,
calendar-year but only when they are installed at least • Replacement of crowns and metallic,
maximum 60 months after the initial placement, porcelain, and composite resin inlays/onlays
and only if the existing appliance cannot once every 60 months for each tooth
be made serviceable
• Post and core or crown buildup once every
• Adding teeth to an existing bridge 60 months per tooth

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

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

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

sexual orientation, or gender identity.
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

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

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

000406004 ® Registered Marks of the Blue Cross and Blue Shield Association. (9/20)
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross

and Blue Shield of Massachusetts HMO Blue, Inc.

55-0530-21

Outline of Coverage

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

Effective January 1, 2021

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

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

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

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

We offer paperless billing for your dental
premiums through eBill.

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

OVERVIEW

Your Dentist If You Have to File a Claim

Dental Blue 65 offers access to more Network dentists will send claims to
than 90 percent of practicing dentists Blue Cross Blue Shield of Massachusetts
in Massachusetts and more than 350,000 for you. Just show them your Dental Blue 65
provider locations nationwide. Out-of-area ID card. The payment will be sent directly to
dentists who participate in our Nationwide your dentist.
Network of dentists are also available to
Dental Blue members. If you receive care from a non-network
dentist, you may have to submit the claim
If you already have a dentist and want to yourself. If you file, send the Attending
know if he or she participates with Blue Dentist’s Statement form with the original
Cross Blue Shield of Massachusetts, you itemized bills. Any benefit payment will
may call the dentist, refer to the most current be sent to you. You can get a copy of
dental provider directory, or call Member the Attending Dentist’s Statement from
Service at the toll-free number on your Dental Member Service.
Blue 65 ID card.
Any claims that you file should be sent to
If you would like help choosing a dentist, Blue Cross Blue Shield of Massachusetts,
you may call the Physician Selection Service P.O. Box 986030, Boston, MA 02298.
at 1-800-821-1388. You may also access All member-submitted claims must be
the online dental provider directory at received within two years of the date of
bluecrossma.org. service. (Coverage is not available for
non-network dentists in Massachusetts
Coverage Begins except for covered emergency services.)

Your coverage will be effective the first of The Blue Cross Blue Shield Grievance
the month following the month we receive Program is fully described in the subscriber
your application. certificate.

New for 2021: Enhanced Other Information
Dental Benefits
Coordination of benefits (COB) applies to
Effective January 1, 2021, Dental Blue 65 plan members who are covered by another
plans now include Enhanced Dental Benefits plan for health care expenses. COB ensures
for at-risk members with qualifying medical that payments from all health care plans
conditions. Eligible members receive do not exceed the total charges billed for
additional, condition-specific support covered services.
including full coverage for preventive
and periodontal services* that have been Your subscriber certificate has a subrogation
connected to improved overall health. clause. This does not affect the scope of
benefits. This clause allows claim payments
*Available on plans that offer periodontal benefits; to be retracted when a member recovers
standard waiting periods apply. payment for the same charges from a third
party due to liability for injury.

3

DENTAL BLUE 65 PREVENTIVE

Monthly Premium Co-insurance, Annual Deductible,
and Annual Maximum
January 1, 2021–December 31, 2021: $22.70
This dental plan provides full benefits based
Services & Benefits on the allowed charge for participating
providers. There are no annual deductibles
Your covered services include: and no annual plan maximums.

• One complete initial oral exam, including initial Waiting Periods and Pre-existing
dental history and charting of the teeth and Condition Limitations
supporting structures
Your dental services will be covered from
• Full mouth X-rays, 7 or more films, or panoramic your effective date of this dental plan without
X-ray with bitewing X-rays once every 60 months a waiting period or pre-existing condition
restrictions.
• Bitewing X-rays once every 6 months
Exclusions and Limitations
• Single-tooth X-rays as needed
Services limited by frequency include
• Study models and casts used in planning treatment but are not limited to:
once every 60 months • X-rays
• Exams
• Periodic or routine oral exams 3 times per 12 months • Cleanings

• Emergency exams Please review your dental policy for a full
listing of limitations and exclusions.
• Routine cleaning, scaling, and polishing of the teeth
3 times per 12 months

4

DENTAL BLUE 65 BASIC

Monthly Premium Other Covered Services
• Occlusal adjustment, once each 24 months
January 1, 2021–December 31, 2021: $37.80
• Services to treat root sensitivity
Services & Benefits
• General anesthesia when administered in conjunction
Your covered services include: with covered surgical services
• 100% coverage for all services covered under Dental
• Emergency dental treatment to relieve acute pain
Blue 65 Preventive, plus 50% coverage for:
Restorative Services • Emergency dental treatment to control a dental
condition that requires immediate care to prevent
• Amalgam (silver) fillings (limited to one filling for each permanent harm to the member
tooth surface in each 12 months)
Co-insurance, Annual Deductible,
• Composite resin (tooth color) fillings on teeth (limited and Annual Maximum
to one filling per tooth surface in each 12 months)
This dental plan provides:
• Pin retention for fillings
• 100% coverage for all preventive services
Oral Surgery
• 50% coverage for services outlined in the plan’s
• Tooth extractions, root removal, and biopsies Services & Benefits section above
Periodontics (Gum and Bone)
• Coverage is based on the allowed charge for
• Periodontal scaling and root planning, once in each participating providers.
quadrant each 24 months
• There is a $100 annual deductible and $1,250
• Periodontal surgery (soft-and hard-tissue surgeries), calendar-year maximum.
once in each quadrant each 36 months
Waiting Periods and Pre-existing
• Periodontal maintenance following active periodontal Condition Limitations
therapy, once each 3 months
Your dental services will be covered from
Endodontics (Root and Pulp) your effective date of this dental plan without
a waiting period or pre-existing condition
• Root canal therapy on permanent teeth, once per restrictions for all preventive services. For
lifetime for each tooth services that fall outside of preventive, a six-
month waiting period from the effective date
• Retreatment root canal therapy on permanent teeth, is required. If you’ve had continuous prior
once in a lifetime for each tooth dental coverage, you may be eligible to have all
waiting periods waived to allow you to receive
• Other endodontic surgery intended to treat or remove minor and major restorative services right away.
the dental root
Exclusions and Limitations
Prosthetic Maintenance
Certain services may be limited or excluded
• Repair of partial or complete dentures, crowns, from this plan. These services may include:
and bridges, once each 12 months
• Fillings on tooth surfaces where a sealant was applied
• Adding teeth to existing partial or complete dentures within the prior 12 months
• Rebase or reline dentures, once each 36 months
• Recementing of crowns, inlays, onlays, and fixed • Replacement of a filling within 12 months of the date
of prior restoration
bridgework, once each 12 months
• A service, supply, procedure, or appliance to stabilize
teeth when it is due to periodontal disease

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

5

DENTAL BLUE 65 PREMIER

Monthly Premium • 80% coverage for minor restorative services,
oral surgery, periodontics, endodontics, prosthetic
January 1, 2021–December 31, 2021: $68.70 maintenance, and other services originally covered
by Dental Blue 65 Basic
Service & Benefits
• 50% coverage for major restorative services,
Your covered services include: prosthodontics/tooth replacements, crowns, inlays,
onlays, dental implants and other services outlined in
• 100% coverage for all services covered under Dental the plan’s Services & Benefits section above
Blue 65 Preventive, plus
• Benefits are based on the allowed charge for
• 80% coverage for all services covered under Dental participating providers
Blue 65 Basic, plus
• There is a $50 annual deductible and $1,500
• 50% coverage for: calendar-year maximum

• Prosthodontics (Tooth Replacement) Waiting Periods and Pre-existing
Condition Limitations
• Complete or partial dentures, including services to
fabricate, measure, fit, and adjust them once each 60 Your dental services will be covered from
months for each arch your effective date of this dental plan without
a waiting period or pre-existing condition
• Fixed bridges, including services to fabricate, measure, restrictions for all preventive services.
fit, and adjust them once each 60 months per tooth For services that fall outside of preventive, a
6-month waiting period from the effective date
• Replacement of dentures and bridges, but only when is required for minor restorative services, and
they are installed at least 60 months after the initial a 12-month waiting period from the effective
placement, and only if the existing appliance cannot date is required for major restorative services.
be made serviceable
If you’ve had continuous prior dental coverage,
• Adding teeth to an existing bridge you may be eligible to have all waiting periods
waived to allow you to receive minor and major
• Temporary partial dentures to replace any of the six restorative services right away.
upper or lower front teeth, but only if they are installed
immediately following the loss of teeth and during the Exclusions and Limitations
period of healing
Certain services may be limited or excluded
Major Restorative Services (Crowns, Inlays, Onlays) from this plan. These services may include:

• Crowns once each 60 months for each tooth • Fillings on tooth surfaces where a sealant was applied
within the prior 12 months
• Metallic, porcelain, and composite resin inlays
and onlays once every 60 months per tooth • Replacement of a filling within 12 months of the date
of prior restoration
• Surgical placement of dental implant once
per tooth per lifetime • Duplicate dentures or bridges

• Replacement of crowns once every 60 months Cast restorations, copings, or attachments
for each tooth for installing overdentures, including
associated endodontic procedures such
• Replacement of metallic, porcelain, and composite as root canals, precision attachments, or
resin inlays and onlays once every 60 months semiprecision attachments

• Post and core or crown build up once every Please review your dental policy for a full listing of
60 months per tooth limitations and exclusions.

Co-insurance, Annual Deductible,
and Annual Maximum

This dental plan provides:

• 100% coverage for all preventive services

6

Renewal and Premium Changes

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

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

7

Complaints

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

Important: In the event of any inconsistency between this outline
of coverage and the subscriber certificate, the terms
of the subscriber certificate will govern.

Limitations and Exclusions. These pages summarize the benefits of your
dental care plan. Your plan description and riders define the full terms

and conditions. Should any questions arise concerning benefits, the plan
description and riders will govern. For a complete list of limitations and

exclusions, refer to your plan description and riders.

Nondiscrimination Notice

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

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

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

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

9

Translation Resources

PrTofriacinensclyatoifoLnanRgueasgoe uAsrsciestsance Services

Proficiency of Language Assistance Services

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de
identificación (TTY: 711).
Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente
serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no
seu cartão ID (TTY: 711).
Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的
号码联系会员服务部（TTY 号码：711）。
Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang
disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou
Malantandan TTY: 711).
Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho
quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711).
Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными
услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей
идентификационной карте (телетайп: 711).
Arabic/‫ةيبر‬:

‫ اتصل بخدمات الأعضاء على الرقم الموجود على بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬

Mon-Khmer, Cambodian/ខ្រមែ : ការជូនដំណឹ ង៖ ប្រសិនប្រើអន្កនិយាយភាសា ខ្ែរម
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្ក្ន បសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណណ្ សរាគា េ់្ួនៃល រ្រស់អនក្ (TTY: 711)។
French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont
disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré
(TTY : 711).
Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza
linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa
(TTY: 711).
Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있
습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.
Greek/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.

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 दें: ्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/ગુજરાતી: ધ્યાન આપો: જો તમે ગજુ રયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મલૂ ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડડ્ પર આપલે યા નંબર 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.

®16R47e11gMiBstered Marks of the Blue Cross and Blue Shield Association. © 2020 5B5-l1u49e3 (8C/16r)oss and Blue Shield

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

000745124 55-2066 (12/20)

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

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

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

(TTY users can call 711)

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

® Registered Marks of the Blue Cross and Blue Shield Association. © 2020 Blue Cross or Blue Shield
of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000406055 55-0166-21 (9/20)

02

Disclosures



Nondiscrimination Notice

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

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

000404530 55-2067 (9/20)



Translation Resources

PrTofriacinensclyatoifoLnanRgueasgoe uAsrsciestsance Services

Proficiency of Language Assistance Services

Spanish/Español: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos
de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de
identificación (TTY: 711).
Portuguese/Português: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente
serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no
seu cartão ID (TTY: 711).
Chinese/简体中文: 注意：如果您讲中文，我们可向您免费提供语言协助服务。请拨打您 ID 卡上的
号码联系会员服务部（TTY 号码：711）。
Haitian Creole/Kreyòl Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang
disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou
Malantandan TTY: 711).
Vietnamese/Tiếng Việt: LƯU Ý: Nếu quý vị nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ được cung cấp cho
quý vị miễn phí. Gọi cho Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711).
Russian/Русский: ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными
услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей
идентификационной карте (телетайп: 711).
Arabic/‫ةيبر‬:

‫ اتصل بخدمات الأعضاء على الرقم الموجود على بطاقة ُهويتك )جهاز الهاتف‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬

Mon-Khmer, Cambodian/ខ្រមែ : ការជូនដំណឹ ង៖ ប្រសិនប្រើអន្កនិយាយភាសា ខ្ែរម
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អ្នក។ សូមទូរស័ព្ទបៅខ្ក្ន បសវាសរាជិកតាមបេ្
បៅបេើ្រ័ណណ្ សរាគា េ់្ួនៃល រ្រស់អនក្ (TTY: 711)។
French/Français: ATTENTION : si vous parlez français, des services d’assistance linguistique sont
disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré
(TTY : 711).
Italian/Italiano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza
linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa
(TTY: 711).
Korean/한국어: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있
습니다. 귀하의 ID 카드에 있는 전화번호(TTY: 711)를 사용하여 회원 서비스에 전화하십시오.
Greek/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.

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 दें: ्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/ગુજરાતી: ધ્યાન આપો: જો તમે ગજુ રયાતી બોલતયા હો, તો તમને ભયાષયાકી્ સહયા્તયા સેવયાઓ વવનયા મલૂ ્ે ઉપલબ્ધ છે.
તમયારયા આઈડી કયાડડ્ પર આપલે યા નંબર 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.

®16R47e11gMiBstered Marks of the Blue Cross and Blue Shield Association. © 2020 5B5-l1u49e3 (8C/16r)oss and Blue Shield

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

000745124 55-2066 (12/20)

03

Enrollment



Dental Blue® 65

APPLICATION FOR DENTAL BLUE 65

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

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

Please answer all questions.

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

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

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

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
If you want your Dental Blue 65 bill sent to an address other than your home address,
complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
Your email address:

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

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

Applicant’s Signature: ______________________________________ Date: ___________________________

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

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

Notice to Applicant

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

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

Applicant’s Signature: ______________________________________ Date: ___________________________

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000406206 55-0167-21 (9/20)

Dental Blue® 65

APPLICATION FOR DENTAL BLUE 65

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

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

Please answer all questions.

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

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

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

1st of the month 15th of the month

First Name Last Name Middle Initial

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

Your permanent home address:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
If you want your Dental Blue 65 bill sent to an address other than your home address,
complete the following section.
Your billing address only:
Number and Street ________________________________________________________________________

City ________________________________________________ State __________ Zip ______________
Your email address:

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

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

Applicant’s Signature: ______________________________________ Date: ___________________________

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

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

Notice to Applicant

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

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

Applicant’s Signature: ______________________________________ Date: ___________________________

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association.
© 2020 Blue Cross and Blue Shield of Massachusetts, Inc., or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

000406206 55-0167-21 (9/20)



FOR MORE INFORMATION, OR TO ENROLL:

Medicare Plan Sales: 1-800-678-2265 (TTY: 711)
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bluecrossma.com/Medicare

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

000405801 ® 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.

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