BVCBSMA Medex Choice Sales Kit Book V2 11/01/2018 Approved by Jazmin 11/1/2018 2:29 PM

Medicare Supplement Choice: Medex Choice (continued)

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

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

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

Special Medical Formulas Mandated by Law

Covered by Medicare $0 $185 $0 $0 $185 (Part B
First $185 of Medicare-approved amounts** deductible)
20% 20%
Remainder of Medicare-approved amounts 80% All allowed charges $0 $0
Not covered by Medicare $0
Balance

Medicare (Parts A & B)

Services Medicare Pays Plan Pays You Pay

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

Durable medical equipment $185 $0 $0 $185 (Part B
20% 20% deductible)
First $185 of Medicare-approved amounts**
$0 $0
Remainder of Medicare-approved amounts 80%

Other Benefits—Not Covered By Medicare

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

**Once you have been billed $185 of Medicare-approved amounts for covered services (which are noted with
a double asterisk), your Part B deductible will have been met for the calendar year.

The Deductible and Co-insurance amounts listed above reflect the 2019 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.
19

Blue Cross Blue Shield Resources

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

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

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

®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association.

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

®˝ Registered Marks are the property of their respective owners. © 2018 Blue Cross and Blue Shield
of Massachusetts, Inc.

188555 32-3000-19 (08/18)

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 Call 1-800-262-BLUE (2583)
Medicare and supplemental insurance
coverage, and hear what other people (TTY/TDD 711) 7:00 a.m.–12:00 a.m.,
who are in your shoes are asking us at 7 days a week (Excluding holidays).
one of our informational meetings.
You can also make your reservation online anytime,
24 hours a day, seven days a week by visiting
www.bluecrossma.com/seminar.

Reserve your seat at the location nearest you.

RESERVE We are always adding and updating seminars on an ongoing basis.
NOW
Visit our website at bluecrossma.com/seminars to see the most
up-to-date list.

Comprehensive 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:

Hyannis 11/05/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Cambridge 11/05/2018 10:30 AM-12:30 PM Courtyard by Marriott 777 Memorial Drive
Watertown 11/06/2018 10:30 AM-12:30 PM Residence Inn 570 Arsenal Street
Peabody 11/06/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Middleboro 11/07/2018 10:30 AM-12:30 PM Lorenzo's Italian Restaurant 500 West Grove Street
Braintree 11/07/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Fall River 11/08/2018 10:30 AM-12:30 PM McGovern's Family Restaurant 310 Shove Street
Westborough 11/08/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive

Blue Cross Blue Shield of Massachusetts is an Independent Continued
Licensee of the Blue Cross and Blue Shield Association.
Y0014_18211_M
S2893_18136_M

Comprehensive 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:

Hadley 11/09/2018 10:30 AM-12:30 PM Hadley Farms Meeting House 41 Russell Street
Taunton 11/09/2018 10:30 AM-12:30 PM Holiday Inn 700 Myles Standish Blvd
Springfield 11/12/2018 10:30 AM-12:30 PM La Quinta Inn & Suites 100 Congress Street
Leominster 11/12/2018 10:30 AM-12:30 PM DoubleTree by Hilton 99 Erdman Way
Dedham 11/13/2018 10:30 AM-12:30 PM Holiday Inn 55 Ariadne Road
Salem 11/13/2018 10:30 AM-12:30 PM Hawthorne Hotel 18 Washington Square West
Natick 11/14/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Concord 11/14/2018 10:30 AM-12:30 PM Residence Inn 320 Baker Avenue
Worcester 11/15/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Boston 11/15/2018 10:30 AM-12:30 PM Sheraton Boston Hotel 39 Dalton Street
Newton 11/16/2018 10:30 AM-12:30 PM Marriott 2345 Commonwealth Avenue
Andover 11/17/2018 10:30 AM-12:30 PM Courtyard by Marriott 10 Campanelli Drive
Plymouth 11/19/2018 10:30 AM-12:30 PM John Carver Inn 25 Summer Street
New Bedford 11/19/2018 10:30 AM-12:30 PM Fairfield Inn & Suites 185 MacArthur Drive
Milford 11/20/2018 10:30 AM-12:30 PM DoubleTree by Hilton 11 Beaver Street
Gardner 11/21/2018 10:30 AM-12:30 PM Colonial Hotel 625 Betty Spring Road
Westborough 11/21/2018 10:30 AM-12:30 PM DoubleTree by Hilton 5400 Computer Drive
Tewksbury 11/27/2018 10:30 AM-12:30 PM Holiday Inn 4 Highwood Drive
Hyannis 11/28/2018 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Braintree 11/29/2018 10:30 AM-12:30 PM Hyatt Place 50 Forbes Road
Natick 11/29/2018 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Lynnfield 11/30/2018 10:30 AM-12:30 PM Spinelli's Function Facility Route One South
Burlington 12/04/2018 10:30 AM-12:30 PM Marriott One Burlington Mall Road
Worcester 12/04/2018 10:30 AM-12:30 PM Beechwood Hotel 363 Plantation Street
Peabody 12/05/2018 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Rockland 12/06/2018 10:30 AM-12:30 PM DoubleTree by Hilton 929 Hingham Street
Waltham 12/07/2018 10:30 AM-12:30 PM Embassy Suites 550 Winter Street

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

A salesperson will be present with information and applications. For accommodations for persons with special needs,
please call 1-800-262-BLUE (2583) (TTY/TDD users please call 711) 7:00 a.m.–12:00 a.m., 7 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. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.
and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
188947-2M 55-1758 (10/18)



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



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)



Translation Resources
TPrroaficniesnlcaytoifoLnangRuaegseoAussrisctaensce 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
Sidpenatnifiicsahc/Eiósnp(aTñTYo:l:7A1T1E).NCIÓN: Si habla español, tiene a su disposición servicios gratuitos

Pdeoratsuigstueensceia/Pconrtuegl iudêiosm: aA.TLElNamÇeÃOal: nSúemfearlao pdoertSuegruvêicsi,osaãloC-llhieentdeisqpuoenifbigiluizraadeons sguratauritjeatmaednete
sideernvitçifiocsacdióenas(TsTisYt:ên7c1i1a).de idiomas. Telefone para os Serviços aos Membros, através do número no
PseourtcuagrutãeosIeD/P(ToTrYtu: g7u1ê1s).: ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente

sCehrviniçeosse/d简e 体as中sis文tên: c注ia意de：id如io果ma您s.讲Te中le文fon，e我pa们ra可os向S您er免viç费os提a供os语M言em协b助ros服, 务atr。av请és拨do打n您úmIDero卡n上o 的
号se码u c联ar系tão会ID员(服TT务Y:部71（1)T.TY 号码：711）。

HCahitniaenseC/简re体ole中/K文re:y注òl意A：yis如ye果n您: A讲TA中NS文Y，ON我: 们Si 可ou向p您ale免k费rey提òl供ay语isy言en协, s助èv服is务as。is请tan拨s 打na您n laIDng卡上的
d号is码po联nib系p会ou员o服u 务gra部tis（. RTTeYle 号nim码e：wo71S1è）vis。Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou
HMaailatinatnanCdraenoTleT/YK:r7e1y1ò)l. Ayisyen: ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang

Vdiiseptnonaimb epsoeu/ToiuếnggraVtisiệ.tR: LeƯleUnÝim: NeếwuoqSuýèvviịsnMóiaTniếmngnaVniệtk,icsáocudkịcaht vIdụahnỗtititfrkợasnygoônnwnglaữnđ(ưSợècvcisupngoucấp cho
MquaýlavnịtmaniễdnanphTíT. GY:ọ7i c1h1o).Dịch vụ Hội viên theo số trên thẻ ID của quý vị (TTY: 711).

RViuestnsiaamn/eРsуeс/сTкiиếnйg: ВVНiệИtМ: LАƯНUИÝЕ::NеếсuлиqВuыý vгịоnвóоiрTиiếтеngпоV-iрệtу,сcсáкcиd, Вịcыhмvоụжhеỗтеtrвợоnсgпôоnльnзgоữваđтưьợсяc бcuесnпgлcаấтpныcмhиo
уqсuлýуvгаị мmиiễпnеpрhевí.оGдọчiиcкhаo. ПDоịcзhвоvнụиHтеộiвvоiêтnдеtлheоoбсsлốуtжrêиnваthнẻияIDклcиủеaнqтuоýв vпịо(TнTоYм: е7р1у1,)у. казанному в Вашей
иRдuеsнsтiиaфnи/Ркауцсискоинйно: йВНкаИрМтеАН(тИелЕе: етасйлпи: В7ы11го).ворите по-русски, Вы можете воспользоваться бесплатными
Aусrлaуbгаicм/и‫يبر‬п‫ة‬:ереводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей
иде‫ف‬н‫ت‬т‫ها‬и‫ال‬ф‫ز‬и‫جها‬к)ац‫ك‬и‫ويت‬о‫ ُه‬н‫ة‬н‫ق‬о‫طا‬й‫ى ب‬к‫عل‬ар‫ود‬т‫ج‬е‫ا(لمو‬т‫م‬е‫ق‬л‫لر‬е‫ى ا‬т‫ل‬а‫ع‬й‫ء‬п‫ضا‬:‫ع‬7‫الأ‬1‫ت‬1‫م)ا‬.‫ اتصل بخد‬.‫ فتتوفر خدمات المساعدة اللغوية مجانًا بالنسبة لك‬،‫ إذا كنت تتحدث اللغة العربية‬:‫انتباه‬
.(711 :”TTY“ ‫النصي للصم والبكم‬
Arabic/‫ةيبر‬:
Mo‫ف‬n‫ت‬-‫ها‬K‫ ال‬h‫از‬m‫)جه‬e‫ك‬r,‫يت‬C‫ ُهو‬a‫ة‬m‫طاق‬b‫ى ب‬o‫عل‬d‫د‬i‫و‬a‫ج‬n‫مو‬/‫ال‬ខ្‫قم‬ែមរ‫ر‬:‫ال‬
ក‫لى‬ា‫ ع‬រ‫اء‬ជ‫ូعض‬ន‫الأ‬ដ‫ំت‬ណ‫ب ឹخدما‬ង‫ل‬៖‫اتص‬ប.្‫ك‬រ‫ل‬ស‫ិسبة‬ន‫الن‬ប‫نًا្ ب‬រ‫جا‬ើអ‫ م‬កន្ ‫وية‬ន‫ិلغ‬យ‫ة ال‬ា‫عد‬យ‫لمسا‬ភ‫ت ا‬ា‫ا‬ស‫دم‬ា‫فر خ‬ខ‫تت្و‬.‫(ف‬មែរ7،‫ة‬1‫ربي‬1‫الع‬:”‫ة‬T‫لغ‬T‫ال‬Y‫لإلذاصكمنواتلبتتكمحد“ث‬ :‫انتباه‬
‫النصي‬
បសវាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសបរា្រ់អកន្ ។ សូមទូរស័ព្ទបៅខ្្កន បសវាសរាជិកតាមបេ្
Mបៅonបេ-Kើ្hរm័ណer្ណស, Cរaាាគmេb់្odួនលៃ iaរ្nរ/សខ្់អមរែ : កន្ កា(TរជTYូន:ដ7ំណ11ឹ)។ង៖ ប្រសិនប្រើអន្កនិយាយភាសា ខ្ែរម
Fបសrenវាcជhំន/Fួយraភnាçសaiាs:ឥAតTគTEិតNថT្IOៃល គNឺអ:ាsចi រvកouបsានpaសrleបzរាfra្រn់អçនក្ais។, dសesូមsទeូរrសvic័ពesបទ្ ៅd’aខs្sនក្ isបtaសncវeាសlinរgាuជistិកiqតuាeមsបoេnt ្
dបៅispបoេnibើ្រle័ណs gណ្សratរuាiគាteេm់្enួនៃល t.រ្Aរpសpe់អleនក្ z (leTTSYe: r7v1ic1e)។adhérents au numéro indiqué sur votre carte d’assuré
(FTrTeYnc: h7/1F1r)a. nçais: ATTENTION : si vous parlez français, des services d’assistance linguistique sont

dItiaslpiaon/ibItleasliagnraot:uAiteTmTEeNntZ.IOApNpEe:lesze lpeaSrlaetrevicitealiadnhoé, rseonntso aduisnpuomnibéirloi pinedr ivqouiésesurvrizviogtreatuciatirtdei das’assisstuernéza
(liTnTgYuis: t7ic1a1.)C. hiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa

I(TtaTlYia: n7/1It1a).liano: ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza

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)

03

Enrollment



Medex®´

Application For Direct
Billed Medex®´ Choice

Directions • To enroll by phone, please call
1-800-678-2265.
Medex Choice requires applicants to select
a primary care provider (PCP). Please go to • Medex premium rates and benefits are
www.bluecrossma.com/findadoctor to explained in the booklet you received
choose your Medex Choice PCP and add with this application. If you need more
this information, along with the PCP ID information or assistance, call us at
number, to this application. You will also 1-800-678-2265.
find the provider’s PCP ID number within the
Find A Doctor tool. If you need help choosing • For all other questions, contact:
a PCP or finding the PCP ID number, please Medex Member Service: 1-800-258-2226
call 1-800-258-2226 (TTY: 711), Monday TTY: 711
through Friday, 8:00 a.m. to 6:00 p.m.
You are eligible to apply for a
• Please print clearly. Medex plan if you meet all of
the following requirements:
• Please carefully read and answer all
questions. Incomplete applications will • You are a resident of Massachusetts and
not be accepted. Please keep you actually live in Massachusetts.
a copy of the application for your records.
• You are eligible for Medicare Part A and
• Please do not send us your application until Medicare Part B and enrolled in Medicare
you have received your red, white, and blue Part B.
Medicare card.
• If you are under age 65, you qualify for
• Do not send money with this application. Medicare coverage because of disability
You will receive a bill when payment is due. except for end-stage renal disease.

• Please complete and return the white copy to: Note: If you are covered by Medicaid,
Direct Sales you may or may not be eligible to enroll in
Blue Cross Blue Shield of Massachusetts Direct Billed Medex. See paragraph (f) of
One Enterprise Drive the “Important Information” section of this
Quincy, MA 02171-1753 application form.

Or fax the application 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.

In order to enroll in this plan, you must select a PCP

Name of PCP City State Zip
PCP ID#
Current PCP? q Yes q No

Your Social Security Number: How often would you like to be billed?

________ - _______ - _____________ q Monthly q Quarterly

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

q 1st of the month q 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
City ()–
q Male q Female
State Zip
Your permanent home address:
Number and Street

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

Your billing address only: City State Zip
Number and Street

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? q Yes q No
If yes, give your Blue Cross Blue Shield identification number:

1

Important Information

Please read the “Important Information” section. Then answer questions 1 through 5 on page 2 and 3.

(a) You do not need more than one Medicare supplemental insurance policy.

(b) If you purchase this Policy, you may want to evaluate your existing health coverage and decide if you need multiple
coverage.

(c) You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy.

(d) The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during
your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming
eligible for Medicaid. If you are no longer entitled to Medicaid, your Policy will be reinstituted if requested within 90 days
of losing Medicaid eligibility.

If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled
in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug
coverage, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

(e) If you are eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later
become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare
supplemental insurance policy can be suspended, if requested, while you are covered under the employer or union-based
group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose
your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no
longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or
union-based group health plan.

If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled
in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug
coverage, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

(f) Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental
Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified
Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts
Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166) or write to that
office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108.

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.

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

To the best of your knowledge,

1. (a) Did you turn age 65 in the last 6 months? q Yes q No
(b) Did you enroll in Medicare Part B in the last 6 months? q Yes q No

(c) If yes, what is the effective date?_______________

2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT:
If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this

question.] q Yes q No

If yes,

(a) Will Medicaid pay your premiums for this Medicare supplemental policy? q Yes q No

(b) Do you receive any benefits from Medicaid OTHER THAN payments toward your

Medicare Part B premium? q Yes q No

2

3. (a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days
(for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end
dates below. If you are still covered under this plan, leave “END” blank. Start __/__/__ End __/__/__

(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare

supplemental policy? q Yes q No
(c) Was this your first time in this type of Medicare plan? q Yes q No
(d) Did you drop a Medicare supplemental policy to enroll in the Medicare plan? q Yes q No
4. (a) Do you have another Medicare supplemental policy in force? q Yes q No

(b) If so, with what company, and what plan do you have?

__________________________________________________________________________________________

(c) If so, do you intend to replace your current Medicare supplemental policy with this policy? q Yes q No
5. Have you had coverage under any other health insurance within the past 63 days? q Yes q No

(For example, an employer, union, or individual plan)

(a) If so, with what company and what kind of policy? __________________________________________________

__________________________________________________________________________________________

(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 hereby acknowledge I have been informed that my Medex Choice Policy shall not restrict payment for covered
services provided by non-network providers if both of the following conditions exist: (a) The services are for symptoms
requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and (b) It is not
reasonable to obtain services through an HMO Blue Network Provider. I also understand that to be eligible to receive
Medex Choice coverage, I must choose an HMO Blue PCP and receive all my care from HMO Blue Network Providers,
except when both of the two conditions above exist.

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

Applicant’s Signature: Date:

_______________________________________________ __________________________________________

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (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 Mark of Blue Cross
and Blue Shield of Massachusetts, Inc. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.
188572M 42-0435-19 (08/18) 3

Medex®´

Application For Direct
Billed Medex®´ Choice

Directions • To enroll by phone, please call
1-800-678-2265.
Medex Choice requires applicants to select
a primary care provider (PCP). Please go to • Medex premium rates and benefits are
www.bluecrossma.com/findadoctor to explained in the booklet you received
choose your Medex Choice PCP and add with this application. If you need more
this information, along with the PCP ID information or assistance, call us at
number, to this application. You will also 1-800-678-2265.
find the provider’s PCP ID number within the
Find A Doctor tool. If you need help choosing • For all other questions, contact:
a PCP or finding the PCP ID number, please Medex Member Service: 1-800-258-2226
call 1-800-258-2226 (TTY: 711), Monday TTY: 711
through Friday, 8:00 a.m. to 6:00 p.m.
You are eligible to apply for a
• Please print clearly. Medex plan if you meet all of
the following requirements:
• Please carefully read and answer all
questions. Incomplete applications will • You are a resident of Massachusetts and
not be accepted. Please keep you actually live in Massachusetts.
a copy of the application for your records.
• You are eligible for Medicare Part A and
• Please do not send us your application until Medicare Part B and enrolled in Medicare
you have received your red, white, and blue Part B.
Medicare card.
• If you are under age 65, you qualify for
• Do not send money with this application. Medicare coverage because of disability
You will receive a bill when payment is due. except for end-stage renal disease.

• Please complete and return the white copy to: Note: If you are covered by Medicaid,
Direct Sales you may or may not be eligible to enroll in
Blue Cross Blue Shield of Massachusetts Direct Billed Medex. See paragraph (f) of
One Enterprise Drive the “Important Information” section of this
Quincy, MA 02171-1753 application form.

Or fax the application 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.

In order to enroll in this plan, you must select a PCP

Name of PCP City State Zip
PCP ID#
Current PCP? q Yes q No

Your Social Security Number: How often would you like to be billed?

________ - _______ - _____________ q Monthly q Quarterly

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

q 1st of the month q 15th of the month

First Name Last Name Middle Initial

Your gender: Your complete date of birth: Your telephone number:
City ()–
q Male q Female
State Zip
Your permanent home address:
Number and Street

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

Your billing address only: City State Zip
Number and Street

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? q Yes q No
If yes, give your Blue Cross Blue Shield identification number:

1

Important Information

Please read the “Important Information” section. Then answer questions 1 through 5 on page 2 and 3.

(a) You do not need more than one Medicare supplemental insurance policy.

(b) If you purchase this Policy, you may want to evaluate your existing health coverage and decide if you need multiple
coverage.

(c) You may be eligible for Medicaid benefits and may not need a Medicare supplemental insurance policy.

(d) The benefits and premiums under your Medicare supplemental insurance policy can be suspended, if requested, during
your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming
eligible for Medicaid. If you are no longer entitled to Medicaid, your Policy will be reinstituted if requested within 90 days
of losing Medicaid eligibility.

If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled
in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug
coverage, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

(e) If you are eligible for, and have enrolled in a Medicare supplemental insurance policy by reason of disability and you later
become covered by an employer or union-based group health plan, the benefits and premiums under your Medicare
supplemental insurance policy can be suspended, if requested, while you are covered under the employer or union-based
group health plan. If you suspend your Medicare supplemental insurance policy under these circumstances, and later lose
your employer or union-based group health plan, your suspended Medicare supplemental insurance policy (or, if that is no
longer available, a substantially equivalent policy) will be reinstituted if requested within 90 days of losing your employer or
union-based group health plan.

If the Medicare supplemental insurance policy provided coverage for outpatient prescription drugs and you enrolled
in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug
coverage, as you will be enrolled in the most comparable plan without outpatient prescription drug coverage.

(f) Counseling services are available in Massachusetts to provide advice concerning your purchase of Medicare supplemental
Insurance policy and concerning medical assistance through the state Medicaid program, including benefits as a Qualified
Medicare Beneficiary (QMB) and a Specified Low-Income Medicare Beneficiary (SLMB). You may call the Massachusetts
Executive Office of Elder Affairs insurance counseling program at 1-800-243-4636 (TTY: 1-800-872-0166) or write to that
office at the following address for more information: One Ashburton Place, 5th Floor, Boston, MA 02108.

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.

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

To the best of your knowledge,

1. (a) Did you turn age 65 in the last 6 months? q Yes q No
(b) Did you enroll in Medicare Part B in the last 6 months? q Yes q No

(c) If yes, what is the effective date?_______________

2. Are you covered for medical assistance through the state Medicaid program? [NOTE TO APPLICANT:
If you are participating in a “Spend-Down Program” and have not met your “Share of Cost,” please answer NO to this

question.] q Yes q No

If yes,

(a) Will Medicaid pay your premiums for this Medicare supplemental policy? q Yes q No

(b) Do you receive any benefits from Medicaid OTHER THAN payments toward your

Medicare Part B premium? q Yes q No

2

3. (a) If you had coverage from any Medicare plan other than original Medicare within the past 63 days
(for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your start and end
dates below. If you are still covered under this plan, leave “END” blank. Start __/__/__ End __/__/__

(b) If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare

supplemental policy? q Yes q No
(c) Was this your first time in this type of Medicare plan? q Yes q No
(d) Did you drop a Medicare supplemental policy to enroll in the Medicare plan? q Yes q No
4. (a) Do you have another Medicare supplemental policy in force? q Yes q No

(b) If so, with what company, and what plan do you have?

__________________________________________________________________________________________

(c) If so, do you intend to replace your current Medicare supplemental policy with this policy? q Yes q No
5. Have you had coverage under any other health insurance within the past 63 days? q Yes q No

(For example, an employer, union, or individual plan)

(a) If so, with what company and what kind of policy? __________________________________________________

__________________________________________________________________________________________

(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 hereby acknowledge I have been informed that my Medex Choice Policy shall not restrict payment for covered
services provided by non-network providers if both of the following conditions exist: (a) The services are for symptoms
requiring emergency care or are immediately required for an unforeseen illness, injury or a condition; and (b) It is not
reasonable to obtain services through an HMO Blue Network Provider. I also understand that to be eligible to receive
Medex Choice coverage, I must choose an HMO Blue PCP and receive all my care from HMO Blue Network Providers,
except when both of the two conditions above exist.

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

Applicant’s Signature: Date:

_______________________________________________ __________________________________________

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (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 Mark of Blue Cross
and Blue Shield of Massachusetts, Inc. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc.
188572M 42-0435-19 (08/18) 3



For More Information, or to Enroll:

Call: 1-800-678-2265 (TTY: 711)
8:00 a.m. to 6:00 p.m. ET
Monday through Friday
or

Visit: www.bluecrossma.com/medicare

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

188798M (11/01/(0188/V128))