BCBSMA Medex Core Sapphire SalesKit Book 07/01/2021 Approved by Danielle Roy 0/21/2021 4:55 PM

Medicare Supplement Plans

Medex®´ Core | Medex®´ Sapphire

MEDEX®´ 2021

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.

(07/01/21)



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

Dear Prospective Member:
Thank you for your interest in our Medex®´ plans. Our two plan options, Medex®´ Core
and Medex®´ Sapphire, are designed to fill the gaps in Original Medicare and add real value
to your health care coverage.

Our goal is to provide you with information that will help you choose the plan
that fits your needs and budget. Please see the enclosed guide, which will help you:

 

Learn about the value Compare coverage options Enroll in Medex using the
of Medex from our Freedom with a detailed overview enclosed application and
self-addressed envelope,
of Choice brochure of Medex Core and
Medex Sapphire or through one of the
methods listed below.

If you became eligible for Medicare before January 1, 2020, you may be eligible for our
Medex Bronze plan. Call us today to learn more.
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).

000405495 ® Registered Marks of the Blue Cross and Blue Shield Association.
®´ Registered Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross

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

99-0483-21 (9/20)

IN THIS BOOKLET

01 Plan Information
• Solutions to Supplement
Medicare
• Outline of Medicare
Supplement Coverage

02 Resources
• Seminar Information
• It Pays to Stay Blue
• Vision and Hearing
• GeoBlue® International
Medical Coverage

03 Disclosures
• Nondiscrimination Notice
• Translation Resources

04 Enrollment
• Enrollment Forms
• Business Reply Envelope



01

Plan
Information



Medex®´ Core
Medex®´ Sapphire

FREEDOM OF CHOICE
SOLUTIONS TO SUPPLEMENT MEDICARE

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

With Medex from Blue Cross Blue Shield
of Massachusetts, the choice is yours.

Our plan options let you choose
what you need from your health plan.

CONTENTS

Medex . . . . . . . . . . . . . . . . 1–2
The Freedom of Medex . . . . . . . . 1
An Introduction to Medex . . . . . . . 2

Medicare . . . . . . . . . . . . . . .4–6
What Is Original Medicare? . . . . . . 4
Why Do I Need
to Supplement Medicare? . . . . . . . 5
Medicare Coverage . . . . . . . . . . 6

Medicare and Medex Together . . . 7–14
Medicare Coverage Combined
with a Medex Plan . . . . . . . . 7–11
Medex Coverage
Wellness Programs . . . . . . . . . 13
How Medex Works . . . . . . . . . 14

Enrollment in Medex . . . . . . . .15–17
Am I Eligible for Medex?. . . . . . . 15
When Do I Enroll? . . . . . . . . . . 15
How Do I Enroll? . . . . . . . . . . 16
When Will My Coverage Begin? . . . 17

Miscellaneous Information . . . . 18–19
Premium Rates . . . . . . . . . . . 18
Helpful Numbers . . . . . . . . . . 19

THE FREEDOM OF MEDEX

Many people who enroll in Original Medicare are surprised to learn
that it doesn’t provide the coverage they expect. After all, deductibles,
co-insurance, and gaps in health care coverage can amount to thousands
of dollars in expenses a year. That’s why so many Massachusetts residents
turn to Blue Cross Blue Shield of Massachusetts.

Medex, our family of Medicare supplement plans, is designed to add real value and flexibility
to your Medicare solution. Medex helps you save money by lowering your out-of-pocket
expenses. It also fills the gaps in Original Medicare coverage and gives you the power
to see any Medicare provider in the country without a referral.

With Medex, you’ll gain access to benefit features, including:

  The peace of mind
of a Blue Cross Blue Shield
The versatility Medex Core and Sapphire members of Massachusetts ID card—the
of worldwide coverage are entitled to a fitness benefit most recognized ID card
($150 a year) and weight-loss
benefit ($150 a year) in health care today

Please take a moment to review this easy-to-follow booklet.
We’ll explain everything you need to know about Medicare supplement plans

and Medex. If you have any questions about coverage—or if you think
Medex is right for you—call us toll-free at 1-800-678-2265 (TTY: 711).

Our office hours are Monday through Friday,
8:00 a.m. to 5:00 p.m. ET. You can also visit our website

at bluecrossma.com/medicare for more information.

1 Medex Sales: 1-800-678-2265

AN INTRODUCTION TO MEDEX

Medex is a Medicare supplement plan offered by Blue Cross Blue Shield
of Massachusetts. It can be added to Medicare Part A and Part B coverage
to fill “gaps” in your Medicare coverage.

As a supplemental insurance plan, Medex helps cover health care expenses
left over after Medicare has covered its portion of costs.

Medex offers you a choice of two plans with varying coverage levels and premiums,
making it easy to find a plan that meets your unique needs.

Parts Keep + Medicare +
A&B Original Supplement
Medicare Insurance Medex Sapphire
and add… Enhanced Supplemental

Coverage
— or —
Medex Core
Basic Supplemental
Coverage

Depending on which option you choose, Medex may cover most of Medicare cost-sharing
amounts, or “gaps,” as well as some services not covered by Medicare. You’ll learn more
about Medicare cost-sharing amounts in the next few pages.
We’ll also help you determine which Medex plan is right for you by discussing what each
plan covers and comparing costs.
But let’s begin by exploring what Medicare actually is and how you might benefit from
a Medex supplemental plan.

bluecrossma.com/medicare 2

Important: If you haven’t enrolled in Medicare,
it’s recommended that you contact
your local Social Security office

three months prior to your 65th birthday.

WHAT IS ORIGINAL MEDICARE?

Original Medicare is a federally funded health insurance plan. It’s designed
for people age 65 or older and some disabled people under age 65.

Original Medicare has two parts:

 

Medicare Part A Medicare Part B

(Hospital insurance) pays for inpatient (Medical insurance) pays for outpatient
hospital expenses. hospital charges, doctor visits, and many
other medical services not covered by
Services covered: Part A.
Facility Care
Services covered:
• Inpatient hospital care Medical Expenses

• Skilled nursing facility care • Doctors’ services
• Physical and speech therapy
• Hospice care • Diagnostic tests
• Ambulance trips
• Home health services • Durable medical equipment
• Diabetic testing supplies

bluecrossma.com/medicare 4

MEDICARE COVERAGE

(Without Supplemental Insurance)

Why Do I Need to Supplement Medicare?

Although Medicare pays a large portion of your medical expenses, you’re responsible
for the remaining costs. Also, Medicare doesn’t cover all medical services in all situations.

Here are some important things to know about Medicare:

• You may have to pay deductible and co-insurance costs. When Medicare covers a service,
you often must pay for a portion of the cost. Your portion is referred to as a deductible or
co-insurance. Deductibles are the amount you’re responsible for before Medicare begins to
pay, and they’re subject to change from year to year. After your deductible is paid, you may
need to pay an additional amount—usually 20 percent of the cost for the service, called co-
insurance.

• In most cases, Medicare doesn’t cover you outside the United States, even in the event of
an emergency. Please refer to the chart on page 6 for an illustration of Medicare coverage
that’s not supplemented with a Medex plan. The chart highlights Medicare’s benefits,
deductible, and co-insurance costs, and some of the services Medicare doesn’t cover.

• Expenses that aren’t covered by Medicare are often referred to as “gaps.” Medicare
supplement (Medigap) plans, such as Medex, help to fill in these coverage gaps. They
help you pay Medicare’s deductible and co-insurance costs, and cover certain services
Medicare doesn’t.

Please refer to the charts on pages 7 through 14 for coverage when Medicare is combined
with a Medex plan.

5 Medex Sales: 1-800-678-2265

These Medicare benefits are effective January 1, 2021.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Part A Your Cost

Inpatient Hospital Care $1,484 deductible
$371 per day co-insurance
Days 1–60 each benefit period: 100% coverage after you pay $742 per day co-insurance
the $1,484 deductible All costs after 150 days

Days 61–90 each benefit period: 100% coverage after you pay No cost
$371 per day co-insurance $185.50 per day co-insurance
All costs after 100 days
Days 91–150 (60 lifetime reserve days): 100% coverage after you pay
$742 per day co-insurance

Days 150+: no coverage

Skilled Nursing Facility Care

Days 1–20 each benefit period: 100% coverage

Days 21–100 each benefit period: 100% coverage after you pay
$185.50 per day co-insurance

No coverage after 100 days in a benefit period

Medicare Part B Your Cost

Medical Expenses • Ambulance • Doctors’ services
• Diagnostic tests • Durable medical equipment
• Diabetic testing supplies • Physical & speech therapy

Coverage begins after you pay the $203 calendar-year deductible $203 deductible
20% co-insurance
Medicare covers 80% of the Medicare-approved amount; you pay 20%
co-insurance Most outpatient prescription costs
No cost when Medicare covers the
Prescription Drugs preventive service in full and provider
accepts assignment
Members may voluntarily purchase Medicare Part D, which covers
prescription drugs (unless the drug is covered under Part B)

Routine Services and Preventive Care

100% coverage for specific Medicare preventive services.
A complete listing is found on the Medicare website,
medicare.gov

Travel Outside the United States

No coverage for medical costs incurred outside the United States All costs

bluecrossma.com/medicare 6

MEDICARE COVERAGE Medex Core
(Medicare Supplement Core)
(Combined with a Medex Core Plan) Coverage for Medicare daily
co-insurance after you pay
Days Medicare $1,484 Part A deductible
Full coverage for lifetime reserve
Hospital 1–60 Coverage for 60 days, co-insurance, then an additional
Services 61–90 after the $1,484 deductible1 365 days per lifetime when
Medicare benefits end
Lifetime Coverage for 61–90 days, Covered by Medicare
Reserve after $371 daily co-insurance
No coverage
Coverage for an additional No coverage
60 lifetime reserve days, Coverage of 20% co-insurance,
after $742 daily co-insurance after you pay $203 annual
Part B deductible
Skilled 1–20 Full coverage for 20 days in a
Nursing 21–100 Medicare-participating facility Coverage of 20% co-insurance,
Facility 101+ after you pay $203 annual
Coverage for days 21–100, Part B deductible
after $185.50 daily co-insurance
Coverage of 20% co-insurance,
No coverage after 100 days after you pay $203 annual
Part B deductible
Physician and Other 80% coverage of approved
Provider Services services, after the $203 annual
Care in the Hospital Part B deductible

Physician and Other 80% coverage of approved
Provider Services services, after the $203 annual
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits 80% coverage of approved
services, after the $203 annual
Other Part B Services Part B deductible
Ambulance Trips, Durable
Medical Equipment, Etc.

Note: Although the $203 calendar-year Medicare medical insurance (Part B) deductible appears more than once in this
benefit chart, only one $203 deductible is applicable in a calendar year. The Medex policy defines the terms and conditions
of all the Medex plans in greater detail. Should any questions arise concerning benefits, the Medex policy will govern.

This chart doesn’t include all Medicare benefits. Please refer to the Medicare & You handbook published by the
Centers for Medicare and Medicaid Services for more information about Medicare benefits, or call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048). You can also visit cms.gov for more information.

Refer to the Index on page 20 for an explanation of the footnotes above.

7 Medex Sales: 1-800-678-2265

MEDICARE COVERAGE Medex Sapphire
(Medicare Supplement 1A)
(Combined with a Medex Sapphire Plan)
Full coverage of Medicare
Days Medicare deductible and co-insurance

Hospital 1–60 Coverage for 60 days, Full coverage for lifetime reserve
Services 61–90 after the $1,484 deductible1 co-insurance, then an additional
Skilled Lifetime 365 days per lifetime when
Nursing Reserve Coverage for 61–90 days, Medicare benefits end
Facility 1–20 after $371 daily co-insurance Covered by Medicare
21–100 Full coverage for Medicare daily
101+ Coverage for an additional co-insurance for days 21–100
60 lifetime reserve days, $10 a day for days 101–3652 at a
after $742 daily co-insurance Medicare-participating facility
Coverage of 20% co-insurance,
Full coverage for 20 days in a after you pay $203 annual
Medicare-participating facility Part B deductible

Coverage for days 21–100, Coverage of 20% co-insurance,
after $185.50 daily co-insurance after you pay $203 annual
Part B deductible
No coverage after 100 days
Coverage of 20% co-insurance,
Physician and Other 80% coverage of approved after you pay $203 annual
Provider Services services, after the $203 annual Part B deductible
Care in the Hospital Part B deductible
Continued
Physician and Other 80% coverage of approved
Provider Services services, after the $203 annual
Outpatient Department Visits, Part B deductible
Office Visits, and Patient
Home Visits

Other Part B Services 80% coverage of approved
Ambulance Trips, Durable services, after the $203 annual
Medical Equipment, Etc. Part B deductible

Refer to the Index on page 20 for an explanation of the footnotes above.

bluecrossma.com/medicare 8

These Medicare benefits are effective January 1, 2021.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core & Medex Sapphire

Inpatient • Coverage for days 1–60 per • Full coverage of the Medicare
Admissions in a benefit period, after the deductible3 and co-insurance
General Hospital $1,484 inpatient deductible2
or Mental • Full coverage of lifetime reserve
Hospital • Coverage for days 61–90, days co-insurance
after $371 daily co-insurance
Biologically • Full coverage of up to 365
Based Mental • Coverage for an additional additional hospital days
Conditions1 60 lifetime reserve days, in your lifetime when
after $742 daily co-insurance Medicare benefits end4

• Coverage for mental hospital • When covered by Medicare,
admissions is limited to coverage of 20% co-insurance,
190 days per lifetime after you pay $203 annual
Part B deductible, with no
• Full benefits, less the visit maximum
Part B deductible and the
Part B co-insurance • When not covered by Medicare,
full Medex benefits with no
Outpatient Visits visit maximum

Refer to the Index on page 20 for an explanation of the footnotes above.

9 Medex Sales: 1-800-678-2265

MEDICARE COVERAGE

(Combined with a Medex Plan)

Medicare Medex Core & Medex Sapphire

Inpatient • Coverage for days 1–60 per • Full coverage of the Medicare
Admissions in a benefit period, after the deductible2 and co-insurance
General Hospital $1,484 inpatient deductible1
• Full coverage of lifetime
• Coverage for days 61–90, reserve days co-insurance
after $371 daily co-insurance
• Full coverage of up to 365
• Coverage for an additional 60 additional hospital days
lifetime reserve days, after in your lifetime when
$742 daily co-insurance Medicare benefits end3

• Coverage for mental hospital • Full coverage of Medicare
admissions is limited to 190 deductible2 and co-insurance
days per lifetime
• Full coverage of lifetime reserve
Non-Biologically • Same coverage as general day co-insurance
Based Mental hospital, but coverage limited
Conditions • When Medicare days are used
(includes drug to 190 days per lifetime up, 120 days per benefit period
addiction and (at least 60 days per calendar
alcoholism) Inpatient year), less any days in a mental
Admissions in a hospital already covered by
Mental Hospital Medicare or Medex in that
benefit period (or calendar year)
• Full benefits, less the Part B
deductible and the Part B • When covered by Medicare,
co-insurance coverage of 20% co-insurance,
after you pay $203 annual
Outpatient Visits Part B deductible, with no visit
maximum

• When not covered by Medicare,
full Medex benefits with no
visit maximum

Refer to the Index on page 20 for an explanation of the footnotes above.

bluecrossma.com/medicare 10

These Medicare benefits are effective January 1, 2021.
Medicare deductibles and co-insurances are subject to change each year.

Medicare Medex Core & Medex Sapphire

Travel Outside the No Coverage Full Coverage (same as in United States.)
United States
Diabetic Testing Supplies1 80% coverage of approved For blood glucose monitoring equipment
Fitness Benefit services, after $203 annual Part and supplies covered by Medicare:
Weight-loss Benefit B deductible
• Coverage for Medicare co-insurance

For urine-testing materials (not covered
by Medicare):

• 100% coverage of allowed charges

No Coverage Medex members may receive up to $150
per calendar year in qualified health club
membership fees and exercise classes

No Coverage Medex members may receive up to $150
per calendar year when enrolled in a
qualified weight-loss program

Refer to the Index on page 20 for an explanation of the footnotes above.

11 Medex Sales: 1-800-678-2265

Earn up to $150
(per calendar year)

When a member is enrolled in a qualified fitness
or weight-loss program.

(See details for qualifying programs.)

MEDEX COVERAGE WELLNESS PROGRAMS

Fitness Benefit

When a member is enrolled in a qualified health club or fitness facility, they can receive
up to $150 per calendar year toward club membership fees and exercise classes.

Qualifying programs include: Programs that DO NOT qualify:

• Health clubs with a variety of • One-time initiation or termination fees
cardiovascular and strength-training • Fees paid for gymnastics, tennis,
exercise equipment—e.g., traditional
health clubs, YMCAs, YWCAs, and pool-only facilities, martial arts schools,
community fitness centers instructional dance studios, country clubs
or social clubs, sports teams or leagues
• Fitness studios with instructor-led group • Personal trainer sessions
classes such as yoga, Pilates, Zumba®´´, • Fitness equipment or clothing
kickboxing, indoor cycling/spinning,
and other exercise programs Earn Up To $150 (per calendar year)

• Virtual/on-line fitness memberships, when a member is enrolled in a qualified
subscriptions, programs, or classes that fitness or weight-loss program.
provide cardiovascular and strength-
training using a digital platform. (See details for qualifying programs.)

• Fitness classes available at participating
Councils on Aging facilities

Weight-Loss Benefit

When a member is enrolled in a qualified weight-loss program, they can receive
up to $150 per calendar year toward program fees.

Qualifying programs include: Programs that DO NOT qualify:

• Traditional WW (formerly knows as Weight • One-time initiation or termination fees
Watchers®´´) meetings, WW At Work, WW • Food, supplements, books, scales,
online and other non-hospital programs
(in-person or online) that combine healthy or exercise equipment
eating, exercise, and coaching sessions • Individual nutrition counseling sessions
with certified health professionals such
as nutritionists, registered dietitians, or (see your health plan coverage)
exercise physiologists

• Hospital based weight-loss programs

13 Medex Sales: 1-800-678-2265

HOW MEDEX WORKS

With Medex, you show two cards when you receive medical care:
your Medicare card and your Medex card. Medicare pays first.

Medex plans have many advantages

• You can seek care from any • You can adjust your Medex coverage
Medicare physician or hospital at any time during the year. Your coverage
throughout the United States. in the new plan will begin the first of the
month following receipt of your request
• You don’t need to choose a PCP. to change plans.
• You don’t need to get referrals for
• Your Blue Cross Blue Shield of
specialty care. Massachusetts ID card is recognized
• There are no copayments for around the world.

physician services.

Am I Eligible for Medex?

You don’t need to complete a health care screening to qualify for Medex coverage.

You’re eligible for Medex if you meet the following requirements:

• You live in Massachusetts. • You may also be eligible if you’re under
• You’re enrolled (or will be enrolling) in age 65 and have a disability.

Medicare Parts A and Part B.

Note: If you’re already covered by both Medicare and Medicaid, you may not need the additional coverage that Medex
would provide. For more information, contact the Massachusetts Executive Office of Elder Affairs insurance counseling
program at 1-800-882-2003.

bluecrossma.com/medicare 14

WHEN DO I ENROLL?

You can apply for Medex during initial eligibility or continuous
Open Enrollment, and in special situations.

Initial eligibility

You’re considered “initially eligible” if one of the situations in the chart below applies to you.

If You Are: You May Apply for Medex:

Under 65 Within six months of your Medicare Part B
effective date
Enrolling in Medicare due to a disability
Within six months of your 65th birthday
Approaching 65 Within six months of your Medicare Part B
effective date
Enrolling in both parts of Medicare
Within six months of the event
Retiring from an employer-sponsored health plan
and enrolled in Medicare Part B or enrolling in
Medicare Part B

Over or Under 65

Involuntarily losing an employer-sponsored
retiree health plan

Moving out of the service area of a Medicare health
maintenance organization (HMO)

Becoming a resident of Massachusetts

Medex Continuous Open Enrollment

You may apply for Medex coverage at any time. Your coverage will begin the first of the month
following the receipt of the application.

Note: If you wish to switch from a Medicare Advantage plan to a Medex plan, call 1-800-MEDICARE
(1-800-633-4227) (TTY: 1-877-486-2048) to learn how to dis-enroll from your Medicare Advantage plan.

15 Medex Sales: 1-800-678-2265

HOW DO I ENROLL?

If you want to enroll in Medex, just follow these easy steps:

 

Choose a Medex plan. Decide if you want to be billed Enroll online, by phone,
The charts in this brochure let monthly or quarterly. You may by mail, or by fax. See below
you compare plan coverage find the quarterly billing option for details. In addition to your name
and determine which option more convenient if you plan and address, you’ll need to
best suits your unique needs. provide the Medicare number that
to travel for more than appears on your Medicare card.
a few weeks at a time. You must (If you don’t have your Medicare
card, contact the Social Security
also decide if you want your
premium due on the 1st Administration office).
or 15th of each month.

Please note that spouses need to enroll separately. If you receive your health benefits through a group contract
(such as a former employer), please follow that group’s enrollment procedures. Make sure that you keep a copy
for your records.

Enrolling Is Easy

If you’re ready to enroll in Medex, you can enroll by telephone, online, by mail, or by fax:

• Telephone: Call 1-800-678-2265, • Mail: Complete and return the enclosed
Monday through Friday, 8:00 a.m. to 5:00 p.m. ET. enrollment form in the pre-addressed business
reply envelope provided.
• Online: Visit our website, bluecrossma.com/
medicare, and click Enroll, then Online. • Fax: You may also fax your completed
enrollment form to us at 1-617-246-3633.

And that’s it! No need to send your premium payment with the application. You’ll receive a bill after your
application has been processed. If you have any questions about enrolling, please call us at 1-800-678-2265.

bluecrossma.com/medicare 16

WHEN WILL MY COVERAGE BEGIN?

Effective Date of Your Coverage

If you don’t have Medicare coverage yet, the effective date of your Medex coverage
is determined by the effective date of your Medicare Part B coverage.
If you already have Medicare coverage, your effective date is determined by the date
we receive your application.

When Your Application Is Received Your Medex Coverage Will Begin

Before the effective date of your Medicare coverage The same day as your Medicare coverage

• If you enroll within the first six months • The first day of the month following the month
of your Medicare Part B coverage or your application is received

• If you enroll during continuous open enrollment

Please Note: If you haven’t enrolled in Medicare, contact your local Social Security Administration office
three months prior to your 65th birthday.

17 Medex Sales: 1-800-678-2265

PREMIUM RATES

When you turn 65 and become initially eligible for Medicare, you may qualify
for a discounted Direct Pay Medex premium rate for up to three years.
If you’re eligible for this discount, you’ll receive a 15 percent discount
the first year of enrollment, a 10 percent discount during the second year
of enrollment, and a 5 percent discount during the third year of enrollment.
After the third year, there is no discounted premium rate. To determine
if you’re eligible for the discount, call 1-800-678-2265.

15% 10% 5%

FIRST YEAR SECOND YEAR THIRD YEAR
SAVINGS SAVINGS SAVINGS

2021 Rates Billed Monthly Billed Quarterly
Medex Core $107.88 $323.22
Medex Sapphire $183.48 $549.72

Rates effective January 1, 2021 through December 31, 2021.
Note: If you obtained Medicare under the age of 65 due to disability, you’re not eligible for the discount.

bluecrossma.com/medicare 18

HELPFUL NUMBERS

We understand that health care can be confusing, particularly when
combining plans like Medicare and Medex. The resources provided below
can help you determine who to call to get the information you need.

Blue Cross Blue Shield Medicare
of Massachusetts
If you have questions regarding
Blue Cross Blue Shield of Massachusetts Medicare, or to order a Medicare & You
associates can answer questions regarding handbook, call 1-800-MEDICARE
Medex options, premium rates, applications, (1-800-633-4227) (TTY: 1-877-486-2048)
timing, enrollment, and other Medex-related or visit cms.gov.
issues.
Medex Sales: 1-800-678-2265 TTY: 711 24/7 Nurse Line:
1-888-247-BLUE (2583)
Serving the Health Information
Needs of Everyone (SHINE) Not sure if you need to see a doctor? Medex
members can call a registered nurse 24
SHINE is an independent organization hours a day at the Nurse Line for immediate
dedicated to helping you understand assistance with health-related questions.
and compare all your health plan options.
Trained and certified counselors help We think it’s important
you determine if you qualify for any for you to know...
supplemental assistance programs.
All services are free of charge. At the onset of an emergency medical
1-800-AGE-INFO (1-800-243-4636) condition that in your judgment requires
immediate attention, you should go to the
nearest emergency room. For assistance,
call your local emergency medical service
system by dialing 911, or your local
emergency telephone number.

19 Medex Sales: 1-800-678-2265

Index

Medicare Coverage (Combined with a Medex Core or Medex Sapphire Plan) Refer to Pages 7 & 8
1. A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have

been out of the hospital and have not received skilled care in any other facility for 60 consecutive days.
2. Medex Sapphire coverage also includes $8 a day for days 1–365 at a non-Medicare-participating facility.

Refer to Page 9
1. Biologically based mental conditions are defined as: schizophrenia; schizoaffective disorder; major depressive

disorder; bipolar disorder; paranoia and other psychotic disorders; obsessive-compulsive disorder; panic disorder;
delirium and dementia; affective disorders; eating disorders; substance abuse; post-traumatic stress disorder
(PTSD); autism; and any biologically based mental disorders that are scientifically recognized and approved by the
Massachusetts Department of Mental Health. Treatment for rape-related mental or emotional disorders is covered
to the same extent as biologically based conditions.
2. A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
3. Medex Core provides full coverage for Medicare daily co-insurance after you pay $1,484 Part A deductible,
and mental hospital coverage is limited to 60 days per calendar year.
4. Both days in a general hospital and days in a mental hospital count toward the 365 additional days per lifetime.

Medicare Coverage (Combined with a Medex Plan) Refer to Page 10
1. A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have

been out of the hospital and have not received skilled care in any other facility for 60 days in a row.
2. Medex Core provides full coverage for Medicare daily co-insurance after you pay $1,484 Part A deductible,

and mental hospital coverage is limited to 60 days per calendar year.
3. Both days in a general hospital and days in a mental hospital count toward the 365 additional days per lifetime.

Refer to Page 11
1. Medicare covers blood glucose materials for all diabetics, whether or not insulin-dependent. Medicare does not

cover urine-testing materials.

1-800-678-2265 (TTY: 711) Monday through Friday, 8:00 a.m. to 5:00 p.m.
For plan information and a personal consultation.

bluecrossma.com/medicare 20

RESOURCES

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

bluecrossma.com/medicare

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

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

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

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

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

®´´Registered Marks are the property of their respective owners.

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

000708800 55-2395-21v2 (11/20)

Medex®´

OUTLINE OF MEDICARE
SUPPLEMENT COVERAGE

Cover Page: Benefit Plans Medicare Supplement Core
Through Supplement 1A

Medicare Supplement Insurance can be sold in only standard plans. This chart shows the benefits
included in each plan. Every company must make available the “Core” plan. For persons who became
Medicare Eligible prior to January 1, 2020, companies which make Medicare Supplement 1A plans
available are to also make Medicare Supplement 1 plans available. For persons who became Medicare
Eligible after January 1, 2020, companies may make Medicare Supplement 1A plans available, but they
are not permitted to make Medicare Supplement 1 plans available. Companies may add certain benefits
to the standard benefits, if approved by the Commissioner. Look at each company’s materials to find out
what benefits, if any, the company has added to the standard benefits for each plan it offers.

Basic Benefits Included in all plans.
Hospitalization
Part A co-insurance coverage for the first 90 days per benefit period (not including
Medical Expenses the Medicare Part A deductible) and the 60 Medicare lifetime reserve days, plus coverage
Blood for 365 additional days after Medicare benefits end. This shall include benefits for
biologically based mental disorders.

Part B co-insurance (generally 20% of Medicare-approved expenses) or, in the case of
hospital outpatient department services under a prospective payment system, applicable
copayments. This shall also include benefits for biologically based mental disorders.

First three pints of blood each year.

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

Blue Cross Blue Shield of Massachusetts is an Independent Licensee bluecrossma.com/medicare 1
of the Blue Cross and Blue Shield Association.

Medicare Supplement Core Medicare Supplement 1 Medicare Supplement 1A
Medex®´ Core Medex®´ Bronze Medex®´ Sapphire

Standard Benefits Hospitalization Hospitalization
Basic Benefits For biologically based mental For biologically based mental
disorders, stays in a licensed mental disorders, stays in a licensed mental
Hospitalization hospital; for other mental disorders: hospital; for other mental disorders:
For biologically based mental stays in a licensed mental hospital stays in a licensed mental hospital
disorders, stays in a licensed mental for a minimum of 120 days per for a minimum of 120 days per
hospital, less Part A deductibles; benefit period (at least 60 days per benefit period (at least 60 days per
for other mental disorders: stays calendar year) less days covered by calendar year) less days covered by
in a licensed mental hospital for at Medicare or already covered by plan Medicare or already covered by plan
least 60 days per calendar year less in that calendar year for the other in that calendar year for the other
days covered by Medicare or already mental disorders. mental disorders.
covered by plan in that calendar year
for the other mental disorders, less Skilled nursing co-insurance Skilled nursing co-insurance
Part A deductibles.

Part A deductible Part A deductible

Part B deductible Foreign travel
Foreign travel

Additional Benefits

Fitness program Fitness program Fitness program

Weight-loss program Weight-loss program Weight-loss program

Foreign travel

Rates: Effective 1/1/21 Billed monthly: $215.45 Billed monthly: $183.48
Billed monthly: $107.88

Billed quarterly: $323.22 Billed quarterly: $645.51 Billed quarterly: $549.72

2 Medex Outline of Medicare Supplement Coverage

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Blue Cross and Blue Shield of Massachusetts, Inc.

• Medicare Supplement Core—Medex Core (ME 11 DB)
• Medicare Supplement 1—Medex Bronze (ME 2 DB)
• Medicare Supplement 1A —Medex Sapphire (ME 2ADED DB)

Policy Category: Medicare Supplement Insurance

“NOTICE TO BUYER: This policy may not cover all of the costs associated with medical care incurred by the buyer
during the period of coverage. The buyer is advised to review carefully all policy limitations.”

Premium Information Policy Replacement

We, Blue Cross Blue Shield of Massachusetts, can only If you are replacing another health insurance policy,
raise your premium if we raise the premium for all do NOT cancel it until you have actually received your
policies like yours in Massachusetts, and if approved by new policy and are sure you want to keep it. If you cancel
the Commissioner of Insurance. If you choose to pay your present policy and then decide that you do not want
your premium on a monthly or quarterly basis, upon to keep your new policy, it may not be possible to get
your death, we will refund the unearned portion of the back the coverage of the present policy.
premium paid. If you choose to pay your premium on a
monthly or quarterly basis and you cancel your policy, If you newly enroll in a Medicare Supplement 1 plan
we will refund the unearned portion of the premium paid. and you became Medicare Eligible before January 1, 2020,
In the case of death, the unearned portion of the premium you will not be able to switch into the same company’s
will be refunded on a pro-rata basis. Medicare Supplement 1A plan until you have been
covered under the Medicare Supplement 1 plan for
Disclosures a period of at least 12 months.

Use this outline to compare benefits and premiums Notice
among policies.
This policy may not fully cover all of your medical costs.
Read Your Policy Very Carefully Blue Cross Blue Shield of Massachusetts is not connected
with Medicare. This outline of coverage does not give all
This is only an outline describing your policy’s most the details of Medicare coverage. Contact your local
important features. The policy is your insurance Social Security office or consult “Medicare & You” for
contract. You must read the policy itself to understand more details.
all of the rights and duties of both yourself and your
insurance company. Complete Answers Are Very Important

Right To Return Policy When you fill out the application for the new policy,
be sure to answer all the questions truthfully and
If you find you are not satisfied with your policy, you may completely. The company may cancel your policy and
return it to Blue Cross Blue Shield of Massachusetts, refuse to pay any claims if you leave out or falsify
Medex Member Services, P.O. Box 9130, North Quincy, important information.
MA 02171-9130. If you send the policy back to us within
30 days after you receive it, we will treat the policy as if it Review the application carefully before you sign it.
had never been issued and return all of your payments. Be certain that all information has been properly recorded.

bluecrossma.com/medicare 3

Massachusetts Medicare Supplement Insurance: Outline Of Coverage

Massachusetts Summary The Benefits-to-Premium Ratio
for Medex Bronze Is 93.6%
The Commissioner of Insurance has set standards for
the sale of Medicare Supplement Insurance policies. This means that during the anticipated life of your
Such policies help you pay hospital and doctor bills, and policy and others just like it, Blue Cross Blue Shield of
some other bills, that are not covered in full by Medicare. Massachusetts expects to pay out $93.60 in claims made
Please note that the benefits provided by Medicare and this by you and other policyholders for every $100 we collect
Medicare Supplement Insurance policy may not cover all of in premiums. The minimum loss ratio for Blue Cross Blue
the costs associated with your treatment. It is important that Shield of Massachusetts policies of this type is 90%. The
you become familiar with the benefits provided by Medicare minimum loss ratio for non-Blue Cross Blue Shield of
and your Medicare Supplement Insurance policy. This policy Massachusetts policies of this type is 65%. A higher ratio
summary outlines the different coverages you have if, is to your advantage, as long as it allows the company
in addition to this policy, you are also covered by Part A reasonable return so that the product remains available.
(hospital bills, mainly) and Part B (doctors’ bills, mainly)
of Medicare. The Benefits-to-Premium Ratio
for Medex Core Is 93.6%
Under Massachusetts General Laws, c. 112, s. 2, no
physician who agrees to treat a Medicare beneficiary may This means that during the anticipated life of your
charge to or collect from that beneficiary any amount policy and others just like it, Blue Cross Blue Shield of
in excess of the reasonable charge for that service as Massachusetts expects to pay out $93.60 in claims made
determined by the United States Secretary of Health and by you and other policyholders for every $100 we collect in
Human Services. This prohibition is commonly referred premiums. The minimum loss ratio for Blue Cross
to as the “ban on balance billing.” A physician is allowed Blue Shield of Massachusetts policies of this type is 90%.
to charge you or collect from your insurer a copayment The minimum loss ratio for non-Blue Cross Blue Shield
or co-insurance for Medicare-covered services. However, of Massachusetts policies of this type is 65%. A higher
if your physician charges you or attempts to collect from ratio is to your advantage, as long as it allows the company
you an amount, which together with your copayment reasonable return so that the product remains available.
or co-insurance is greater than the Medicare-approved
amount, please contact the Board of Registration in The Benefits-to-Premium Ratio
Medicine at (781) 876-8200. for Medex Sapphire Is 93.6%

We cannot explain everything here. Massachusetts law This means that during the anticipated life of your
requires that personal insurance policies be written in policy and others just like it, Blue Cross Blue Shield of
easy-to-read language. So, if you have questions about Massachusetts expects to pay out $93.60 in claims made
your coverage that are not answered in this brochure, by you and other policyholders for every $100 we collect
read your policy. If you still have questions, ask your in premiums. The minimum loss ratio for Blue Cross
agent or company. You may also wish to get a copy Blue Shield of Massachusetts policies of this type is 90%.
of “Medicare & You”, a small book put out by Medicare A higher ratio is to your advantage, as long as it allows
that describes Medicare benefits. the company reasonable return so that the product
remains available.

4 Medex Outline of Medicare Supplement Coverage

Complaints Internal Formal Grievance Review

If you have a complaint, call Medex Member How to Request a Grievance Review: To request
Service at 1-800-258-2226. If you are not satisfied, a formal review from the Blue Cross Blue Shield of
you may write to The Massachusetts Division of Massachusetts internal Member Grievance Program,
Insurance, 1000 Washington Street, Suite 810, you (or your authorized representative) have three options.
Boston, Massachusetts 02118-6200 or call
(617) 521-7794 (Boston). • Write or Fax: The preferred option is for you to send
your grievance in writing to: Member Grievance
Grievance Program Program, Blue Cross Blue Shield of Massachusetts,
One Enterprise Drive, Quincy, MA 02171-2126. Or, you
As a Medex member, you have the right to a review may fax your grievance to 1-617-246-3616. Blue Cross
when you disagree with a decision made by Blue Cross Blue Shield will let you know that your request was
Blue Shield of Massachusetts to deny payment for ser- received by sending you a written confirmation within
vices that may be eligible for benefits under Medex or if 15 calendar days.
you have a complaint about the care or service that you
received from Blue Cross Blue Shield of Massachusetts • Email: Or, you may send your grievance to the
or from a provider. Blue Cross Blue Shield Member Grievance Program
at [email protected]. Blue Cross Blue Shield
Medex Inquiries or Claim Problems of Massachusetts will let you know that your request
was received by sending you a confirmation immediately
Most Medex problems or concerns can be handled by email.
with just one phone call. For help to resolve a Medex
problem or concern, you should first call the Blue Cross • Telephone: Or, you may call the Blue Cross Blue Shield
Blue Shield of Massachusetts customer service office at of Massachusetts Member Grievance Program at
1-800-258-2226, Monday through Friday, 8:00 a.m. to 1-800-472-2689. When your request is made by phone,
6:00 p.m. ET. The TTY toll-free number is 711. A customer Blue Cross Blue Shield of Massachusetts will send you
service representative will work with you. They will help a written account of the grievance within 48 hours of
you understand your Medex coverage. Or, they will work your phone call.
with you to resolve your Medex problem or concern.
They will do this as quickly as possible. If after speaking Once your request is received, Blue Cross Blue Shield of
with a Blue Cross Blue Shield of Massachusetts customer Massachusetts will research the case in detail. They will
service representative, you still disagree with a decision ask for more information if it is needed. Blue Cross Blue
that is given to you, you may request a review through the Shield of Massachusetts will let you know in writing of the
Blue Cross Blue Shield of Massachusetts internal formal decision or the outcome of the review.
grievance program.
Note: Medicare has its own policies and procedures
for handling appeals and grievances. If you do not
agree with a decision by Medicare on the amount that
Medicare has paid on a claim or whether the services
you received are covered by Medicare, you have the
right to appeal the decision. The steps you should take
to appeal the decision are explained in your Medicare
handbook. You may also look on the Medicare website
at medicare.gov for more detailed information about the
Medicare appeals process.

bluecrossma.com/medicare 5

Medicare Supplement Core: Medex Core

Medicare (Part A)—Hospital Services—Per Benefit Period

Services Medicare Pays Plan Pays You Pay

Hospitalization*
Semiprivate room and board, general
hospital nursing and miscellaneous services
and supplies, and licensed mental hospital
stays for biologically based mental disorders
or other mental disorders prior to the
190-day Medicare lifetime maximum

First 60 days of a benefit period All but $1,484 $0 $1,484
$371 a day (Part A deductible)
61st through 90th day of a benefit period All but $371 a day
91st day and after of a benefit period: All but $742 a day $0
– While using 60 lifetime reserve days
– Once lifetime reserve days are used: $742 a day $0

• Additional 365 days $0 100% of Medicare $0
eligible expenses All Costs
• Beyond the additional 365 days $0
$0
Licensed mental hospital stays
not covered by Medicare for biologically
based mental disorders

First 60 days of a benefit period $0 All but $1,484 $1,484
(Part A deductible)
61st through 90th day of a benefit period $0 100% of Medicare
91st day and after of a benefit period: eligible expenses $0
– While using 60 lifetime reserve days $0
– Once lifetime reserve days are used: 100% of Medicare $0
• Additional 365 days $0 eligible expenses
• Beyond the additional 365 days $0
100% of Medicare $0
eligible expenses All Costs

$0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

6 Medex Outline of Medicare Supplement Coverage

Medicare (Part A) —Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

Licensed mental hospital stays
not covered by Medicare for other mental disorders

First 60 days per calendar year less days $0 All but $1,484 $1,484
covered by Medicare or plan in that calendar year (Part A deductible)
100% of
61st through 120th day of a benefit period $0 Medicare $0
eligible expenses

Days after 60 days per calendar year less days $0 $0 All Costs
covered by Medicare or plan in that calendar year
Skilled Nursing Facility Care* All approved $0 $0
(Participating with Medicare) amounts
You must meet Medicare’s requirements, including All but $185.50 $0 Up to $185.50
having been in a hospital for at least a day a day
three days and entered a Medicare-approved $0
facility within 30 days after having left the hospital $0 All Costs
$0
First 20 days of a benefit period 100% Three pints $0
All but very limited $0 $0
21st through 100th day of a benefit period co-insurance for
outpatient drugs Actual billed $0
101st day and after of a benefit period and inpatient charges up to the
Blood respite care co-insurance
First three pints amount
Additional amounts

Hospice Care
Available as long as your doctor certifies
you are terminally ill and you elect to
receive these services

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 7

Medicare Supplement Core: Medex Core (continued)

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

Services Medicare Pays Plan Pays You Pay

Medical expenses in or out of the hospital $203 (Part B
and outpatient hospital treatment, such as physician’s deductible)
services, inpatient and outpatient $0

medical and surgical services and supplies, $203 (Part B
deductible)
physical and speech therapy, diagnostic tests, $0
$0
and durable medical equipment
$0
First $203 of Medicare-approved amounts** $0 $0 $203 (Part B
deductible)
Remainder of Medicare-approved amounts Generally 80% Generally 20% $0

Outpatient treatment for biologically based
mental disorders and other mental health disorders
(for services covered by Medicare)

First $203 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%
$0 100% of
Outpatient treatment for biologically based expenses
mental disorders and other mental health disorders $0
(for services not covered by Medicare) All Costs

Blood

First three pints

Next $203 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

8 Medex Outline of Medicare Supplement Coverage

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

Services Medicare Pays Plan Pays You Pay

Clinical Laboratory Services $0

Blood tests for diagnostic services 100% $0 $203
Special Medical Formulas Mandated by Law (Part B deductible)
Covered by Medicare $0
Balance
First $203 of Medicare-approved amounts** $0 $0

Remainder of Medicare-approved amounts 80% 20%
Not covered by Medicare $0 All allowed charges

Medicare (Parts A & B) Medicare Pays Plan Pays You Pay
100% $0
Services $0
$0
Home Health Care—Medicare-Approved Services 20% $203
Medically necessary skilled-care services (Part B deductible)
and medical supplies $0
Durable medical equipment

First $203 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

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

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 9

Medicare Supplement 1: Medex Bronze

Medicare (Part A)—Hospital Services—Per Benefit Period Medicare Pays Plan Pays You Pay

Services $1,484 $0
(Part A deductible) $0
Hospitalization* $371 a day $0
Semiprivate room and board, general hospital nursing $0
and miscellaneous services and supplies, and licensed $742 a day All Costs
mental hospital stays for biologically based mental disorders
or other mental disorders prior to the 190-day Medicare 100% of Medicare $0
lifetime maximum eligible expenses $0
$0 $0
First 60 days of a benefit period All but $1,484 $0
100% of Medicare All Costs
61st through 90th day of a benefit period All but $371 a day eligible expenses
91st day and after of a benefit period: All but $742 a day 100% of Medicare
– While using 60 lifetime reserve days eligible expenses
– Once lifetime reserve days are used:
100% of Medicare
• Additional 365 days $0 eligible expenses

• Beyond the additional 365 days $0 100% of Medicare
eligible expenses
Licensed mental hospital stays for biologically based $0
mental disorders not covered by Medicare

First 60 days of a benefit period $0

61st through 90th day of a benefit period $0
91st day and after of a benefit period:
– While using 60 lifetime reserve days $0
– Once lifetime reserve days are used:
• Additional 365 days $0
• Beyond the additional 365 days $0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

10 Medex Outline of Medicare Supplement Coverage

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

Licensed mental hospital stays not covered by Medicare
for other mental disorders

First 120 days per benefit period (at least 60 days per
calendar year) less days covered by Medicare or plan in
that calendar year

First 60 days of a benefit period $0 100% of Medicare $0
eligible expenses $0
61st through 120th day of a benefit period $0
100% of Medicare
eligible expenses

Days after 120 days per benefit period (or 60 days per $0 $0 All Costs
calendar year) less days covered by Medicare or plan in
that calendar year All approved $0 $0
Skilled Nursing Facility Care* amounts
Participating with Medicare) All but $185.50 Up to $185.50 $0
You must meet Medicare’s requirements, including having a day a day Balance
been in a hospital for at least three days and entered a $0 $10 a day All Costs
Medicare-approved facility within 30 days after having left $0 $0
the hospital

First 20 days of a benefit period

21st through 100th day of a benefit period

101st day through 365th day of a benefit period
Beyond the 365th day of a benefit period

(Not participating with Medicare)
You must meet Medicare’s requirements, including having

been in a hospital for at least three days and transferred to

the facility within 30 days after having left the hospital

1st day through 365th day of a benefit period $0 $8 a day Balance
Beyond the 365th day of a benefit period $0 $0 All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 11

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay
$0
Blood three pints $0
$0
First three pints $0 Actual billed $0
charges up
Additional amounts 100% to the
co-insurance
Hospice Care All but very limited amount
Available as long as your doctor certifies co-insurance for
outpatient drugs
you are terminally ill and you elect to and inpatient
respite care
receive these services

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will
pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

Medicare (Part B)—Medical Services—Per Calendar Year Medicare Pays Plan Pays You Pay

Services

Medical expenses in or out of the hospital and
outpatient hospital treatment, such as physician’s
services, inpatient and outpatient medical and surgical
services and supplies, physical and speech therapy,
diagnostic tests, and durable medical equipment

First $203 of Medicare-approved amounts** $0 $203 $0
(Part B deductible) $0
Remainder of Medicare-approved amounts Generally 80%
Generally 20%
Outpatient treatment for biologically based mental
disorders and other mental health disorders
(for services covered by Medicare)

First $203 of Medicare-approved amounts** $0 $203 $0
(Part B deductible) $0
Remainder of Medicare-approved amounts 80%
$0 20%
Outpatient treatment for biologically based mental
disorders and other mental health disorders 100% of expenses $0
(for services not covered by Medicare)

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

12 Medex Outline of Medicare Supplement Coverage

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

Services Medicare Pays Plan Pays You Pay
$0
Blood $0
$0
First three pints $0 All Costs $0

Next $203 of Medicare-approved amounts** $0 $203 $0
(Part B deductible) $0
Balance
Remainder of Medicare-approved amounts 80% 20%
Clinical Laboratory Services 100% $0
Blood tests for diagnostic services
Special Medical Formulas Mandated by Law
Covered by Medicare

First $203 of Medicare-approved amounts** $0 $203
(Part B deductible)

Remainder of Medicare-approved amounts 80% 20%

Not covered by Medicare $0 All allowed charges

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 13

Medicare Supplement 1: Medex Bronze (continued)

Medicare (Parts A & B) Medicare Pays Plan Pays You Pay
Services 100%
Home Health Care—Medicare-Approved Services $0 $0
Medically necessary skilled care services $0
and medical supplies 80% $203 $0
Durable medical equipment (Part B deductible) $0

First $203 of Medicare-approved amounts** 20%

Remainder of Medicare-approved amounts

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

Other Benefits—Not Covered By Medicare Medicare Pays Plan Pays You Pay
Services

Foreign Travel—Not Covered by Medicare

Only the services listed above while traveling $0 Remainder of $0
outside the United States charges (including
$0 portion normally
Outpatient Prescription Drugs—Not Covered $0 paid by Medicare)
by Medicare $0
Fitness Program—Not Covered by Medicare $0 All Costs
Weight-Loss Program—Not Covered
by Medicare $150 per All charges
calendar year after $150
$150 per All charges
calendar year after $150

14 Medex Outline of Medicare Supplement Coverage

Medicare Supplement 1A: Medex Sapphire

Medicare (Part A)—Hospital Services—Per Benefit Period Medicare Pays Plan Pays You Pay

Services $1,484 $0
(Part A deductible) $0
Hospitalization* $371 a day $0
Semiprivate room and board, general hospital nursing $0
and miscellaneous services and supplies, and licensed $742 a day All Costs
mental hospital stays for biologically based mental disorders 100% of Medicare
or other mental disorders prior to the 190-day Medicare eligible expenses
lifetime maximum $0

First 60 days of a benefit period All but $1,484

61st through 90th day of a benefit period All but $371 a day
91st day and after of a benefit period: All but $742 a day
– While using 60 lifetime reserve days
– Once lifetime reserve days are used:

• Additional 365 days $0

• Beyond the additional 365 days $0

Licensed mental hospital stays not covered by Medicare
for biologically based mental disorders

First 60 days of a benefit period $0 100% of Medicare $0
eligible expenses

61st through 90th day of a benefit period $0 100% of Medicare $0
91st day and after of a benefit period: eligible expenses
– While using 60 lifetime reserve days
– Once lifetime reserve days are used: $0 100% of Medicare $0
• Additional 365 days eligible expenses
• Beyond the additional 365 days
$0 100% of Medicare $0
eligible expenses

$0 $0 All Costs

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 15

Medicare Supplement 1A: Medex Sapphire (continued)

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

Licensed mental hospital stays not covered by Medicare
for other mental disorders

First 120 days per benefit period (at least 60 days per
calendar year) less days covered by Medicare or plan in
that calendar year

First 60 days of a benefit period $0 100% of Medicare $0
eligible expenses $0
61st through 120th day of a benefit period $0
100% of Medicare
eligible expenses

Days after 120 days per benefit period (or 60 days per $0 $0 All Costs
calendar year) less days covered by Medicare or plan in
that calendar year All approved $0 $0
amounts
Skilled Nursing Facility Care* Up to $185.50 $0
(Participating with Medicare) a day Balance
You must meet Medicare’s requirements, including having $10 a day All Costs
been in a hospital for at least three days and entered a $0
Medicare-approved facility within 30 days after having left
the hospital

First 20 days of a benefit period

21st through 100th day of a benefit period All but $185.50
a day

101st day and after of a benefit period $0

Beyond the 365th day of a benefit period $0

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

16 Medex Outline of Medicare Supplement Coverage

Medicare (Part A)—Hospital Services—Per Benefit Period (continued)

Services Medicare Pays Plan Pays You Pay

(Not participating with Medicare) You must meet $8 a day Balance
Medicare’s requirements, including having been in a $0 All costs
$0
hospital for at least three days and transferred to the Three pints $0
$0 $0
facility within 30 days after having left the hospital Actual billed
charges up to the
1st day through 365th day of a benefit period $0 co-insurance
amount
Beyond the 365th day of a benefit period $0

Blood

First three pints $0

Additional amounts 100%

Hospice Care All but very limited
Available as long as your doctor certifies co-insurance for
outpatient drugs
you are terminally ill and you elect to and inpatient
respite care
receive these services

NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay
whatever amount Medicare would have paid for up to an additional 365 days as provided in the Policy’s “Core Benefits.”
During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges
and the amount Medicare would have paid.

The Deductible and Co-insurance amounts listed above reflect the 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

bluecrossma.com/medicare 17

Medicare Supplement 1A: Medex Sapphire (continued)

Medicare (Part B)—Medical Services—Per Calendar Year Medicare Pays Plan Pays You Pay

Services $0 $203
Generally 20% (Part B deductible)
Medical expenses in or out of the hospital and outpatient $0
hospital treatment, such as physician’s services, inpatient $0
and outpatient medical and surgical services and supplies, 20% $203
physical and speech therapy, diagnostic tests, and durable 100% (Part B deductible)
medical equipment of expenses $0
All Costs $0
First $203 of Medicare-approved amounts** $0 $0
20% $0
Remainder of Medicare-approved amounts Generally 80% $203
Outpatient treatment for biologically based mental $0 (Part B deductible)
disorders and other mental health disorders $0
(for services covered by Medicare)

First $203 of Medicare-approved amounts**

Remainder of Medicare-approved amounts 80%
$0
Outpatient treatment for biologically based mental
disorders and other mental health disorders $0
(for services not covered by Medicare)
Blood

First three pints

Next $203 of Medicare-approved amounts** $0

Remainder of Medicare-approved amounts 80%

**Once you have been billed $203 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 2021 Medicare Deductible and Co-insurance amounts.
These amounts are subject to change each year.

18 Medex Outline of Medicare Supplement Coverage