BCBSMA Medex Core Sales Kit Book 12/01/2018

02

Resources



Join us for a FREE informational
meeting in your neighborhood.

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

Get answers to your questions about Medicare and supplemental insurance
coverage, and hear what other people who are in your shoes are asking us,
at one of our informational meetings. Choose one of the three seminar
options below:

• All Medicare Plan Options—A detailed look • Medicare Supplement and Prescription Drug
at how Medicare works and all of our extensive Plans—Learn how a Supplement (Medigap)
plan options plan can help pay for costs not covered
by Original Medicare, and understand the
• Medicare Advantage Only—See how this one importance of adding a Prescription Drug plan
simple plan covers your medical, hospital, and
medical costs with a low monthly premium

Call 1-800-262-BLUE (2583)

(TTY/TDD 711) 7:00 a.m.–12:00 a.m., Seven days a week (excluding holidays).

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. Visit our website
NOW at bluecrossma.com/seminars to see the latest list.

All Medicare Plan Options

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

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

Burlington 12/04/2018 10:30 AM-12:30 PM Marriott 1 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
Waltham 01/03/2019 10:30 AM-12:30 PM Embassy Suites 550 Winter Street

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

All Medicare Plan Options

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

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

Plymouth 01/08/2019 10:30 AM-12:30 PM John Carver Inn 25 Summer Street
Peabody 01/10/2019 10:30 AM-12:30 PM Marriott 8A Centennial Drive
Randolph 01/16/2019 10:30 AM-12:30 PM Lombardo's 6 Billings Street
Natick 01/17/2019 10:30 AM-12:30 PM Crowne Plaza 1360 Worcester Street
Fall River 01/23/2019 10:30 AM-12:30 PM McGovern's Family Restaurant 310 Shove Street
Chelmsford 01/24/2019 10:30 AM-12:30 PM Radisson 10 Independence Drive
Hyannis 02/06/2019 10:30 AM-12:30 PM Resort and Conference Center 35 Scudder Avenue
Leominster 02/07/2019 10:30 AM-12:30 PM DoubleTree by Hilton 99 Erdman Way
Brockton 02/12/2019 10:30 AM-12:30 PM Holiday Inn Express 405 Westgate Drive
Chelmsford 02/13/2019 10:30 AM-12:30 PM Radisson 10 Independence Drive
Brookline 02/27/2019 10:30 AM-12:30 PM Courtyard by Marriott 40 Webster Street
Randolph 02/28/2019 10:30 AM-12:30 PM Lombardo's 6 Billings Street

Medicare Advantage Only

Attend this seminar if you prefer a low monthly premium and the simplicity of a single plan to
cover your medical, hospital, and prescription costs. You’ll learn about how the plan works, as
well as additional benefits not included in Original Medicare, such as vision, hearing, dental,
wellness programs, and more.

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

Hyde Park 01/18/2019 10:30 AM-12:00 PM Iora Primary Care 912 River Street
Medford 01/31/2019 10:30 AM-12:00 PM Iora Primary Care 287 Middlesex Avenue
Hyde Park 02/15/2019 10:30 AM-12:00 PM Iora Primary Care 912 River Street
Medford 02/21/2019 10:30 AM-12:00 PM Iora Primary Care 287 Middlesex Avenue

Medicare Supplement and Prescription Drug Plans

If you have Original Medicare but need more coverage, you may want to consider a Medicare
Supplement and Prescription Drug (PDP) plan. By attending this seminar, you’ll learn how Medicare
Supplement plans and Prescription Drug Plans (PDPs) differ from Medicare Advantage Plans and
help pay the costs that Original Medicare doesn’t cover.

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

Waltham 01/03/2019 1:30 PM-2:30 PM Embassy Suites 550 Winter Street

Plymouth 01/08/2019 1:30 PM-2:30 PM John Carver Inn 25 Summer Street

Peabody 01/10/2019 1:30 PM-2:30 PM Marriott 8A Centennial Drive

Continued

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

Medicare Supplement and Prescription Drug Plans

If you have Original Medicare but need more coverage, you may want to consider a Medicare
Supplement and Prescription Drug (PDP) plan. By attending this seminar, you’ll learn how Medicare
Supplement plans and Prescription Drug Plans (PDPs) differ from Medicare Advantage Plans and
help pay the costs that Original Medicare doesn’t cover.

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

Randolph 01/16/2019 1:30 PM-2:30 PM Lombardo's 6 Billings Street
Natick 01/17/2019 1:30 PM-2:30 PM Crowne Plaza 1360 Worcester Street
Chelmsford 01/24/2019 1:30 PM-2:30 PM Radisson 10 Independence Drive
Hyannis 02/06/2019 1:30 PM-2:30 PM Resort and Conference Center 35 Scudder Avenue
Leominster 02/07/2019 1:30 PM-2:30 PM DoubleTree by Hilton 99 Erdman Way
Brockton 02/12/2019 1:30 PM-2:30 PM Holiday Inn Express 405 Westgate Drive
Chelmsford 02/13/2019 1:30 PM-2:30 PM Radisson 10 Independence Drive
Brookline 02/27/2019 1:30 PM-2:30 PM Courtyard by Marriott 40 Webster Street
Randolph 02/28/2019 1:30 PM-2:30 PM Lombardo's 6 Billings Street

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.,seven days a week.
A Blue Cross Blue Shield of Massachusetts representative will be present to discuss our
Medicare HMO, PPO, PDP, and Medicare Supplement plan options and benefits, answer your
questions, and explain how to enroll. Blue Cross Blue Shield of Massachusetts is an HMO and
PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts
depends on contract renewal.
Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc.,
Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are
the legal entities that 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.

188947-3M 55-1758A (11/18)



Medex®´

It Pays to Stay Blue

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

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

PLAN FULL RATE* FIRST YEAR: SECOND YEAR: THIRD YEAR:
15% DISCOUNT* 10% DISCOUNT* 5% DISCOUNT*
Medex Bronze $197.74
Medex Core $98.42 $168.08 $177.97 $187.85

$83.66 $88.58 $93.50

* Rates effective January 1, 2019 to December 31, 2019

Member Perks and Wellness Benefits

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

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

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

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

• Pay your premiums online with eBill.

For more www.bluecrossma.com/medicare
information:
1-800-678-2265 (TTY: 711)
Monday through Friday, 8:00 a.m. to 6:00 p.m.

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

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-800-200-4255 (TTY: 711).
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis.
Ligue para 1-800-200-4255 (TTY: 711).
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
®, SM Registered Marks and Service Marks of the Blue Cross and Blue Shield Association. ®´, SM´ Registered
Marks and Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., © 2018 Blue Cross and Blue Shield
of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
188553

99-0290-19 (8/18)

Direct-Billed Medex®´ Members

Vision and Hearing Benefits

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

Good eyesight and hearing are so important to your quality of life, but glasses and hearing
aids aren’t covered by Medicare. The Medex Vision and Hearing benefit plan covers these
benefits so you can more easily afford the glasses and hearing aids you need—all for one
low price of $3.04/month.

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

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

• Starting in 2019—Routine vision exams: • Routine hearing exams: Reimbursement for
Covers one routine vision exam every calendar one routine hearing exam every two calendar
year to determine if you need corrective lenses. years, when the exam is furnished by a Blue
Any Blue Cross and Blue Shield participating Cross and Blue Shield participating physician
physician or optometrist, or any licensed or audiologist, or any licensed physician
ophthalmologist or optometrist outside of outside of Massachusetts.
Massachusetts can perform your exam.
• Hearing aids: Reimbursement for up to
• Starting in 2019—Eyeglasses or contact $200 every two calendar years for one
lenses: Covers up to $150 every calendar hearing aid (or one set of binaural hearing
year for one set of frames and prescription aids) from a licensed hearing aid dealer.
lenses or contact lenses (in place of This $200 benefit payment includes costs
eyeglasses) from any licensed vision for: dispensing fees, acquisition costs,
care supplier. This $150 benefit payment batteries, and hearing aid repairs.
includes costs for measurement, fitting, and
adjustments. Note: No coverage is provided for costs to replace lost
hearing aids, unless you have gone more than two
Note: No coverage is provided for amounts more than calendar years without receiving a hearing aid benefit.
$150 every calendar year; non-prescription lenses;
sunglasses that do not require a prescription; safety
glasses; replacement of lost or broken frames or lenses;
and special procedures, such as vision training and
subnormal vision aids and similar procedures and devices.

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

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

Yes. At the time you buy your glasses, Effective January 1, 2019 to December 31,
contacts, or hearing aid(s), or at a later date, 2019, the additional benefit coverage cost is
the provider may ask you to pay all charges. If $3.04 per month. This amount will be added
this happens, you will need to file a claim with to your direct-billed Medex premium.
Blue Cross Blue Shield of Massachusetts for
repayment of these covered services. Simply
complete a claim form and send it with your
original itemized bill(s). If you need a claim
form or would like help completing your form,
call Member Service at 1-800-258-2226,
TTY: 711, Monday through Friday, 8:00 a.m.
to 6:00 p.m. ET.

How do I apply?

The easiest way to enroll is by phone.
Phone: 1-800-678-2265, TTY: 711
Monday–Friday | 8 a.m.–6 p.m.

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

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

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

® Registered Marks of the Blue Cross and Blue Shield Association. ®´ Registered Marks of Blue Cross and Blue

Shield of Massachusetts. © 2018 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue

Shield of Massachusetts HMO Blue, Inc.

188557 55-0435-18 (09/18)

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.



03

Disclosures



Nondiscrimination Notice

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

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

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

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

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

189008M 55-2067 (8/18)



Translation Resources
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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)

04

Enrollment



Medex®´

Application For
Direct Billed Medex®´

Directions You are eligible to apply for
a Medex plan if you meet all
• Please print clearly. of the following requirements:

• Please carefully read and answer all • You are a resident of Massachusetts
questions. Incomplete applications will and you actually live in Massachusetts.
not be accepted. Please keep a copy
of the application for your records. • You are eligible for Medicare Part A
and Medicare Part B and enrolled in
• Please do not send us your application Medicare Part B.
until you have received your red, white,
and blue Medicare card. • If you are under age 65, you qualify for
Medicare coverage because of disability
• Do not send money with this application. except for end-stage renal disease.
You will receive a bill when payment is due.
Note: If you are covered by Medicaid, you may
• Please complete and return the white copy to: or may not be eligible to enroll in Direct Billed
Medex. See paragraph (f) of the “Important
Direct Sales Information” section of this application form.
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-1753

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

• To enroll by phone, please call
1-800-678-2265.

• Medex premium rates and benefits are
explained in the booklet you received
with this application. If you need more
information or assistance, call us at
1-800-678-2265.

• For all other questions, contact:
Medex Member Service:
1-800-258-2226
TTY: 711

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

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

q Medex Core (Medicare Supplement Core)
q Medex Core with Vision and Hearing Benefit

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 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.
188573M 55-0936-19 (08/18)

3

Medex®´

Application For
Direct Billed Medex®´

Directions You are eligible to apply for
a Medex plan if you meet all
• Please print clearly. of the following requirements:

• Please carefully read and answer all • You are a resident of Massachusetts
questions. Incomplete applications will and you actually live in Massachusetts.
not be accepted. Please keep a copy
of the application for your records. • You are eligible for Medicare Part A
and Medicare Part B and enrolled in
• Please do not send us your application Medicare Part B.
until you have received your red, white,
and blue Medicare card. • If you are under age 65, you qualify for
Medicare coverage because of disability
• Do not send money with this application. except for end-stage renal disease.
You will receive a bill when payment is due.
Note: If you are covered by Medicaid, you may
• Please complete and return the white copy to: or may not be eligible to enroll in Direct Billed
Medex. See paragraph (f) of the “Important
Direct Sales Information” section of this application form.
Blue Cross Blue Shield of Massachusetts
One Enterprise Drive
Quincy, MA 02171-1753

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

• To enroll by phone, please call
1-800-678-2265.

• Medex premium rates and benefits are
explained in the booklet you received
with this application. If you need more
information or assistance, call us at
1-800-678-2265.

• For all other questions, contact:
Medex Member Service:
1-800-258-2226
TTY: 711

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

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

q Medex Core (Medicare Supplement Core)
q Medex Core with Vision and Hearing Benefit

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 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.
188573M 55-0936-19 (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.

188795M (12/(0081//1188))