Plan Information

 

Find out what's covered under Medicare, learn what payment options you have, get important plan document, and more.

Plan Documents

Find everything you need in our collection of Massachusetts Medicare plan forms and documents.

Select from the menu below:

Summary of Benefits/Outlines of Coverage

2018 Medex®' Outline of Coverage

2018 Medex Choice: Solution to Supplement Medicare Brochure

2018 Medex Freedom of Choice

2018 Medicare HMOSM Blue ValueRx/FlexRx/PlusRx Summary of Benefits

2018 Dental Blue 65 Outline of Coverage

2018 Medicare PPO BlueSM SaverRx/ValueRx/PlusRx Summary of Benefits


Evidence of Coverage (EOC)

2018 Medicare HMO Blue PlusRx EOC

2018 Medicare HMO Blue FlexRx EOC

2018 Medicare HMO Blue ValueRx EOC

2018 Medicare PPO Blue PlusRx EOC

2018 Medicare PPO Blue ValueRx EOC

2018 Medicare PPO Blue SaverRx EOC


Annual Notice of Changes (ANOC)

2018 Medicare HMO Blue PlusRx ANOC - All Counties

2018 Medicare HMO Blue ValueRx ANOC - Worcester County

2018 Medicare HMO Blue ValueRx ANOC - Non-Worcester Counties

2018 Medicare HMO Blue FlexRx ANOC - Worcester County

2018 Medicare HMO Blue FlexRx ANOC - Non-Worcester Counties

2018 Medicare PPO Blue PlusRx ANOC - All Counties

2018 Medicare PPO Blue ValueRx ANOC - Worcester County

2018 Medicare PPO Blue ValueRx ANOC - Non-Worcester Counties

2018 Medicare PPO Blue SaverRx ANOC - All Counties


Enrollment Applications

2018 Medex Bronze and Medex Core Application

2018 Medex Choice Application

2018 Medicare HMO Blue ValueRx/FlexRx/PlusRx Enrollment Form

2018 Medicare PPO Blue SaverRx/ValueRx/PlusRx Enrollment Form

2018 Dental Blue 65 Preventive/Basic/Premier Application

2018 Blue MedicareRx Application


Medicare Advantage

2018 LIS Premium Summary Chart

2018 Medicare HMO Blue Star Rating

2018 Medicare PPO Blue Star Rating

Medicare Advantage Member's Designation of a Personal Representative Form

Value-Based Insurance Design (VBID) Drug List

Medicare Advantage Subscriber Claim Form

Medicare Advantage Appointment of a Representative Form


Prescription Coverage

2018 Medicare Advantage Prescription Claim Form

Express Scripts Home Delivery Form 

2018 List of Medicare Advantage Network Pharmacies

2018 Medicare HMO Blue ValueRx/FlexRx/PlusRx Formulary
Updated 10/01/2017

2018 Medicare PPO Blue SaverRx/ValueRx/PlusRx Formulary
Updated 10/01/2017

2018 Medicare Advantage Group Formulary
Updated 10/01/2017

2018 Request for Medicare Prescription Drug Coverage Determination 

2018 Medicare Advantage Prior Authorization Criteria

2018 Medicare Advantage Step Therapy Criteria 
Updated 10/01/2017

2018 Request for Redetermination of Medicare Prescription Drug Denial 

2018 Medicare Advantage Vaccine Claim Form


Fitness and Weight Loss Forms

2018 Medex Fitness Benefit Form

2018 Medex Weight Loss Benefit Form

2018 Medicare Advantage Fitness Benefit Form

2018 Medicare Advantage Weight Loss Benefit Form


Medex

Medex Choice Referral Fact Sheet

Medex Subscriber Claim Form

Medex Payment Options


Privacy, Nondiscrimination, and Translation Resources

Commitment to Confidentiality

Nondiscrimination Disclosure

Language Translation Services

Debit Authorization

With permission, we’ll automatically deduct monthly payments from your bank account. 

Medicare Advantage members: download this Debit Authorization form.

Medex members: Sign up here.

eBilling

Log in to pay bills quickly and securely.

Note: Enter your name as it is on your member ID card.

Register today

Online Banking

Add us as a payee on your bank’s bill pay feature. You’ll need the following information:

  • Member ID Number

  • Blue Cross Blue Shield of Massachusetts PO Box 371314

 

National Coverage Determinations

Know your rights, and learn exactly what is covered under Medicare according to the latest determinations.

April 13, 2015

Medicare Advantage plans shall cover screening for HIV when ordered by the beneficiary's physician or practitioner within the context of a health care setting and performed by an eligible Medicare provider or supplier for these services, for beneficiaries who meet certain conditions. A list of conditions and the complete NCD announcement can be found at cms.gov

February 5, 2015

Medicare covers lung cancer screening counseling and shared decision making, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT) as an additional preventive service benefit under the Medicare program if eligibility criteria is met.

June 2, 2014

Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV) that affects the liver. HCV is spread by blood-to-blood contact. A newly-infected individual goes through an acute phase where there may or may not be symptoms of infection such as abdominal pain, fatigue, or nausea. A few individuals are able to clear the virus after an acute infection but most will go on to develop chronic HCV infection. The most serious risks from chronic HCV infection are cirrhosis, liver failure, and liver cancer. Currently Medicare does not cover HCV screening but will cover testing for individuals with blood work showing elevated liver enzymes or prior to a liver transplant. The new NCD expands coverage for HCV screening in individuals considered by their primary care provider as "high risk." High risk individuals include persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992. Illicit drug users are covered for repeat screening annually if they continue to use. A single screening test is covered for adults who do not meet the high risk criteria but who were born between 1945 and 1965.

May 30, 2014

The Department of Health and Human Services Departmental Appeals Board – Appellate Division, issued a ruling (the "HHS Decision") on May 30, 2014 holding that the existing "National Coverage Determination" (NCD) that prohibited transsexual surgery dating from 1981 is "no longer a valid basis for denying claims for Medicare coverage of transsexual surgery, and local coverage determinations (LCDs) used to adjudicate such claims may not rely on the provisions of the NCD." NCD 140.3, Transsexual Surgery; Docket No. A-13-87, Decision No. 2576, May 30, 2014). Since the NCD is no longer valid, effective May 30, 2014, its provisions are no longer a valid basis for denying claims for Medicare coverage of transsexual surgery, and local coverage determinations (LCDs) used to adjudicate such claims may not rely on the provisions of NCD 140.3. The decision does not bar CMS or its contractors from denying individual claims for payment for transsexual surgery for other reasons permitted by law. Nor does the decision address treatments for transsexualism other than transsexual surgery. According to the HHS Decision, "transsexual surgery," also known as "sex reassignment surgery" or "intersex surgery," is the culmination of a series of procedures designed to change the anatomy of transsexuals to conform to their gender identity. The HHS Decision notes that transsexuals are persons with an overwhelming desire to change anatomic sex because of their fixed conviction that they are members of the opposite sex.

April 3, 2013

Age-related macular degeneration is a condition, usually associated with advancing age, that results in a deterioration of eyesight, although it rarely results in total blindness. One form of this condition, known as wet macular degeneration, is due to an abnormal growth of blood vessels in the part of the eye that accounts for the majority of our visual acuity, i.e., sharpness of our vision. There are grades of severity of the abnormal growth of these blood vessels. Wet macular degeneration is typically treated by injecting a drug into the bloodstream, followed by shining a laser at the part of the eye that is degenerating. This treatment destroys the abnormal blood vessels and prevents the ongoing deterioration of vision. Until now, the laser treatment was covered for only the most severe grade of blood vessel growth. The new NCD expands coverage to the less severe grades as well. This is the major change in the new NCD. In addition, the old NCD required that the initial diagnosis and monthly follow up after treatments be conducted using a test called fluorescein angiography, which involves injecting a dye into the bloodstream that fluoresces and taking pictures of the back of the eye using a special camera. The new NCD allows for the use of a different test to follow the results of treatment. This test is known as optical coherence tomography. It essentially uses a sophisticated microscope to look at the back of the eye and does not require any injections into the bloodstream.

March 8, 2013

This revised NCD indicates that Medicare will cover the use of special proteins that are extracted from a patient's own blood to promote healing in three types of wounds: Non-healing wounds in patients with diabetes Non-healing wounds in patients with disease of the veins in the legs Non-healing wounds caused by pressure from lying in one position for too long Coverage is only provided when the treatments with these special proteins for the above indications are given as part of a clinical research study to determine whether the proteins in fact do promote healing of these wounds.

June 27, 2012

Medicare contractors may cover a weight-reduction surgical procedure called Laparoscopic Sleeve Gastrostomy (LSG). This will be in addition to the coverage for Bariatric Surgery for the treatment of morbid obesity, as defined by Medicare.

June 21, 2012

Medicare covers liver transplantation for patients with certain malignancies in carefully selected cases.

June 8, 2012

Medicare will only allow coverage of Transcutaneous Electrical Nerve Stimulators (TENS) for Chronic Low Back Pain (CLBP) under certain conditions.

May 1, 2012

Medicare covers Transcatheter Aortic Valve Replacement (TAVR - a new technology for use in treating certain patients with aortic stenosis) under certain conditions.

April 30, 2012

CMS covers extracorporeal photopheresis for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation if it is a part of a clinical research study.

November 29, 2011

Medicare covers certain screenings and counseling for obesity.

November 8, 2011

Medicare covers intensive behavioral therapy for cardiovascular disease (CVD).

November 8, 2011

Medicare covers screening for Sexually Transmitted Infections (STI) and high intensity behavioral counseling to prevent STI.

October 14, 2011

Medicare covers certain screenings for depression in adults.

October 14, 2011

Medicare covers certain screenings & behavioral counseling interventions in primary care to reduce alcohol misuse.

July 7, 2011

Medicare covers Magnetic Resonance Imaging (MRI) with FDA Approved implanted permanent pacemaker.

June 30, 2011

Medicare covers autologous cellular immunotherapy treatment with sipuleuce-T PROVENGE®.

Ending Your Membership

How to Disenroll from your Medicare Advantage plan

You may end your membership in our plan only during certain times of the year, known as enrollment periods*.

You can cancel your plan during:

  • The Annual Enrollment Period (October 15 to December 7 of each year).

  • The Annual Medicare Advantage Disenrollment Period (January 1 to February 14 of each year).

*In certain situations, you may also be eligible to leave at other times of the year.

Reasons for ending your membership:

Ending your membership in our plan may be voluntary or involuntary :

  • You might leave our plan because you want to leave.

  • There are only certain times during the year, or certain situations, when you may voluntarily end your membership. Chapter 10, Section 2 in the Evidence of Coverage tells you when you can end your membership in the plan.

  • The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. Chapter 10, Section 3 in the Evidence of Coverage tells you how to end your membership in each situation.

How to end your membership

Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods. However, if you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan. 

There are two ways you can ask to be disenrolled:

  1. You can make a request in writing to us. Contact Member Service if you need more information on how to do this. (See number below).
  2. You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Note: If you discontinue your Medicare prescription drug coverage, and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. See Chapter 6, Section 9 of your Evidence of Coverage for more information about the late enrollment penalty.

Instances when we end your membership

There are certain situations where we must end your membership in the plan. A few common examples include:

  • If you don't stay continuously enrolled in Medicare Part A and Part B.

  • If you move out of our service area.

For a complete list of situations where we must end your membership in the plan, see Chapter 10, Section 5 of your Evidence of Coverage.

If you're leaving our plan, you must continue to get your medical care and prescription drugs through our plan until your membership ends.

If you leave our plan, it may take time before your membership ends and your new Medicare coverage goes into effect. During this time, you must continue to get your medical care and prescription drugs through our plan.

  • You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends.

  • Usually, your prescription drugs are only covered if they're filled at a network pharmacy or through our mail-order pharmacy services.

  • If you're hospitalized on the day that your membership ends, your hospital stay will usually be covered by our plan until you're discharged (even if you're discharged after your new health coverage begins).

Questions

If you have any questions or would like more information on when you can end your membership:

  • Call Member Service at 1-800-200-4255 (TTY: 711), as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

  • You can find the information in the Medicare & You Handbook. Download a copy here Medicare website. Or, you can order a printed copy by calling Medicare at the number below.

  • Call Medicare directly at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Quality Assurance

Learn how we make sure your care and coverage meets the highest quality standards.

Primary Care Incentives and Hospital Quality Improvement

Our Primary Care Physician Incentive Plan and Hospital Quality Improvement Plan allow both providers and hospitals to participate in an incentive program that rewards them for meeting certain nationally-recognized quality standards and patient safety goals. Doctors must choose to participate in this program, and you can check to see if your physician group participates by using our Find A Doctor.

 

Quality Improvement Initiatives

Per our CMS contract, annually we implement new Quality Initiatives that will help improve how members manage their care and health. One of the initiatives we are proud to promote is our Case Management Program—our solution for members managing complex health conditions. If you’re enrolled in this program, a registered nurse case manager will call you to:

  • Assess your health needs

  • Provide education about your symptoms, condition, and medication

  • Help you follow your doctor’s treatment plan

  • Collaborate with you to develop health care goals

  • Help you develop self-management skills

  • Collaborate and coordinate care with your doctors

  • Inform you about community resources

  • Assist you in understanding your health plan benefits

Learn more about Care Management Program

Chronic Condition Management

Our Chronic Condition Management program is a voluntary service offered at no cost to members managing one or more chronic health conditions. This program is designed to help members with the day-to-day management of conditions such as coronary artery disease, diabetes, and other chronic conditions. If you're invited to participate, you have the right to decline, but we recommend you take full advantage of the assistance the program can provide.

This information isn't a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

 

Fraud Hotline

If you suspect fraud—an intentional misrepresentation or deception that an individual or entity makes knowing the representation could result in an unauthorized benefit or payment—please call Blue Cross Blue Shield of Massachusetts' Fraud Hotline at 1-800-992-4100(TTY: 711). You can call 24 hours a day, 7 days a week. To learn more about how to protect yourself and others, read the Fraud Protection flyer from the Centers for Medicare & Medicaid Services.

Disaster Readiness

Blue Cross Blue Shield of Massachusetts is committed to excellence in the event of a disaster. To learn more Disaster Readiness.