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MEDICARE

Medicare Supplement plan documents

All of your Blue Shield of California Medicare Supplement plan documents, including the multi-language notice, are listed on this page.

Plan documents can help you understand your plan.

Evidence of Coverage (EOC) describes in detail the health care benefits your plan covers.

Summary of Benefits (SOB) is a simplified document that summarizes your health benefits and coverage.

New or Innovative Benefits Form details specific plan benefits, copayments, and coinsurance amounts for plans with extra benefits.

You can also log into your online account and visit the Benefits section on your member dashboard.

If you want help understanding your documents, please call Blue Shield of California Medicare Supplement plan Customer Care at (800) 248-2341 [TTY: 711], 8 a.m. to 8 p.m., seven days a week.

Medicare Supplement plans

  • Medicare Supplement Summary of Benefits

    Summary of Benefits (SOB) English (PDF, 1.1 MB)
    Summary of Benefits (SOB) Español  (PDF, 1.1 MB)
    Summary of Benefits (SOB) Chinese (PDF, 1.3 MB)
    Summary of Benefits (SOB) Vietnamese (PDF, 3.2 MB)

  • Plan A

    Evidence of Coverage (EOC) English (PDF, 869 KB)

  • Plan N

    Evidence of Coverage (EOC) English (PDF, 872 KB)

  • Plan G

    Evidence of Coverage (EOC) English (PDF, 883 KB)

  • Plan G Extra²

    Evidence of Coverage (EOC) English (PDF, 965 KB)

    Plan G Extra Notice of New or Innovative Benefits Form English (PDF, 169 KB)

  • Plan F Extra¹ ²

    Evidence of Coverage (EOC) English (PDF, 967 KB)

    Plan F Extra Notice of New or Innovative Benefits Form English (PDF, 165 KB)

  • Plan G Inspire² ³

    Evidence of Coverage (EOC) English (PDF, 981 KB)

    Plan G Inspire Notice of New or Innovative Benefits Form English (PDF, 160 KB)

Medicare Supplement Dental plans

  • Dental PPO 1000

    Evidence of Coverage (EOC) English (PDF, 876 KB)

  • Dental PPO 1500

    Evidence of Coverage (EOC) English (PDF, 875 KB)

Language assistance and Nondiscrimination Notice

Please refer to our list of compatible browsers when downloading or viewing PDF documents.

1. Plan F Extra is only available to applicants who attained age 65 before January 1, 2020, or first became eligible for Medicare benefits due to disability before January 1, 2020.

2. Please note, the extra benefits are embedded in your medical benefits under your Medicare Supplement Plan. This separate rate is part of your Total Amount Due.

3. Plan G Inspire is only available in the following counties: Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Kings, Lake, Lassen, Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo and Yuba.

Page last updated: 10/1/2022

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