Help Medicare Supplement plan clients

Here are PDF resources that can help you manage your existing Blue Shield of California Medicare Supplement plan clients in our plans for Medicare beneficiaries.

Including:

  • Evidence of Coverage documents
  • Open and closed plan rate sheets
  • Dental PPO enrollment form
  • Transfer and other forms
  • Over-the-counter (OTC) items catalog

Please note:

  • All provider directories and materials you need for enrollment are located on the Arvato Storefront

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Evidence of Coverage for open plans

Get complete descriptions of our open Medicare Supplement plans.

Plan A (PDF, 224 KB)
Plan F Extra (PDF, 817 KB)
Plan G (PDF, 232 KB)
Plan G Extra (PDF, 296 KB)
Plan N (PDF, 230 KB)

Evidence of Coverage for 2010 Standardized Closed Plans (closed 9/30/2019)

Get complete descriptions of our closed Medicare Supplement plans effective 10/1/2019.

Plan C (PDF, 206 KB)
Plan D (PDF, 206 KB)
Plan F (PDF, 208 KB)
High Deductible Plan F (PDF, 206 KB)
Plan K (PDF, 206 KB)

Evidence of Coverage for Standardized and Pre-Standardized Closed Plans (closed prior to 5/31/2010) and specialty closed plans

Get complete descriptions of our closed Medicare Supplement plans.

Plan A (pre June 2010) (PDF, 206 KB)
Plan B (pre June 2010) (PDF, 206 KB)
Plan C (pre June 2010) (PDF, 208 KB)
Plan D (pre June 2010) (PDF, 206 KB)
Plan F (pre June 2010) (PDF, 206 KB)
Plan G (pre June 2010) (PDF, 133 KB)
Plan J (pre June 2010) (PDF, 134 KB)
Plan K (pre June 2010) (PDF, 139 KB)
Plan H Standard (PDF, 140 KB)
Plan H Plus Rx (PDF, 141 KB)
Plan I Standard (PDF, 214 KB)
Plan I Plus Rx (PDF, 146 KB)
Coronet Major Medicare (PDF, 135 KB)
Coronet Senior Standard (PDF, 133 KB)
Coronet Senior Plus Rx (PDF, 133 KB)
Golden Coronet Senior Standard (PDF, 133 KB)
Golden Coronet Senior Plus Rx (PDF, 134 KB)
Preferred Senior (PDF, 138 KB)
Specialty Duo Dental Policy* (PDF, 873 KB)
Specialty Duo Vision Policy* (PDF, 1.4 MB)

* Underwritten by Blue Shield Life and Health

Closed Plan G Inspire materials

Evidence of Coverage for Dental PPO plans

Dental PPO 1000 (PDF, 875 KB)
Dental PPO 1500 (PDF, 617 KB)

Innovative plan notices

Plan G Extra Notice of New or Innovative Benefits Form English (PDF, 168 KB)
Plan F Extra Notice of New or Innovative Benefits Form English (PDF, 224 KB)

Open medical plan rates and specialty rates

Closed medical plan rates and specialty rates

Medicare Supplement plan dental PPO flyer and enrollment form

Dental PPO flyer English (PDF, 198 KB)
Spanish (PDF, 237 KB)
Dental PPO enrollment form English (PDF, 51 KB)
Spanish (PDF, 46 KB)

Transfer forms and other forms

The transfer application is used when a current Blue Shield of California Medicare Supplement plan member wants to transfer to a Medicare Supplement plan of equal or lesser value during their Open Enrollment Period with guaranteed acceptance, enroll into the Household Savings Program under your current plan, or enroll in a dental plan. Please note, to help with our paperless initiative the transfer application is now only available for download. There are two copies built into the document, one for Blue Shield and one for the member.

Please note, a current Blue Shield Medicare Supplement plan member interested in applying for a richer benefit plan or an equal or lesser plan outside the Open Enrollment Period must fill out the Medicare Supplement plan Enrollment Application and complete the Statement of Health.

If a current Blue Shield Medicare Supplement plan member is interested in transferring to a plan with equal or lesser benefits, please have them work with you, their broker, for assistance in completing the transfer application.

Medicare Supplement Plan Transfer Form English (PDF, 283 KB)
Spanish (PDF, 163 KB)
Chinese (Traditional) (PDF, 293 KB)
Korean (PDF, 219 KB)
Vietnamese (PDF, 215 KB)
Vision claim form English (PDF, 73 KB)
Dentist nomination form English (PDF, 238 KB)

2024 Over-The-Counter (OTC) items catalog

2024 Medicare Supplement plans with the OTC Items Benefit:

Medicare Supplemental Plan G Extra

Medicare Supplemental Plan G Inspire

OTC Catalog English (PDF, 173 KB)
Spanish (PDF, 145 KB)
Chinese (Traditional) (PDF, 285 KB)
Korean (PDF, 186 KB)
Vietnamese (PDF, 287 KB)

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Page last updated: 4/1/2024

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