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Medicare Supplement Plan Documents

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

Plan documents can help you understand the plan.

Evidence of Coverage (EOC) describes in detail the healthcare benefits the plan covers.
Summary of Benefits (SOB) is a simplified document that summarizes the plans' health benefits and coverage.
New or Innovative Benefits Form details specific plan benefits, copays, and coinsurance amounts for plans with extra benefits.

Medicare Supplement plans

Medicare Supplement Summary of Benefits

Summary of Benefits (SOB) English (PDF, 1.6 MB)
Summary of Benefits (SOB) Español (PDF, 707 MB)
Summary of Benefits (SOB) Chinese (PDF, 602 KB)

Plan A

Evidence of Coverage (EOC) English (PDF, 691 KB)

Plan N

Evidence of Coverage (EOC) English (PDF, 733 KB)

Plan G

Evidence of Coverage (EOC) English (PDF, 690 KB)

Plan G Extra²

Evidence of Coverage (EOC) English (PDF, 937 KB)

Plan G Extra Notice of New or Innovative Benefits Form English (PDF, 158 KB)

Plan F Extra¹ ²

Evidence of Coverage (EOC) English (PDF, 948 KB)

Plan F Extra Notice of New or Innovative Benefits Form English (PDF, 149 KB)

Medicare Supplement Dental plans

Dental PPO 1000

Evidence of Coverage (EOC) English (PDF, 2.3 MB)

Dental PPO 1500

Evidence of Coverage (EOC) English (PDF, 610 KB)

Language assistance and nondiscrimination notice

Medicare Supplement language assistance and nondiscrimination notice English (PDF, 695 KB)

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

Members, 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 Service at (800) 248-2341 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.

1. Plan F Extra is only available to applicants who reached 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.

Page last updated: 12/30/2024

*Free digital copy with no obligation to enroll.

† Blue Shield Medicare Advisers are available April 1 through September 30: 8 a.m. to 8 p.m., weekdays and October 1 through March 31: 8 a.m. to 8 p.m., seven days a week.

California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California 601 12th Street, Oakland, CA 94607.

For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.

Nondiscrimination notice

The company complies with applicable state laws and federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, ethnic group identification, medical condition, genetic information, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, mental disability, or physical disability. La compañía cumple con las leyes de derechos civiles federales y estatales aplicables, y no discrimina, ni excluye ni trata de manera diferente a las personas por su raza, color, país de origen, identificación con determinado grupo étnico, condición médica, información genética, ascendencia, religión, sexo, estado civil, género, identidad de género, orientación sexual, edad, ni discapacidad física ni mental. 本公司遵守適用的州法律和聯邦民權法律，並且不會以種族、膚色、原國籍、族群認同、醫療狀況、遺傳資訊、血統、宗教、性別、婚姻狀況、性別認同、性取向、年齡、精神殘疾或身體殘疾而進行歧視、排斥或區別對待他人。