Blue Shield offers

Medicare Supplement Plan Documents

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, copayments, and coinsurance amounts for plans with extra benefits.

Medicare Supplement plans

Summary of Benefits (SOB) English (PDF, 569 KB)
Summary of Benefits (SOB) Español  (PDF, 457 KB)
Summary of Benefits (SOB) Chinese (PDF, 824 KB)
Summary of Benefits (SOB) Vietnamese (PDF, 648 KB)


 

Evidence of Coverage (EOC) English (PDF, 255 KB)


 

Evidence of Coverage (EOC) English (PDF, 230 KB)


 

Evidence of Coverage (EOC) English (PDF, 232 KB)


 

Evidence of Coverage (EOC) English (PDF, 296 KB)

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


 

Evidence of Coverage (EOC) English (PDF, 289 KB)

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


 

Evidence of Coverage (EOC) English (PDF, 306 KB)

Plan G Inspire Notice of New or Innovative Benefits Form English (PDF, 215 KB)


 

Medicare Supplement Dental plans

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


 

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


 

Language assistance and Nondiscrimination Notice

Medicare Supplement language assistance and nondiscrimination notice English (PDF, 1.2 MB)

 


 

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.

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.

Y0118_23_408A_M Accepted 09192023 

H2819_23_408A_M Accepted 09192023

Page last updated: 10/01/2023

*Free copy with no obligation to enroll.

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

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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.

 
 
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