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

Medicare Supplement plans

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)


 

Evidence of Coverage (EOC) English (PDF, X KB) Coming soon


 

Evidence of Coverage (EOC) English (PDF,  X KB) Coming soon


 

Evidence of Coverage (EOC) English (PDF, X KB) Coming soon


 

Evidence of Coverage (EOC) English (PDF, X KB) Coming soon

Plan G Extra Notice of New or Innovative Benefits Form English (PDF, 61 KB)


 

Evidence of Coverage (EOC) English (PDF, X KB) Coming soon

Plan F Extra Notice of New or Innovative Benefits Form English (PDF, 56 KB)


 

Medicare Supplement Dental plans

Evidence of Coverage (EOC) English (PDF, X MB) Coming soon


 

Evidence of Coverage (EOC) English (PDF, X KB) Coming soon


 

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