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

Medicare Supplement plans

Summary of Benefits (SOB) English (PDF, 488 KB)
Summary of Benefits (SOB) Español (PDF, 540 KB)
Summary of Benefits (SOB) Chinese (PDF, 746 KB)
Summary of Benefits (SOB) Vietnamese (PDF, 643 KB)


 

Evidence of Coverage (EOC) English (PDF, 566 KB)


 

Evidence of Coverage (EOC) English (PDF, 431 KB)


 

Evidence of Coverage (EOC) English (PDF, 600 KB)


 

Evidence of Coverage (EOC) English (PDF, 952 KB)

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


 

Evidence of Coverage (EOC) English (PDF, 1.1 MB)

Plan F Extra Notice of New or Innovative Benefits Form English (PDF, 103 KB)


 

Medicare Supplement Dental plans

Evidence of Coverage (EOC) English (PDF, 632 KB)


 

Evidence of Coverage (EOC) English (PDF, 617 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.

Page last updated: 4/1/2024

*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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