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Paper Application  * Short Form - Transfers  65 Insipre, Plus, Choice & Trio
Medi Gap 

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Under 65 ACA preventative care

Blue Shield Medi Gap
Evidence of Coverage 

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Get complete descriptions Evidences of Coverage
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Evidences of Coverage for Open Plans
Get complete descriptions of our open Medicare Supplement plans.

Plan A, Jan. 2018 (PDF)
Plan F Extra, Oct. 2018  (PDF)
Plan G, Jan. 2018 (PDF)
Plan N, Jan. 2018 (PDF)

Evidences 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, Jan. 2018 (PDF)
Plan D, Jan. 2018 (PDF)
Plan F, Jan. 2018  (PDF)
High Deductible Plan F, Jan. 2019 (PDF)
Plan K, Jan. 2019 (PDF) 

Evidences of Coverage for Standardized and Pre-Standardized Closed Plans (closed prior to 5/31/2010)
Get complete descriptions of our closed Medicare Supplement plans.

Plan A (pre June 2010) (PDF)
Plan B (pre June 2010) (PDF)
Plan C (pre June 2010) (PDF)
Plan D (pre June 2010) (PDF)
Plan F (pre June 2010)  (PDF)
Plan G (pre June 2010)  (PDF)
Plan J (pre June 2010)  (PDF)
Plan K (pre June 2010)  (PDF)
Plan H Standard  (PDF)
Plan H Plus Rx  (PDF)
Plan I Standard (PDF)
Plan I Plus Rx (PDF)
Coronet Major Medicare (PDF)
Coronet Senior Standard  (PDF)
Coronet Senior Plus Rx  (PDF)
Golden Coronet Senior Standard  (PDF)
Golden Coronet Senior Plus Rx  (PDF)
Preferred Senior  (PDF)

Dental PPO plan EOC and Dental + Vision Package Policies
Dental PPO 1000 EOC (PDF)
Dental PPO 1500 EOC (PDF)
Specialty Duo Dental Policy (PDF)
Specialty Duo Vision Policy (PDF)

Closed plan rate sheets 
2010 Standardized Closed Plans (closed 5/31/2010) (PDF)
1990 Standardized Closed Plans (closed 5/31/2010) (PDF)
1990 Standardized Closed Plans (closed 12/31/2005) (PDF)

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