Plan Documents

View important plan documents including your Summary of Benefits, Evidence of Coverage, and Annual Notice of Change (if available). Since these documents vary by region and plan, we need some information from you. Use the form below and we’ll find your specific plan documents.

Existing Members: Request to receive printed versions of your specific documents by mail.

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Plan Documents - Script and Style

Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_10519_C.

This page last updated 10-01-2024.

Plan Documents

Medicare Blue Dual (HMO D-SNP)

Medicare Blue Choice Access PPO

Medicare Blue Choice Advanced HMO-POS

Medicare Blue Choice Extra HMO

Medicare Blue Choice Freedom HMO-POS

Medicare Blue Choice Optimum HMO-POS

Medicare Blue Choice Select HMO

Medicare Blue Choice Value Plus HMO-POS

Medicare BluePlus PPO

Medicare BlueSalute PPO

Medicare BlueActive PPO

Medicare BlueClassic PPO

Medicare BlueEnhanced PPO

Medicare BlueEssential PPO

Medicare BlueFlex PPO

Medicare BlueSalute PPO

Medicare Blue Dual (HMO D-SNP)

Medicare Blue Choice Advanced HMO-POS

Medicare Blue Choice Discovery PPO

Medicare Blue Choice Extra HMO

Medicare Blue Choice Freedom HMO-POS

Medicare Blue Choice Optimum HMO-POS

Medicare Blue Choice Select HMO

Medicare Blue Choice Value Plus HMO-POS

Medicare BluePlus PPO

Medicare BlueSalute PPO

Medicare BlueActive PPO

Medicare BlueClassic PPO

Medicare BlueEnhanced PPO

Medicare BlueEssential PPO

Medicare BlueFlex PPO

Medicare BlueSalute PPO

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