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/PPO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Medicaid program. 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_11355_C.

This page last updated 10-01-2025.

Plan Documents

Medicare Blue Dual (HMO D-SNP)

Medicare Blue Choice Core HMO

Medicare Blue Choice Prime HMO

Medicare Blue Choice Freedom HMO-POS

Medicare Blue Choice Optimum HMO-POS

Medicare BluePlus PPO

Medicare BlueSalute PPO

Medicare BlueActive PPO

Medicare BlueClassic PPO

Medicare BlueEnhanced PPO

Medicare BlueEssential PPO

Medicare BlueSalute PPO

Medicare BlueBalanced PPO

Medicare BlueVital PPO

Medicare Blue Dual (HMO D-SNP)

Medicare Blue Choice Core HMO

Medicare Blue Choice Freedom HMO-POS

Medicare Blue Choice Optimum HMO-POS

Medicare Blue Choice Prime HMO-POS

Medicare Blue Choice 032 HMO-POS

Medicare Blue Choice 033 HMO-POS

Medicare Blue Choice 024 HMO

Medicare Blue Choice 025 HMO-POS

Medicare Blue Choice 026 HMO-POS

Medicare Blue Choice 027 HMO-POS

Medicare Blue Choice 028 HMO

Medicare Blue Choice 029 HMO-POS

Medicare Blue Choice 030 HMO-POS

Medicare Blue Choice 031 HMO-POS

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