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Medicare Advantage Prescription Drug Plan Documents

All your Blue Shield of California Medicare Advantage plan documents, including the enrollment form, enrollment checklist, multi-language notice, and Medicare Star Ratings are listed on this page.

You can use plan documents to help you understand your plan.

Evidence of Coverage (EOC) describes in detail the healthcare benefits covered by your plan.

Summary of Benefits (SOB) is a simplified document that outlines your health benefits and coverage.

Annual Notice of Changes (ANOC) is a summary of any changes in the costs and coverage of your plan, effective every January 1.

For information on members and Blue Shield of California’s rights and responsibilities upon disenrollment, please refer to Chapter 10 in your EOC linked below.

Blue Shield 65 Plus (HMO)

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF, 1.7 MB)
Summary of Benefits (SOB): English (PDF, 441 KB) / Español (PDF, 699 KB)
Annual Notice of Changes: English (PDF, 344 KB) / Español (PDF, 417 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.4 MB) / Español (PDF, 1.6 MB)
Summary of Benefits (SOB): English (PDF, 533 KB) / Español (PDF, 758 KB)
Annual Notice of Changes: English (PDF, 289 KB) / Español (PDF, 650 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.4 MB) / Español (PDF, 1.6 MB)
Summary of Benefits (SOB): English (PDF, 363 KB) / Español (PDF, 595 KB)
Annual Notice of Changes: English (PDF, 322 KB)  / Español (PDF, 621 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF, 1.7 MB)
Summary of Benefits (SOB): English (PDF, 561 KB) / Español (PDF, 790 KB)
Annual Notice of Changes: English (PDF, 291 KB) / Español (PDF, 365 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF,  1.7 MB)
Summary of Benefits (SOB): English (PDF, 706 KB) / Español (PDF, 686 KB)
Annual Notice of Changes: English (PDF, 250 KB) / Español (PDF, 348 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF, 1.6 MB)
Summary of Benefits (SOB): English (PDF, 122 KB) / Español (PDF, 171 KB)
Annual Notice of Changes: English (PDF, 288 KB) / Español (PDF, 329 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.6 MB) / Español (PDF, 1.8 MB)
Summary of Benefits (SOB): English (PDF, 138 KB) / Español (PDF, 663 KB)
Annual Notice of Changes: English (PDF, 343 KB) / Español (PDF, 622 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 


 

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF, 1.7 MB)
Summary of Benefits (SOB): English (PDF, 736 KB) / Español (PDF, 660 KB)
Annual Notice of Changes: English (PDF, 336 KB) / Español (PDF, 573 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Blue Shield Inspire (HMO), Blue Shield Enhanced (HMO), and Blue Shield Select (PPO)

Evidence of Coverage (EOC): English (PDF, 12.5 MB) / Español (PDF, 13.5 MB)
Summary of Benefits (SOB): English (PDF, 830 KB) / Español (PDF, 912 KB)
Annual Notice of Changes: English (PDF, 294 KB) / Español (PDF, 391 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF 71 KB)
AAA Attestation Form: English (PDF, 78 KB) / Español (PDF, 77 KB)


 

Evidence of Coverage (EOC): English (PDF, 4.2 MB) / Español (PDF, 4.5 MB)
Summary of Benefits (SOB): English (PDF, 616 KB) / Español (PDF, 846 KB)
Annual Notice of Changes: English (PDF, 241 KB) / Español (PDF, 618 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)
AAA Attestation Form: English (PDF, 77 KB) / Español (PDF, 78 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.6 MB) / Español (PDF, 1.7 MB)
Summary of Benefits (SOB): English (PDF, 765 KB) / Español (PDF, 698 KB)
Annual Notice of Changes: English (PDF, 241 KB) / Español (PDF, 323 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.7 MB) / Español (PDF, 1.7 MB)
Summary of Benefits (SOB): English (PDF, 122 KB) / Español (PDF, 167 KB)
Annual Notice of Changes: English (PDF, 234 KB) / Español (PDF, 216 KB)
Enrollment Form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 11.2 MB) / Español (PDF, 11.7 MB) / Chinese (Traditional) (PDF, 11.1 MB)
Summary of Benefits (SOB): English (PDF, 889 KB) / Español (PDF, 1.1 MB) / Chinese (Traditional) (PDF, 887 MB)
Annual Notice of Changes: English (PDF, 251 KB) / Español (PDF, 328 KB) / Chinese (Traditional) (PDF, 948 KB)
Enrollment Form: English (PDF, 298 KB) / Español (PDF, 317 KB) / Chinese (Traditional) (PDF, 492 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)  / Chinese (Traditional) (PDF, 220 KB)
AAA Attestation Form: English (PDF, 77 KB) / Español (PDF, 78 KB) / Chinese (Traditional) (PDF 129 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.5 MB) / Español (PDF, 1.6 MB)
Summary of Benefits (SOB): English (PDF, 165 KB) / Español (PDF, 1.1 MB)
Annual Notice of Changes: English (PDF, 313 KB) / Español (PDF, 263 KB)
Enrollment Form: English (PDF, 298 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Blue Shield AdvantageOptimum Plan (HMO)

Evidence of Coverage (EOC): English (PDF, 1.3 MB) / Español (PDF, 1.5 MB)
Summary of Benefits (SOB): English (119 KB) / Español (PDF, 507 KB)
Annual Notice of Changes: English (PDF, 498 KB) / Español (PDF, 429 KB)
Enrollment form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.4 MB) / Español (PDF, 1.5 MB)
Summary of Benefits (SOB): English (PDF, 592 KB) / Español (PDF, 699 KB)
Annual Notice of Changes: English (PDF, 453 KB) / Español (PDF, 708 KB)
Enrollment form: English (PDF, 324 KB) / Español (PDF, 317 KB)
Pre-enrollment Checklist: English (PDF, 160 KB) / Español (PDF, 71 KB)


 

Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP)

Evidence of Coverage (EOC):
English (PDF, 1.5 MB)
Español  (PDF, 2 MB)  
Arabic (PDF, 3 MB)
Armenian (PDF, 3.2 MB)
Chinese (Simplified) (PDF, 2.1 MB)
Chinese (Traditional) (PDF, 2.1 MB)
Farsi (PDF, 3.1 MB)
Khmer (PDF, 2.6 MB)
Korean (PDF, 3.7 MB)
Russian (PDF, 2.6 MB)
Tagalog (PDF, 2.1 MB)
Vietnamese (PDF, 3 MB)

Summary of Benefits (SOB):
English (PDF, 476 KB)
Español (PDF, 678 KB)
Arabic (PDF, 835 KB)
Armenian (PDF, 901 KB)
Chinese (Simplified) (PDF, 768 KB)
Chinese (Traditional) (PDF, 719 KB)
Farsi (PDF, 808 KB)
Khmer (PDF, 736 KB)
Korean (PDF, 1 MB)
Russian (PDF, 902 KB)
Tagalog (PDF, 648 KB)
Vietnamese (PDF, 905 KB)

Annual Notice of Changes: 
English (PDF, 370 KB)
Español (PDF, 251 KB)
Arabic (PDF, 573 KB)
Armenian (PDF, 501 KB)
Chinese (Simplified) (PDF, 453 KB)
Chinese (Traditional) (PDF, 502 KB)
Farsi (PDF, 593 KB)
Khmer (PDF, 587 KB)
Korean (PDF, 537 KB)
Russian (PDF, 434 KB)
Tagalog (PDF, 337 KB)
Vietnamese (PDF, 509 KB)

Enrollment Form: 
English (PDF, 290 KB)
Español  (PDF, 332 KB)  
Arabic (PDF, 450 KB)
Armenian (PDF, 355 KB)
Chinese (Simplified) (PDF, 399 KB)
Chinese (Traditional) (PDF, 470 KB)
Farsi (PDF, 477 KB)
Khmer (PDF, 374 KB)
Korean (PDF, 328 KB)
Russian (PDF, 366 KB)
Tagalog (PDF, 279 KB)
Vietnamese (PDF, 396 KB)

Pre-enrollment Checklist: 
English (PDF, 69 KB)
Español (PDF, 69 KB) 
Arabic (PDF, 287, KB)
Armenian (PDF,  90 KB)
Chinese (Simplified) (PDF,  262 KB)
Chinese (Traditional) (PDF, 216 KB)
Farsi (PDF, 268 KB)
Khmer (PDF, 96 KB)
Korean (PDF,  196 KB)
Russian (PDF, 271 KB)
Tagalog (PDF,  141 MB)
Vietnamese (PDF,  218 KB)


Model of Care Evaluation Summary of Findings: 
English (PDF, 710 KB)
Español (PDF, 843 KB) 
Arabic (PDF, 351, KB)
Armenian (PDF, 292 KB)
Chinese (Simplified) (PDF, 326 KB)
Chinese (Traditional) (PDF, 509 KB)
Farsi (PDF, 387 KB)
Khmer (PDF, 497 KB)
Korean (PDF, 367 KB)
Russian (PDF, 384 KB)
Tagalog (PDF, 962 KB)
Vietnamese (PDF, 342 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.4 MB) / Español (PDF, 1.6 MB)

Summary of Benefits (SOB): English (PDF, 250 KB) / Español (PDF, 825 KB)

Annual Notice of Changes: English (PDF, 706 KB) / Español (PDF, 768 KB)

Pre-enrollment Checklist: 

English (PDF, 69 KB)
Español (PDF, 69 KB) 
Arabic (PDF, 287, KB)
Armenian (PDF,  90 KB)
Chinese (Simplified) (PDF,  262 KB)
Chinese (Traditional) (PDF, 216 KB)
Farsi (PDF, 268 KB)
Khmer (PDF, 96 KB)
Korean (PDF,  196 KB)
Russian (PDF, 271 KB)
Tagalog (PDF,  141 MB)
Vietnamese (PDF,  218 KB)

Model of Care Evaluation Summary of Findings: 
English (PDF, 710 KB)
Español (PDF, 843 KB) 
Arabic (PDF, 351, KB)
Armenian (PDF, 292 KB)
Chinese (Simplified) (PDF, 326 KB)
Chinese (Traditional) (PDF, 509 KB)
Farsi (PDF, 387 KB)
Khmer (PDF, 497 KB)
Korean (PDF, 367 KB)
Russian (PDF, 384 KB)
Tagalog (PDF, 962 KB)
Vietnamese (PDF, 342 KB)


 

Evidence of Coverage (EOC):
English (PDF, 1.9 MB)
Español (PDF, 12.1 MB)

Summary of Benefits (SOB): 
English (PDF, 460 KB)
Español (PDF, 819 KB)

Annual Notice of Changes: 
English (PDF, 801 KB)
Español (PDF, 277 KB)

Enrollment Form: 
English (PDF, 324 KB)
Español (PDF, 317 KB)

Pre-enrollment Checklist: 
English (PDF, 69 KB)
Español (PDF, 69 KB)
Arabic (PDF, 287, KB)
Armenian (PDF,  90 KB)
Chinese (Simplified) (PDF,  262 KB)
Chinese (Traditional) (PDF, 216 KB)
Farsi (PDF, 268 KB)
Khmer (PDF, 96 KB)
Korean (PDF,  196 KB)
Russian (PDF, 271 KB)
Tagalog (PDF,  141 MB)
Vietnamese (PDF,  218 KB)

Model of Care Evaluation Summary of Findings: 
English (PDF, 710 KB)
Español (PDF, 843 KB) 
Arabic (PDF, 351, KB)
Armenian (PDF, 292 KB)
Chinese (Simplified) (PDF, 326 KB)
Chinese (Traditional) (PDF, 509 KB)
Farsi (PDF, 387 KB)
Khmer (PDF, 497 KB)
Korean (PDF, 367 KB)
Russian (PDF, 384 KB)
Tagalog (PDF, 962 KB)
Vietnamese (PDF, 342 KB)

AAA Attestation Form: 
English (PDF, 78 KB) 
Español (PDF, 77 KB)

Healthy Grocery Attestation Form: 
English (PDF, 75 KB)
Español (PDF, 79 KB)


 

Multi-language and Nondiscrimination Notices, and Blue Shield MA-PD star ratings

Blue Shield Medicare Advantage Prescription Drug Plans Multi-language notice: 
English (PDF, 1.1 MB)

Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice: 
English (PDF, 472 KB) / Español (PDF, 414 KB)

Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Multi-language notice: 
English (PDF, 1.1 MB)

Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles and San Diego counties Language assistance notice: 
English (PDF, 1.27 MB)


 

Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield Inspire (HMO), and Blue Shield Enhanced (HMO) Medicare Star Ratings* 
English (PDF, 112 KB)
Español (PDF, 152 KB)

Blue Shield Inspire (HMO D-SNP) and Blue Shield TotalDual Plan (HMO D-SNP) Medicare Star Ratings*

English (PDF, 170 KB)
Español (PDF, 160 KB)
Arabic (PDF, 161 KB)
Armenian (PDF, 154 KB)
Chinese (Simplified) (PDF, 130 KB)
Chinese (Traditional) (PDF, 135 KB)
Farsi (PDF, 182 KB)
Khmer (PDF, 118 KB)
Korean (PDF, 118 KB)
Russian (PDF, 167 KB)
Tagalog (PDF, 94 KB)
Vietnamese (PDF, 187 KB) 

Blue Shield AdvantageOptiumum Plan (HMO) and AdvantageOptiumum Plan 1 (HMO) Medicare Star Ratings* 
English (PDF, 163 KB) / Español (PDF, 135 KB)

Blue Shield PPO Medicare Star Ratings* 
English (PDF, 163 KB)
Español (PDF, 135 KB)
Chinese (PDF, 132 KB)

*Every year, Medicare evaluates plans based on a 5­-star rating system.


 

Please refer to our list of compatible browsers when downloading or viewing PDF documents.

You can also log into your online account and go to the Benefits section on your member dashboard.

If you want help understanding your documents, please call:

  • Blue Shield of California Medicare Advantage Prescription Drug Plans Customer Service at (800) 776-4466 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.
  • Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Customer Service at (800) 452-4413 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.
  • For help in your language, please review the Multi-Language Notice and the Nondiscrimination Notice located for download on this page.

Y0118_23_408A3_M Accepted 12102023
H2819_23_408A3_M Accepted 12102023

Page last updated: 6/21/2024

*Free copy with no obligation to enroll.

© California Physician’s Service DBA Blue Shield of California 1999-2024. All rights reserved.

California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

Blue Shield of California 601 12th Street, Oakland, CA 94607.

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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