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2025 Medicare Advantage Prescription Drug Plan Documents

All your Blue Shield of California Medicare Advantage plan documents, including the enrollment form, enrollment checklist, Multi-language Insert/Multi-language Interpreter Services 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, 1.9 MB) / Español (PDF, 3.4 MB)
Summary of Benefits (SOB): English (PDF, 304 KB) / Español (PDF, 238 KB)
Annual Notice of Changes: English (PDF, 495 KB) KB) / Español (PDF, 485 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.8 MB) / Español (PDF, 3.3 MB)
Summary of Benefits (SOB): English (PDF, 320 KB) / Español (PDF, 215 KB)
Annual Notice of Changes: English (PDF, 499 KB) / Español (PDF, 488 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.3 MB) / Español (PDF, 4.0 MB)
Summary of Benefits (SOB): English (PDF, 363 KB) / Español (PDF, 595 KB)
Annual Notice of Changes: English (PDF, 562 KB) / Español (PDF, 500 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.8 MB) / Español (PDF, 3.4 MB)
Summary of Benefits (SOB): English (PDF, 561 KB) / Español (PDF, 790 KB)
Annual Notice of Changes: English (PDF, 505 KB) / Español (PDF, 483 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.9 MB) / Español (PDF, 7.8 MB)
Summary of Benefits (SOB): English (PDF, 706 KB) / Español (PDF, 686 KB)
Annual Notice of Changes: English (PDF, 504 KB) / Español (PDF, 493 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.7 MB) / Español (PDF, 3.3 MB)
Summary of Benefits (SOB): English (PDF, 122 KB) / Español (PDF, 171 KB)
Annual Notice of Changes: English (PDF,  482 KB) / Español (PDF, 491 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.9 MB) / Español (PDF, 3.4 MB)
Summary of Benefits (SOB): English (PDF, 138 KB) / Español (PDF, 663 KB)
Annual Notice of Changes: English (PDF, 500 KB) / Español (PDF, 489 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.9 MB) / Español (PDF, 4.1 MB)
Summary of Benefits (SOB): English (PDF, 736 KB) / Español (PDF, 660 KB)
Annual Notice of Changes: English (PDF, 484 KB) / Español (PDF, X KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

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

Evidence of Coverage (EOC): English (PDF, 1.8 MB) / Español (PDF, 4.0 MB)
Summary of Benefits (SOB): English (PDF, 830 KB) / Español (PDF, 912 KB)
Annual Notice of Changes: English (PDF, 504 KB) / Español (PDF, X KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.8 MB) / Español (PDF, 3.3 MB)
Summary of Benefits (SOB): English (PDF, 616 KB) / Español (PDF, 846 KB)
Annual Notice of Changes: English (PDF, 503 KB) / Español (PDF, 492  KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.2 MB) / Español (PDF, 6.1 MB)
Summary of Benefits (SOB): English (PDF, 765 KB) / Español (PDF, 698 KB)
Annual Notice of Changes: English (PDF, 494 KB) / Español (PDF, 483 KB)
Annual Notice of Changes (For members that were formally in the Blue Shield Enhanced (HMO) plan): English (PDF, 506 KB) / Spanish (PDF, 503 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.2 MB) / Español (PDF, 3.4 MB) / Chinese (Traditional) (PDF, 7.0 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, 505 KB) / Español (PDF, 477  KB) / Chinese (Traditional) (PDF, 813 KB)
Enrollment Form: English (PDF, 614 KB) / Español (PDF, 747 KB) / Chinese (Traditional) (PDF, 914 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)  / Chinese (Traditional) (PDF, 174 KB)


 

Evidence of Coverage (EOC): English (PDF, 1.2 MB) / Español (PDF, 5.2 MB)
Summary of Benefits (SOB): English (PDF, 340 KB) / Español (PDF, 260 KB)
Annual Notice of Changes: English (PDF, 498 KB) / Español (PDF, 473 KB)
Enrollment Form: English (PDF, 614 KB) / Español (PDF, 747 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Blue Shield AdvantageOptimum Plan (HMO)

Evidence of Coverage (EOC): English (PDF, 1.6 MB) / Español (PDF, 5.5 MB)
Summary of Benefits (SOB): English (119 KB) / Español (PDF, 507 KB)
Annual Notice of Changes: English (PDF,  496 KB) / Español (PDF,  484 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF,  1.7 MB) / Español (PDF, 3.2 MB)
Summary of Benefits (SOB): English (PDF, 592 KB) / Español (PDF, 699 KB)
Annual Notice of Changes: English (PDF,  499 KB) / Español (PDF,  487 KB)
Enrollment Form: English (PDF, 636 KB) / Español (PDF, 768 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Multi-language Interpreter Services notice, Nondiscrimination notices, and Blue Shield MA-PD star ratings

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

Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice: 
English (PDF, 525 KB) / Español (PDF, 489 KB)


 

Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), and Blue Shield Inspire (HMO) Medicare Star Ratings* 
English (PDF, 156 KB)
Español (PDF, 139 KB)

Blue Shield AdvantageOptiumum Plan (HMO) and AdvantageOptiumum Plan 1 (HMO) Medicare Star Ratings* 
English (PDF, 158 KB) / Español (PDF, 157 KB)

Blue Shield PPO Medicare Star Ratings* 
English (PDF, 133 KB)
Español (PDF, 156 KB)
Chinese (PDF, 201 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.
  • For help in your language, please review the Multi-language Interpreter Services notice and the Nondiscrimination notice located on this page.

Y0118_24_426A_M Accepted 09172024
H2819_24_426A_M Accepted 09172024 

Page last updated: 10/1/2024

*Free digital copy with no obligation to enroll.

† Blue Shield Medicare Advisers are available April 1 through September 30: 8 a.m. to 8 p.m., weekdays and October 1 through March 31: 8 a.m. to 8 p.m., seven days a week.

© 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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