Blue Shield offers

Prescription Drug Plan Documents

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

Plan documents can help you understand your plan.

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

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 8 in your EOC linked below.

Medicare Prescription Drug Plans (PDP)

Evidence of Coverage (EOC): English (PDF, 770 KB) / Español (PDF, 654 KB)

Summary of Benefits (SOB): English (PDF, 97 KB) / Español (PDF, 543 KB)

Annual Notice of Changes: English (PDF, 299 KB) / Español (PDF, 300 KB)

Enrollment Forms English (PDF, 300 KB) / Español (PDF, 278 KB)

Pre-enrollment Checklist: English (PDF, 99 KB) / Español (PDF, 54 KB)


 

Evidence of Coverage (EOC): English (PDF, 772 KB) / Español (PDF, 834 KB)

Summary of Benefits (SOB): English (PDF, 97 KB) / Español (PDF, 543 KB)

Annual Notice of Changes: English (PDF, 314 KB) / Español (PDF, 297 KB)

Enrollment Forms English (PDF, 300 KB) / Español (PDF, 278 KB)

Pre-enrollment Checklist: English (PDF, 99 KB) / Español (PDF, 54 KB)


 

Multi-language and Nondiscrimination Notices, and Blue Shield PDP Star ratings

Multi-language notice, English (PDF, 1.1 MB)
Nondiscrimination notice, English (PDF, 472 KB) / Español (PDF, 475 KB)


 

Blue Shield PDP Medicare Star Ratings* English (PDF, 164 KB) / Español (PDF, 142 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 visit the Benefits section on your member dashboard.

If you want help understanding your documents, please call Blue Shield of California Medicare Prescription Drug Plan Customer Service at (888) 239-6469 (TTY: 711), 8 a.m. to 8 p.m., seven days a week.

Y0118_23_408A3_M Accepted 12102023

H2819_23_408A3_M Accepted 12102023

Page last updated: 1/1/2024

*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.

 
 
The company complies with applicable state laws and federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, ethnic group identification, medical condition, genetic information, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, mental disability, or physical disability. La compañía cumple con las leyes de derechos civiles federales y estatales aplicables, y no discrimina, ni excluye ni trata de manera diferente a las personas por su raza, color, país de origen, identificación con determinado grupo étnico, condición médica, información genética, ascendencia, religión, sexo, estado civil, género, identidad de género, orientación sexual, edad, ni discapacidad física ni mental. 本公司遵守適用的州法律和聯邦民權法律，並且不會以種族、膚色、原國籍、族群認同、醫療狀況、遺傳資訊、血統、宗教、性別、婚姻狀況、性別認同、性取向、年齡、精神殘疾或身體殘疾而進行歧視、排斥或區別對待他人。