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2026 Medicare Advantage Prescription Drug Plan Documents

2025 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, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 337 KB) / Español (PDF, 352 KB)
Annual Notice of Changes: English (PDF, 1.0 MB) KB) / Español (PDF, 690 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 35 KB) / Español (PDF, 125 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 292 KB) / Español (PDF, 341 KB)
Annual Notice of Changes: English (PDF, 717 KB) / Español (PDF, 978 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 282 KB) / Español (PDF, 336 KB)
Annual Notice of Changes: English (PDF, 973 KB) / Español (PDF, 726 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 326 KB) / Español (PDF, 352 KB)
Annual Notice of Changes: English (PDF, 1.1 MB) / Español (PDF, 728 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 305 KB) / Español (PDF, 359 KB)
Annual Notice of Changes: English (PDF, 917 KB) / Español (PDF, 493 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 281 KB) / Español (PDF, 331 KB)
Annual Notice of Changes: English (PDF,  976 KB) / Español (PDF, 1.0 MB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 299 KB) / Español (PDF, 348 KB)
Annual Notice of Changes: English (PDF, 637 KB) / Español (PDF, 611 KB)
Enrollment Form: English (PDF, 159 KB / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 318 KB) / Español (PDF, 351 KB)
Annual Notice of Changes: English (PDF, 681 KB) / Español (PDF, 2.0 MB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB) 
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Blue Shield Inspire (HMO) 

Evidence of Coverage (EOC):English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 291 KB) / Español (PDF, 344 KB)
Annual Notice of Changes: English (PDF, 907 KB) / Español (PDF, 1.0 MB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 340 KB) / Español (PDF, 336 KB)
Annual Notice of Changes: English (PDF, 503 KB) / Español (PDF, 1.9 MB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 302 KB) / Español (PDF, 352 KB)
Annual Notice of Changes: English (PDF, 879 KB) / Español (PDF, 900 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Blue Shield Advantage (HMO)

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X)
Summary of Benefits (SOB): English (PDF, 296 KB) / Español (PDF, 355 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF 112 KB)


 

Blue Shield AdvantageOptimum Plan (HMO)

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 252 KB) / Español (PDF, 274 KB)
Annual Notice of Changes: English (PDF,  1.5 MB) / Español (PDF,  789 KB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Evidence of Coverage (EOC): English (PDF, X) / Español (PDF, X) Coming soon
Summary of Benefits (SOB): English (PDF, 241 KB) / Español (PDF, 273 KB)
Annual Notice of Changes: English (PDF,  983 KB) / Español (PDF,  2.0 MB)
Enrollment Form: English (PDF, 159 KB) / Español (PDF, 200 KB)
Pre-enrollment Checklist: English (PDF, 137 KB) / Español (PDF, 112 KB)


 

Notice of Availability of Language Services and Auxiliary Aids and Services, Nondiscrimination notice, and Blue Shield MA-PD star ratings

Blue Shield Medicare Advantage Prescription Drug Plans Notice of Availability: 
English (PDF, 1.1 MB)

Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice: 
English (PDF, 525 KB) / Español (PDF, 173 KB) / Chinese (Traditional) (PDF, 315 KB) / Chinese (Simplified) (PDF, 244 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), Blue Shield Advantage (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)

 

*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. Pacific time, seven days a week.
  • Dual Special Needs Plans Customer Service at (800) 452-4413, 8 a.m. to 8 p.m. Pacific time, 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.

 

Blue Shield of California is an HMO, HMO D-SNP, 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.

Y0118_25_341B2_C 09172025
H2819_25_341B2_C Accepted 09232025

Page last updated: 10/1/2025