Help MA-PD clients

Here are PDF resources that can help you manage your existing Blue Shield of California MA-PD clients in our plans for Medicare beneficiaries.

Including:

  • Evidence of Coverage documents
  • Star ratings
  • Pharmacy directories
  • Formularies
  • Dental flyer and dental enrollment forms
  • Authorization for the Use or Disclosure of Health Information
  • Over-the-counter (OTC) items catalog
  • Change of plan and disenrollment forms

Please note:

  • All provider directories and materials you need for enrollment are located on the Arvato Storefront

The following browsers have been found to provide the best experience on the Blue Shield of California website: Google Chrome, Safari, Microsoft Edge, or Mozilla Firefox.

2024 Blue Shield Inspire (HMO) Evidence of Coverage

2024 Blue Shield Inspire (HMO) – Los Angeles and Orange counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield Inspire (HMO) – Alameda and San Mateo counties English (PDF, 1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield Inspire (HMO) – San Joaquin, Stanislaus, Merced, and Santa Clara counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)

2024 Blue Shield Select (PPO) Evidence of Coverage

2024 Blue Shield Select (PPO) – Alameda County English (PDF, 1.4 MB)
Spanish (PDF, 1.2 MB)
Chinese (Traditional) (PDF, 2 MB)
2024 Blue Shield Select (PPO) – Orange and San Diego counties English (PDF, 1.4 MB)
Spanish (PDF, 1.2 MB)

2024 Blue Shield 65 Plus (HMO) Evidence of Coverage

2024 Blue Shield 65 Plus (HMO) – Los Angeles and Orange counties English (PDF, 1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus (HMO) – San Bernardino County English (PDF, 1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus (HMO) – Riverside County English (PDF, 1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus Plan 2 (HMO) – Los Angeles and Orange counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus Choice Plan (HMO) – Riverside and San Bernardino counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus (HMO) – San Diego County English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus (HMO) – Kern County English (PDF, 1 MB)
Spanish (PDF, 1.2 MB)
2024 Blue Shield 65 Plus (HMO) – San Luis Obispo and Santa Barbara counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)

2024 Blue Shield Enhanced (HMO) Evidence of Coverage

2024 Blue Shield Enhanced (HMO) – Los Angeles and Orange counties English (PDF, 1.1 MB)
Spanish (PDF, 1.2 MB)

2024 Blue Shield AdvantageOptimum Plan (HMO) Evidence of Coverage

2024 Blue Shield AdvantageOptimum Plan (HMO) – Los Angeles and Orange counties English (PDF, 10.8 MB)
Spanish (PDF, 1.1 MB)
2024 Blue Shield AdvantageOptimum Plan 1 (HMO) – San Diego County English (PDF, 7.3 MB)
Spanish (PDF, 1.1 MB)

2024 Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Evidence of Coverage

2024 Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles and San Diego counties English (PDF, 1.5 MB)
Spanish (PDF, 2 MB)
Arabic (PDF, 3 MB)
Armenian (PDF, 2.1 MB)
Chinese (Simplified) (PDF, 2.1 MB)
Chinese (Traditional) (PDF, 2.1 MB)
Farsi (PDF, 3.1 MB)
Khmer (PDF, 3 MB)
Korean (PDF, 6.4 MB)
Russian (PDF, 2.6 MB)
Tagalog (PDF, 2.1 MB)
Vietnamese (PDF, 2.1 MB)
2024 Blue Shield TotalDual Plan (HMO D-SNP) – Orange and San Bernardino counties English (PDF, 1 MB)
Spanish (PDF, 1.1 MB)
2024 Blue Shield Inspire (HMO D-SNP) – Merced, San Joaquin, and Stanislaus counties English (PDF, 987 KB)
Spanish (PDF, 1.1 MB)

2024 Star ratings

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, 170 KB)
Spanish (PDF, 160 KB)
Blue Shield Inspire (HMO D-SNP) and Blue Shield TotalDual Plan (HMO D-SNP) Medicare Star Ratings* English (PDF, 196 KB)
Spanish (PDF, 138 KB)
Armenian (PDF, 154 KB)
Arabic (PDF, 161 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 AdvantageOptimum Plan (HMO) and Blue Shield AdvantageOptimum Plan 1 (HMO) Medicare Star Ratings* English (PDF, 163 KB)
Spanish (PDF, 135 KB)
Blue Shield Select (PPO) Medicare Star Ratings* English (PDF, 163 KB)
Spanish (PDF, 135 KB)
Chinese (PDF, 132 KB)

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

2024 Pharmacy directory

Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield Inspire (HMO), Blue Shield Select (PPO), and Blue Shield Enhanced (HMO) English (PDF, 2.9 MB)
Spanish (PDF, 2.9 MB)
Blue Shield Inspire (HMO D-SNP) San Joaquin/Stanislaus/Merced counties and Blue Shield TotalDual Plan (HMO D-SNP) Orange/San Bernardino counties English (PDF, 3.1 MB)
Spanish (PDF, 3.1 MB)
Blue Shield TotalDual Plan (HMO D-SNP) Los Angeles/San Diego English (PDF, 4.5 MB)
Spanish (PDF, X MB)
Chinese (Simplified) (PDF, X MB)
Chinese (Traditional) (PDF, X MB)
Arabic (PDF, 4.2 MB)
Armenian (PDF, 4.2 MB)
Cambodian (PDF, X MB)
Farsi (PDF, 4.4 MB)
Korean (PDF, X MB)
Russian (PDF, X MB)
Tagalog (PDF, X MB)
Vietnamese (PDF, X MB)

2024 MA-PD formularies

2024 Optional supplemental dental HMO and PPO plan flyer and enrollment form

2024 Optional supplemental dental HMO and PPO plan flyer English (PDF, 333 KB)
Spanish (PDF, 314 KB)
2024 Optional supplemental dental HMO and PPO plan enrollment form English (PDF, 94 KB)
Spanish (PDF, 81 KB)

Authorization for the Use or Disclosure of Health Information

Authorization for the Use or Disclosure of Health Information English (PDF, 105 KB)
Spanish (PDF, 85 KB)
Vietnamese (PDF, 185 KB)
Chinese (PDF, 164 KB)
Korean (PDF, 125 KB)
Hindi (PDF, 177 KB)

2024 Over-The-Counter (OTC) items catalog

2024 MA-PD Plans with the OTC Items Benefit:

Blue Shield Inspire (HMO) – Los Angeles, Orange, Alameda, San Mateo, Santa Clara, San Joaquin, Stanislaus, and Merced counties
Blue Shield Inspire (HMO D-SNP) – Merced, San Joaquin, and Stanislaus counties
Blue Shield Select (PPO) – Alameda, Orange, and San Diego counties
Blue Shield 65 Plus (HMO) – San Luis Obispo, Santa Barbara, Kern, and San Diego counties
Blue Shield 65 Plus Choice Plan (HMO) – San Bernardino and Riverside counties
Blue Shield AdvantageOptimum Plan (HMO) – Los Angeles and Orange counties
Blue Shield AdvantageOptimum Plan 1 (HMO) – San Diego County
Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles, Orange, San Bernardino, and San Diego counties

OTC Catalog

English (PDF, 2.4 MB)
Spanish (PDF, X MB)
Arabic (PDF, X MB)
Armenian (PDF, X MB)
Cambodian (PDF, X MB)
Chinese (Simplified) (PDF, X MB)
Chinese (Traditional) (PDF, X MB)
Farsi (PDF, X MB)
Korean (PDF, X MB)
Russian (PDF, X MB)
Tagalog (PDF, X MB)
Vietnamese (PDF, X MB)

2024 Change of plan and disenrollment forms

MA-PD Disenrollment forms English (PDF, 62 KB)
Spanish (PDF, 65 KB)
Arabic (PDF, 147 KB)
Armenian (PDF, 120 KB)
Cambodian (PDF, 156 KB)
Chinese (Simplified) (PDF, 118 KB)
Chinese (Traditional) (PDF, 129 KB)
Farsi (PDF, 160 KB)
Korean (PDF, 85 KB)
Russian (PDF, 137 KB)
Tagalog (PDF, 61 KB)
Vietnamese (PDF, 103 KB)
MA-PD (HMO) Change of Plan forms English (PDF, 240 KB)
Spanish (PDF, 269 KB)
Chinese (Traditional) (PDF, 548 KB)
Korean (PDF, 338 KB)
Vietnamese (PDF, 327 KB)
MA-PD (PPO) Change of Plan forms English (PDF, 222 KB)
Spanish (PDF, 241 KB)
Chinese (Traditional) (PDF, 571 KB)
MA-PD (TotalDual HMO D-SNP) Change of Plan forms English (PDF, 218 KB)
Spanish (PDF, 200 KB)
Arabic (PDF, 286 KB)
Armenian (PDF, 259 KB)
Cambodian (PDF, 242 KB)
Chinese (Simplified) (PDF, 299 KB)
Chinese (Traditional) (PDF, 306 KB)
Farsi (PDF, 282 KB)
Korean (PDF, 218 KB)
Russian (PDF, 236 KB)
Tagalog (PDF, 183 KB)
Vietnamese (PDF, 266 KB)
Optional Supplemental dental disenrollment forms English (PDF, 51 KB)
Spanish (PDF, 43 KB)

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。

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Page last updated: 4/5/2024

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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