Blue Shield offers
2025 Medicare Advantage Dual Special Needs Plan documents
All your Blue Shield of California Medicare Advantage Dual Special Needs Plan documents – including the enrollment form, enrollment checklist, language assistance notice, and Medicare Star Ratings – are listed on this page.
You can use plan documents to help you understand your plan.
- Member handbook 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 each January 1.
For information on members and Blue Shield of California’s rights and responsibilities upon disenrollment, please refer to Chapter 10 in your member handbook linked below.
Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP)
Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles and San Diego counties
Member handbook
English (PDF, 5.3 MB) / Español (PDF, 4 MB) / Arabic (PDF, 2.8 MB / Armenian (PDF, 5.3 MB) / Chinese (Simplified) (PDF, 4.2 MB) / Chinese (Traditional) (PDF, 4.7 MB) / Farsi (PDF, 4.5 MB) / Khmer (PDF, 6.9 MB) / Korean (PDF, 6.5 MB) / Russian (PDF, 5.4 MB) / Tagalog (PDF, 4.1 MB) / Vietnamese (PDF, 5.4 MB)
Summary of Benefits (SOB)
English (PDF, 1.1 MB) / Español (PDF, 1.2 MB) / Arabic (PDF, 1.2 MB) / Armenian (PDF, 1.3 MB) / Chinese (Simplified) (PDF, 1.3 MB) / Chinese (Traditional) (PDF, 1.6 MB) / Farsi (PDF, 1.8 MB) / Khmer (PDF, 1.6 MB) / Korean (PDF, 1.4 MB) / Russian (PDF, 1.4 MB) / Tagalog (PDF, 1.2 MB) / Vietnamese (PDF, 1.4 MB)
Annual Notice of Changes
English (PDF, 904 KB) / Español (PDF, 1.0 MB) / Arabic (PDF, 1.1 MB) / Armenian (PDF, 1.2 MB) / Chinese (Simplified) (PDF, 1.1 MB) / Chinese (Traditional) (PDF, 1.2 MB) / Farsi (PDF, 1.1 MB) / Khmer (PDF, 1.1 MB) / Korean (PDF, 1.6 MB) / Russian (PDF, 988 KB) / Tagalog (PDF, 894 KB) / Vietnamese (PDF, 1.2 MB)
Enrollment form
English (PDF, 624 KB) / Español (PDF, 770 KB) / Arabic (PDF, 879 KB) / Armenian (PDF, 907 KB) / Chinese (Simplified) (PDF, 904 KB) / Chinese (Traditional) (PDF, 935 KB) / Farsi (PDF, 917 KB) / Khmer (PDF, 900 KB) / Korean (PDF, 828 KB) / Russian (PDF, 866 KB) / Tagalog (PDF, 762 KB) / Vietnamese (PDF, 835 KB)
Pre-enrollment Checklist
English (PDF, 148 KB) / Español (PDF, 104 KB) / Arabic (PDF, 253 KB) / Armenian (PDF, 279 KB) / Chinese (Simplified) (PDF, X KB) / Chinese (Traditional) (PDF, 147 KB) / Farsi (PDF, 206 KB) / Khmer (PDF, 214 KB) / Korean (PDF, 134 KB) / Russian (PDF, 209 KB) / Tagalog (PDF, 107 KB) / Vietnamese (PDF, 220 KB)
Model of Care Evaluation Summary of Findings
English (PDF, X KB) / Español (PDF, X KB) / Arabic (PDF, X KB) / Armenian (PDF, X KB) / Chinese (Simplified) (PDF, X KB) / Chinese (Traditional) (PDF, X KB) / Farsi (PDF, X KB) / Khmer (PDF, X KB) / Korean (PDF, X KB) / Russian (PDF, X KB) / Tagalog (PDF, X KB) / Vietnamese (PDF, X KB)
Blue Shield TotalDual Plan (HMO D-SNP) – Orange and San Bernardino counties
Member Handbook
English (PDF, X KB) / Español (PDF, X KB)
Summary of Benefits (SOB)
English (PDF, 320 KB) / Español (PDF, 213 KB)
Annual Notice of Changes
English (PDF, 460 KB) / Español (PDF, 456 KB )
Pre-enrollment Checklist
English (PDF, 148 KB ) / Español (PDF, 104 KB) / Arabic (PDF, 253 KB) / Armenian (PDF, 279 KB ) / Chinese (Simplified) (PDF, X KB ) / Chinese (Traditional) (PDF, 147 KB) / Farsi (PDF, 206 KB) / Khmer (PDF, 214 KB) / Korean (PDF, 134 KB) / Russian (PDF, 209 KB) / Tagalog (PDF, 107 KB) / Vietnamese (PDF, 220 KB)
Model of Care Evaluation Summary of Findings
English (PDF, X KB ) / Español (PDF, X KB ) / Arabic (PDF, X KB) / Armenian (PDF, X KB) / Chinese (Simplified) (PDF, X KB) / Chinese (Traditional) (PDF, X KB) / Farsi (PDF, X KB) / Khmer (PDF, X KB) / Korean (PDF, X KB) / Russian (PDF, X KB) Tagalog (PDF, X KB) / Vietnamese (PDF, X KB)
Blue Shield Inspire (HMO D-SNP) – Merced, San Joaquin, and Stanislaus counties
Member Handbook
English (PDF, X KB) / Español (PDF, X KB)
Summary of Benefits (SOB)
English (PDF, 307 KB) / Español (PDF, 219 KB)
Annual Notice of Changes
English (PDF, 478KB) / Español (PDF, 458KB)
Enrollment Form
English (PDF, 624 KB) / Español (PDF, 770 KB)
Pre-enrollment Checklist
English (PDF, 148 KB) / Español (PDF, 104 KB) Arabic (PDF, 253 KB) / Armenian (PDF, 279 KB) / Chinese (Simplified) (PDF, X KB) / Chinese (Traditional) (PDF, 147 KB) / Farsi (PDF, 206 KB) / Khmer (PDF, 214 KB) / Korean (PDF, 134 KB) / Russian (PDF, 209 KB) / Tagalog (PDF, 107 KB) / Vietnamese (PDF, 220 KB)
Model of Care Evaluation Summary of Findings
English (PDF, X KB) / Español (PDF, X KB)/ Arabic (PDF, X KB) / Armenian (PDF, X KB) / Chinese (Simplified) (PDF, X KB) / Chinese (Traditional) (PDF, X KB) / Farsi (PDF, X KB)/ Khmer (PDF, X KB) / Korean (PDF, X KB) / Russian (PDF, X KB) / Tagalog (PDF, X KB) / Vietnamese (PDF, X KB)
Nondiscrimination notices, Language assistance notices, and Blue Shield MA-PD star ratings
Nondiscrimination and Language assistance notice
Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice
English (PDF, 525 KB) / Español (PDF, 489 KB)
Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Notice of availability of language assistance services and auxiliary aids and services (Notice of Availability)
English (PDF, 2 MB)
Blue Shield MA-PD Star ratings
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)
*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 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.
Blue Shield offers Blue Shield TotalDual plan (HMO D-SNP) to new members in Los Angeles and San Diego counties. Our D-SNP plans in Merced, Orange, San Bernardino, San Joaquin, and Stanislaus counties are closed to new enrollment.
H2819_24_441A_M Accepted 09172024
Y0118_24_441A_M Accepted 09182024
Page last updated: 10/1/2024