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)

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,  154 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)


 

Member Handbook
English (PDF, 1.2 MB) / Español (PDF, 1.3 MB) 

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,  154 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)


 

Member Handbook
English (PDF, 1.2 MB) / Español (PDF, 1.2 MB)

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,  154 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, Multi-Language Interpreter Services notices, and Blue Shield MA-PD star ratings

Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice
English (PDF, 506 KB) / Español (PDF, 478 KB) / Arabic (PDF, 623 KB) / Armenian (PDF, 517 KB) / Chinese (Simplified) (PDF, 555 KB) / Chinese (Traditional) (PDF, 563 KB) / Farsi (PDF, 554 KB) / Khmer (PDF, 508 MB) /  Korean (PDF, 577 KB) / Russian (PDF, 678 B) / Tagalog (PDF, 476 KB) / Vietnamese (PDF, 521 KB) 

Blue Shield TotalDual Plan (HMO D-SNP) and Blue Shield Inspire (HMO D-SNP) Multi-language Interpreter Services notice 
English (PDF, 1.2 MB)


 

Blue Shield Inspire (HMO D-SNP) and Blue Shield TotalDual Plan (HMO D-SNP) Medicare Star Ratings*

English (PDF, 166 KB)
Español (PDF, 158 KB)
Arabic (PDF, 283 KB)
Armenian (PDF, 299 KB)
Chinese (Simplified) (PDF, 258 KB)
Chinese (Traditional) (PDF, 190 KB)
Farsi (PDF, 260 KB)
Khmer (PDF, 242 KB)
Korean (PDF, 135 KB)
Russian (PDF, 169 KB)
Tagalog (PDF, 168  KB)
Vietnamese (PDF, 259 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_441A1_M Accepted 10122024
Y0118_24_441A1_M Accepted 10122024
Page last updated: 10/15/2024

*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.

 
 
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。