2026 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)
Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles and San Diego counties
Member Handbook
English (PDF, 3.4 MB) / Español (PDF, 4.7 MB) / Arabic (PDF, 5.3 MB) / Armenian (PDF, 5.1 MB) / Chinese (Simplified) (PDF, 4.5 MB) / Chinese (Traditional) (PDF, 6.4 MB) / Farsi (PDF, 5.8 MB) / Khmer (PDF, 11.7 MB) / Korean (PDF, 13.1 MB) / Russian (PDF, 3.8 MB) / Tagalog (PDF, 5.7 MB) / Vietnamese (PDF, 4.3 MB)
Summary of Benefits (SOB)
English (PDF, 1.9 MB) / Español (PDF, 1.2 MB) / Arabic (PDF, 1.3 MB) / Armenian (PDF, 1.4 MB) / Chinese (Simplified) (PDF, 1.3 MB) / Chinese (Traditional) (PDF, 1.4 MB) / Farsi (PDF, 1.4 MB) / Khmer (PDF, 1.8 MB) / Korean (PDF, 2 MB) / Russian (PDF, 1.3 MB) / Tagalog (PDF, 1.3 MB) / Vietnamese (PDF, 1.3 MB)
Annual Notice of Changes
English (PDF, 1.3 MB) / Español (PDF, 908 KB) / Arabic (PDF, 999 KB) / Armenian (PDF, 974 KB) / Chinese (Simplified) (PDF, 1.0 MB) / Chinese (Traditional) (PDF, 999 KB) / Farsi (PDF, 959 KB) / Khmer (PDF, 1.0 MB) / Korean (PDF, 972 KB) / Russian (PDF, 980 KB) / Tagalog (PDF, 909 KB) / Vietnamese (PDF, 1.0 MB)
Attestation for Food and Produce Special Supplemental Benefit for the Chronically Ill (SSBCI)
This plan includes a Special Supplemental Benefit for the Chronically Ill (SSBCI) called Food and Produce. Eligibility depends on meeting the definition of a “chronically ill enrollee”. Not all members will qualify. We will inform you whether an attestation from your provider is required to let us know that you meet the definition.
English (PDF, 46 KB) / Español (PDF, 43 KB) / Chinese (Simplified) (PDF, 43 KB) / Chinese (Traditional) (PDF, 43 KB)
Enrollment Form
English (PDF, 263 KB / Español (PDF, 200 KB) / Arabic (PDF, 280 KB) / Armenian (PDF, 262 KB) / Chinese (Simplified) (PDF, 382 KB) / Chinese (Traditional) (PDF, 280 KB) / Farsi (PDF, 322 KB) / Khmer (PDF, 299 KB) / Korean (PDF, 241 KB) / Russian (PDF, 339 KB) / Tagalog (PDF, 199 KB) / Vietnamese (PDF, 349 KB)
Pre-enrollment Checklist
English (PDF, 135 KB) / Español (PDF, 141 KB) / Arabic (PDF, 345 KB) / Armenian (PDF, 225 KB) / Chinese (Simplified) (PDF, 226 KB) / Chinese (Traditional) (PDF, 255 KB) / Farsi (PDF, 293 KB) / Khmer (PDF, 337 KB) / Korean (PDF, 220 KB) / Russian (PDF, 271 KB) / Tagalog (PDF, 134 KB) / Vietnamese (PDF, 43 KB)
Model of Care Evaluation Summary of Findings
English (PDF, 211 KB) / Español (PDF, 193 KB) / Arabic (PDF, 243 KB) / Armenian (PDF, 233 KB) / Chinese (Simplified) (PDF, 391 KB) / Chinese (Traditional) (PDF, 311 KB) / Farsi (PDF, 248 KB) / Khmer (PDF, 204 KB) / Korean (PDF, 298 KB) / Russian (PDF, 236 KB) / Tagalog (PDF, 167 KB) / Vietnamese (PDF, 240 KB)
Dental guide
English (PDF, 392 KB) / Español (PDF, 397 KB)
Nondiscrimination notices, Notice of Availability of Language Services and Auxiliary Aids and Services and Blue Shield MA-PD star ratings
Nondiscrimination and Notice of Availability
Blue Shield Medicare Advantage Prescription Drug Plans Nondiscrimination notice
English (PDF, 103 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) Notice of Availability
English (PDF, 1.2 MB)
Blue Shield MA-PD Star ratings
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, 184 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 see 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:
- Dual Special Needs Plans Customer Service at (800) 452-4413 (TTY: 711), 8 a.m. to 8 p.m., Pacific time, 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.
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_341D3_C 09172025
H2819_25_341D3_C Accepted 09232025
Page last updated: 10/1/2025