Blue Shield of California Medicare 65 Plus HMO - Information & Applications

You can download a comprehensive plan description - a document called an Evidence of Coverage - for each area and plan type, as well as a Summary of Benefits.

For Los Angeles and Orange Counties:

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 356KB)

For San Bernardino County:

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 190KB)

For Sacramento County:

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 350KB)

For San Diego County:

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 260KB)

For Riverside County:

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 343KB)

For Ventura County

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 355KB)

For Blue Shield 65 Plus Choice Plan (HMO):

• Evidence of Coverage: English / Spanish (PDF, 1MB)

• Summary of Benefits: English / Spanish (PDF, 239KB)

Blue Shield 65 Plus (HMO) Plan in Los Angeles, Orange, Sacramento, San Diego, and Ventura counties

• 2013 Blue Shield 65 Plus HMO Formulary  (PDF, 383KB)

Blue Shield 65 Plus (HMO) Plan in Riverside and San Bernardino counties

• 2013 Blue Shield 65 Plus HMO Formulary  (PDF, 366KB)

Blue Shield 65 Plus Choice Plan (HMO)

• 2013 Blue Shield 65 Plus Choice Plan (HMO) Formulary  (PDF, 380KB

• Blue Shield Rx (pdp) Application stand alone plan

Mail your enrollment application to the address below:

Blue Shield Medicare Advantage HMO (pdp) Application

Oleg Skurskiy
18375 Ventura Blvd. # 226
Tarzana , CA 91356

Or can fax complete application to Fax: (818) 776-9865