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Blue Shield 65 Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield 65 Plus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield 65 Plus (HMO) in 2026, please refer to our full plan details page.
Blue Shield 65 Plus (HMO) is a HMO plan offered by California Physicians' Service available for enrollment in 2025 to people living in San Bernardino County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Blue Shield 65 Plus (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Shield 65 Plus (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Shield 65 Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $340.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Shield 65 Plus (HMO) Medicare plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $340.00. During the initial coverage phase, Tier 1 preferred generic drugs require a $10.00 copay at preferred pharmacies or an $18.00 copay at standard pharmacies. Standard generic drugs in Tier 2 are covered with a 20% coinsurance at both preferred and standard pharmacy locations. For higher-tier medications, you will pay a 25% coinsurance for Tier 3 preferred brands and a 29% coinsurance for Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and have no copay for covered Part D drugs. Additionally, those who qualify for the low-income subsidy will pay no cost for their Part D premium.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers robust coverage for essential medical services, featuring no copay for primary care visits, annual physical exams, and urgent care. Inpatient hospital stays require a $50 daily copay for the first five days and no copay thereafter, while outpatient hospital services carry a $250 copay. Emergency room visits have a $150 copay, which is waived if you are admitted, and ground ambulance rides require a $275 copay. Specialty care benefits include routine eye exams with no copay, eyewear for a $20 copay, and dental services with copays ranging up to $525. Skilled nursing facility stays are covered with no copay for the first 20 days, followed by a $100 daily copay up to day 100. Note that this plan does not cover routine hearing aids, cardiac rehabilitation, acupuncture, or over-the-counter items.
Inpatient Hospital See details
Blue Shield 65 Plus (HMO) partially covers inpatient hospital services with no coinsurance, but does not cover upgrades, non-Medicare-covered stays, or additional psychiatric days. Acute stays require a $50 copay per day for days 1 through 5 and no copay for days 6 and beyond, while psychiatric stays incur a $900 copay per stay.
Outpatient Services See details
Blue Shield 65 Plus (HMO) covers outpatient services with no coinsurance, featuring a $250 copay for outpatient hospital services, a $100 copay for ambulatory surgical center services, and a $30 copay for outpatient substance abuse sessions. Outpatient blood services are also covered with no deductible, no copay, and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Blue Shield 65 Plus (HMO) with a $55 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Blue Shield 65 Plus (HMO) partially covers Ambulance and Transportation Services, as transportation services to both plan-approved and any health-related locations are not covered. Covered ground ambulance services require a $275 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay.
Emergency Services See details
Blue Shield 65 Plus (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within one day, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $50,000 maximum with a $150 copay and no coinsurance for emergency and urgent care, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are partially covered by Blue Shield 65 Plus (HMO), though podiatry services and routine chiropractic care are not covered. Covered services require no coinsurance, featuring a $30 copay for mental health and psychiatric sessions, a $15 copay for opioid treatment, and no copay for all other primary care services.
Preventive Services See details
Blue Shield 65 Plus (HMO) preventive services are partially covered with no copay and no coinsurance for annual physical exams and Medicare-covered zero-dollar services. While memory fitness and remote access technologies are included, the plan does not cover sub-services like health education, personal emergency response systems, alternative therapies, and weight management programs.
Hearing Services See details
Blue Shield 65 Plus (HMO) covers some hearing exams with no deductible, though a doctor referral is required. Routine hearing exams, fitting evaluations, prescription hearing aids, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Shield 65 Plus (HMO) with no deductible or coinsurance, offering routine eye exams with no copay. Covered eyewear, such as contact lenses, eyeglass lenses, and frames, requires a $20 copay and no coinsurance, while upgrades and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Dental services are partially covered by Blue Shield 65 Plus (HMO) with no coinsurance and copays ranging from no copay up to $525, though maxillofacial prosthetics and orthodontics are not covered. Covered benefits include oral exams, x-rays, cleanings, fluoride, restorative care, endodontics, periodontics, prosthodontics, and oral surgery, while implant services are available as an optional supplemental benefit.
Home Infusion bundled Services See details
Home infusion bundled services are partially covered by Blue Shield 65 Plus (HMO) with prior authorization, as Part D home infusion drugs are not covered as a bundled service. Covered Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Blue Shield 65 Plus (HMO) covers Dialysis Services with 20% coinsurance and no copay. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Blue Shield 65 Plus (HMO) partially covers medical equipment with no copays, requiring 20% coinsurance for prosthetic devices and ranging from no coinsurance to 20% coinsurance for durable medical equipment. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered under this plan.
Diagnostic and Radiological Services See details
Blue Shield 65 Plus (HMO) partially covers diagnostic and radiological services with a doctor's referral, though diagnostic procedures, lab services, and outpatient X-rays are not covered. Covered diagnostic services require no copay, while diagnostic radiological services require a $20 copay and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Blue Shield 65 Plus (HMO) but require prior authorization and a doctor referral, with specific copay and coinsurance costs not provided in the plan details.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Blue Shield 65 Plus (HMO) plan, meaning no coverage is provided for cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Blue Shield 65 Plus (HMO), requiring prior authorization and a doctor referral, while additional days beyond Medicare-covered limits are not covered. Covered stays feature no copay or coinsurance for days 1 through 20, and a $100 daily copay with no coinsurance for days 21 through 100.
Other Services See details
Other Services are not covered under the Blue Shield 65 Plus (HMO) plan. There is no coverage, and therefore no copays or coinsurance, for acupuncture, over-the-counter (OTC) items, meal benefits, and dual eligible SNPs with highly integrated services.
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