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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 Riverside 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 $2800.00 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) plan features an Enhanced Alternative drug benefit with a $340.00 annual prescription drug deductible. During the initial coverage phase, you will pay a $10.00 copay for Tier 1 preferred generic drugs at preferred pharmacies, or an $18.00 copay at standard pharmacies. For higher drug tiers, you will pay a coinsurance ranging from 20% for standard generics up to 29% for non-preferred drugs. After your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. Additionally, beneficiaries who qualify for the Low-Income Subsidy will see their Part D costs reduced to no cost.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers comprehensive coverage for core medical services with clear, predictable out-of-pocket costs and no deductibles for most care. Inpatient hospital stays require a $75 daily copay for the first five days followed by no copay for days six through 90, while outpatient hospital visits carry a $200 copay. Emergency care is available with a $150 copay that is waived upon hospitalization, and urgently needed services require no copay. For routine care, primary doctor visits and preventive services feature no copay, while routine eye exams require a $10 copay. Specialized services like dialysis and durable medical equipment require up to a 20% coinsurance, and skilled nursing facility stays are covered with no copay for the first 20 days. Keep in mind that this plan does not cover routine dental services, hearing aids, or over-the-counter items.
Inpatient Hospital See details
Blue Shield 65 Plus (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $75 daily copay for days 1 through 5 (no copay for days 6 through 90) for acute care and a $900 copay per stay for psychiatric care. While unlimited additional acute days are covered with no copay, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Shield 65 Plus (HMO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital services and a $50 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay, and outpatient blood services have no deductible, with most services requiring doctor referrals and prior authorization.
Partial Hospitalization See details
Blue Shield 65 Plus (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Blue Shield 65 Plus (HMO), which offers ambulance coverage but does not cover transportation services to health-related locations. Covered ground ambulance services require a $250 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, with the copay waived if you are hospitalized within one day. Urgently needed services have no copay or coinsurance, and worldwide emergency and urgent services are partially covered with a $150 copay and no coinsurance up to a $10,000 maximum limit, though worldwide emergency transportation is not covered.
Primary Care See details
Blue Shield 65 Plus (HMO) partially covers Primary Care benefits, as routine chiropractic care and podiatry services are not covered. Covered care options require no coinsurance, with copays ranging from $15 to $30 for services like therapy and psychiatric sessions.
Preventive Services See details
Blue Shield 65 Plus (HMO) preventive services are partially covered, offering Medicare-covered zero-dollar preventive services, annual physicals, and kidney education with no copay and no coinsurance. Uncovered services include health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, disease management, telemonitoring, home modifications, and counseling.
Hearing Services See details
Blue Shield 65 Plus (HMO) covers hearing exams with a doctor referral and no deductible, though routine exams and hearing aid fitting evaluations are not covered. While some prescription hearing aid services are covered, prescription hearing aids of all types (including inner ear, outer ear, and over the ear) and OTC hearing aids are not covered in practice.
Vision Services See details
Vision services are partially covered by Blue Shield 65 Plus (HMO), with no deductibles or coinsurance. Routine eye exams require a $10 copay, and contact lenses, eyeglass lenses, and frames require a $20 copay, 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), which covers Medicare dental services with a doctor referral. The plan does not cover restorative, endodontic, periodontic, prosthodontic, implant, oral surgery, orthodontic, maxillofacial prosthetic, or adjunctive general services.
Home Infusion bundled Services See details
Blue Shield 65 Plus (HMO) covers home infusion bundled services with prior authorization, offering chemotherapy, radiation, and other Part B drugs with no copay and no coinsurance to 20% coinsurance. Covered Medicare 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, featuring durable medical equipment with no copay and coinsurance ranging from no coinsurance to 20%, alongside prosthetic devices with no copay and 20% coinsurance. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Blue Shield 65 Plus (HMO) partially covers Diagnostic and Radiological Services with a doctor referral, though diagnostic procedures, lab services, and outpatient X-rays are not covered. Covered diagnostic radiological services require a $30 copay and no coinsurance, while therapeutic radiological services have a 20% coinsurance and no copay.
Home Health Services See details
Home health services are covered by Blue Shield 65 Plus (HMO), though members must obtain prior authorization and a doctor referral. Specific copay and coinsurance details are not specified for this covered benefit.
Cardiac Rehabilitation Services See details
Blue Shield 65 Plus (HMO) indicates that some services are covered for Cardiac Rehabilitation Services with no coinsurance and varying copays, but Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization and a doctor referral are required.
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. There is no copay or coinsurance for days 1 through 20, while days 21 through 100 require a $120 daily copay and no coinsurance; however, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Blue Shield 65 Plus (HMO) does not cover Other Services, meaning there is no coverage for acupuncture, over-the-counter (OTC) items, meal benefits, or dual-eligible SNPs under this plan.
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