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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 2025, 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 3.5 out of 5 stars in 2025.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $2700.00 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 has an Enhanced Alternative drug benefit. The plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions, which varies depending on the drug tier and the pharmacy you use. For example, you will pay a $10 copay at a preferred pharmacy for a preferred generic drug. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for your covered drugs.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and partial hospitalization. Emergency services, primary care, preventive services, and home health services are also covered. The plan also covers ambulance services, with a copay for ground and coinsurance for air ambulance services. This plan provides coverage for hearing and vision services. Vision services include eye exams and eyewear with copays. Dental services are covered with copays. The plan also offers coverage for home infusion, dialysis, medical equipment, diagnostic and radiological services, cardiac rehabilitation, and skilled nursing facility stays.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with prior authorization and a doctor's referral required. For Inpatient Hospital-Acute, you'll pay a $75 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, there is a $900 copay.
Outpatient Services See details
Outpatient services include outpatient hospital services with a $200 copay, ambulatory surgical center (ASC) services with a $50 copay, and outpatient substance abuse services with a copay of $30 for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Shield 65 Plus (HMO) plan, requiring prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services. Ground ambulance services have a $250 copay, and air ambulance services have 20% coinsurance; however, transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a copay of $140, $10, and $140 respectively, with no coinsurance. Worldwide Emergency Transportation is not covered. Worldwide Urgent Coverage has a $140 copay and no coinsurance.
Primary Care See details
The Blue Shield 65 Plus (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $5 copay, while occupational therapy services, individual and group mental health sessions, and individual and group psychiatric sessions each have a $25 copay. Specialist visits have a $0-$5 copay, while physical therapy and speech-language pathology services have a $25 copay.
Preventive Services See details
The Blue Shield 65 Plus (HMO) plan covers preventive services including annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. The plan does not cover health education, in-home safety assessment, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, or counseling services.
Hearing Services See details
Hearing services with Blue Shield 65 Plus (HMO) include routine hearing exams with no copay, but fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $5 copay, and routine eye exams with a $10 copay, and eyewear. Eyewear benefits include contact lenses with a $20 copay, eyeglass lenses with a $20 copay, and eyeglass frames with a $20 copay. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services are covered by the Blue Shield 65 Plus (HMO) plan, with a copay between $0 and $5 for Medicare Dental Services. However, Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Blue Shield 65 Plus (HMO) plan, but require prior authorization and a doctor's referral. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetic Devices with a 20% coinsurance, while Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Prosthetics/Medical Supplies have a coinsurance for Medicare-covered Medical Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Blue Shield 65 Plus (HMO) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. For Diagnostic Radiological Services, there is a copay of at most $25.00. For Therapeutic Radiological Services, there is a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Blue Shield 65 Plus (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization and referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Blue Shield 65 Plus (HMO), but the plan does not cover the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization and a doctor referral are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Shield 65 Plus (HMO) plan, but require prior authorization and a doctor referral. There is no copay for days 1-20, and a $120 copay for days 21-100; additional days beyond Medicare and non-Medicare stays are not covered.
Other Services See details
Other Services are not covered under the Blue Shield 65 Plus (HMO) plan, including acupuncture, over-the-counter items, meal benefits, and more. No authorization or referrals are required for these services.
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