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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 Diego 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 $250.00 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 $1750.00 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) prescription drug plan features an Enhanced Alternative benefit with a $250 annual drug deductible. After meeting this deductible, you enter the initial coverage phase where Tier 1 preferred generic drugs have no copay at preferred pharmacies and a $10 copay at standard pharmacies. During this phase, Tier 2 standard generic drugs require a 20% coinsurance at both preferred and standard pharmacies. For higher-tier medications, you will pay a 25% coinsurance for Tier 3 preferred brands and a 30% coinsurance for Tier 4 non-preferred drugs. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, those who qualify for the low-income subsidy can see their Part D premium reduced to $0.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers robust medical coverage with many essential services available at no cost to members. You will pay no copay or coinsurance for primary care, specialist visits, telehealth services, and preventive care. For hospital care, inpatient acute stays require a $150 daily copay for days 1 through 7, while outpatient hospital visits have a $200 copay, both featuring no coinsurance. This plan also includes key supplemental benefits, such as routine hearing exams and dental care with no coinsurance, as well as a $300 allowance for contact lenses and frames. Additionally, members benefit from no copay on up to 18 one-way transportation trips and a $100 quarterly over-the-counter item allowance. While most services require no deductible, some specialized treatments like dialysis and therapeutic radiology carry a 20% coinsurance.
Inpatient Hospital See details
Blue Shield 65 Plus (HMO) partially covers inpatient hospital benefits with no coinsurance, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. For acute hospital stays, there is a $150 daily copay for days 1 through 7 and no copay for days 8 through 90, while psychiatric stays require a $250 daily copay for days 1 through 7 and no copay for days 8 through 90.
Outpatient Services See details
Blue Shield 65 Plus (HMO) covers outpatient services with no coinsurance, including a $200 copay for outpatient hospital services and a $50 copay for ambulatory surgical center services. Outpatient substance abuse services require a $30 copay per session, and outpatient blood services are covered with no copay.
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
Blue Shield 65 Plus (HMO) partially covers ambulance and transportation services, as transportation to any health-related location is not covered. Ground ambulance services require a $275 copay with no coinsurance, air ambulance services require a 20% coinsurance with no copay, and up to 18 one-way trips to plan-approved locations are covered with no copay or coinsurance.
Emergency Services See details
Emergency services are partially covered under Blue Shield 65 Plus (HMO) because worldwide emergency transportation is not covered. Covered emergency services and worldwide emergency or urgent care require a $150 copay with no coinsurance, while urgently needed services are offered with no copay and no coinsurance.
Primary Care See details
Primary Care benefits under Blue Shield 65 Plus (HMO) are covered with no copay and no coinsurance for primary care, specialist, telehealth, chiropractic, and podiatry services. Occupational, physical, and speech therapies require a $40 copay and no coinsurance, while mental health, psychiatric, and opioid treatment services have a $20 copay and no coinsurance.
Preventive Services See details
Blue Shield 65 Plus (HMO) covers Medicare-covered preventive services with no copays or coinsurance, as well as annual physical exams and kidney disease education. While select additional preventive services like memory fitness and personal emergency response systems are covered, most others—including health education, weight management, and nutritional benefits—are not covered.
Hearing Services See details
Hearing services are partially covered by Blue Shield 65 Plus (HMO), offering one annual routine hearing exam and three fitting evaluations with no deductible. Prescription hearing aids (all types) are covered up to two times per year with a copay ranging from $449 to $999 and no coinsurance, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Shield 65 Plus (HMO) with no deductible, though specific copay and coinsurance details are not specified. The plan covers annual routine eye exams, contact lenses up to $300 yearly, eyeglass lenses, and frames up to $300 every two years, 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 maxillofacial prosthetics and orthodontics not covered. Covered dental benefits require no coinsurance, with copays ranging from no copay up to $525 depending on the service.
Home Infusion bundled Services See details
Blue Shield 65 Plus (HMO) covers home infusion bundled services with prior authorization, featuring a $35 copay and no coinsurance to 20% coinsurance for Medicare Part B insulin drugs. Other covered Part B chemotherapy, radiation, and miscellaneous drugs require no copay and carry no coinsurance to 20% coinsurance.
Dialysis Services See details
Blue Shield 65 Plus (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive this covered benefit.
Medical Equipment See details
Blue Shield 65 Plus (HMO) partially covers medical equipment, featuring covered durable medical equipment with no copay and no coinsurance to 20% coinsurance, and prosthetic devices with no copay and 20% coinsurance. Prior authorization is required for covered items, while 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's referral, though diagnostic procedures, lab services, and outpatient x-rays are not covered. Covered diagnostic radiological services require a $50 copay with no coinsurance, while therapeutic radiological services require a 20% coinsurance with no copay.
Home Health Services See details
Home Health Services are covered under the Blue Shield 65 Plus (HMO) plan, though patients must obtain prior authorization and a doctor referral first.
Cardiac Rehabilitation Services See details
Blue Shield 65 Plus (HMO) does not cover Cardiac Rehabilitation Services, meaning there is no coverage or cost-sharing benefits for cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, or supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
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 for days 1 through 20, a $140 daily copay for days 21 through 100, and no coinsurance, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Blue Shield 65 Plus (HMO), featuring a meal benefit for chronic illnesses and a $100 quarterly over-the-counter item allowance with no copay or coinsurance. Acupuncture and dual-eligible SNP services are not covered under this benefit.
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