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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 San Diego 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 $1800.00 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:
Sign up for Blue Shield 65 Plus (HMO)
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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. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $3 copay at preferred pharmacies and a $10 copay at standard pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers a comprehensive range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the service. You'll also find coverage for primary care, preventive services, and a wide array of other services such as hearing, vision, and dental care. Emergency services and ambulance services are covered, with copays and coinsurance applying in certain situations. This plan includes coverage for home health services, skilled nursing, and partial hospitalization with copays. Additionally, the plan provides coverage for medical equipment, dialysis, and diagnostic services with coinsurance and copays. Other notable benefits include transportation services, cardiac rehabilitation, and coverage for over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute with a $150 copay for days 1-7 and no copay for days 8-90, and Inpatient Hospital Psychiatric with a $250 copay for days 1-7 and no copay for days 8-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a $200 copay, and ASC services have a $50 copay, while individual and group outpatient substance abuse sessions have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Shield 65 Plus (HMO) plan, but requires prior authorization and a doctor's referral. You will have a $55 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Shield 65 Plus (HMO) plan. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for 18 one-way trips every year, and transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Blue Shield 65 Plus (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have no copay; all three have no coinsurance. Worldwide Urgent Coverage also has a $140 copay, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Shield 65 Plus (HMO) plan covers primary care physician services, chiropractic services with a $5 copay, occupational therapy with a $40 copay, physician specialist services with a $0-$5 copay, mental health specialty services with a $20 copay for individual and group sessions, podiatry services with a $5 copay, other health care professional services with a $0-$5 copay, psychiatric services with a $20 copay for individual and group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services. Routine foot care is covered.
Preventive Services See details
The Blue Shield 65 Plus (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. Some additional preventive services like Health Education, In-Home Safety Assessment, Medical Nutrition Therapy, and others are not covered.
Hearing Services See details
The Blue Shield 65 Plus (HMO) plan covers hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, with no deductible. Routine hearing exams are limited to one in-person exam yearly when performed by the network hearing aid vendor, and fitting/evaluation for hearing aids is limited to two visits yearly. Prescription hearing aids (all types) are covered with a copay between $449 and $699. Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $5 copay, contact lenses, eyeglass lenses, and eyeglass frames. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Shield 65 Plus (HMO) plan covers a variety of dental services, including oral exams with a copay of $0-$16, dental x-rays with a copay of $0-$10, and other diagnostic services with a copay of $0-$15. Fluoride treatment has a $5 copay, while other preventive services have a copay of $0-$80. Restorative services have a copay of $19-$430, endodontics has a copay of $25-$373, periodontics has a copay of $40-$60, prosthodontics (removable) has a copay of $28-$525, prosthodontics (fixed) has a copay of $40-$430, and oral and maxillofacial surgery has a copay of $23-$80. However, maxillofacial prosthetics and orthodontics are not covered, while implant services are offered as a supplemental benefit, and may require additional payment.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is 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. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with a coinsurance of 0-20%, Prosthetic Devices with a 20% coinsurance, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Blue Shield 65 Plus (HMO) plan. Diagnostic services have no copay, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $50.00, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services are not covered.
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. This benefit requires authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization and a doctor referral are required.
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's referral. For days 1-20, there is no copay, but for days 21-100, there is a $140 copay; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefits. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. The plan provides up to $90 every three months for OTC items, and offers nicotine replacement therapy.
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