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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 Kern 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 $425.00 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 $2300.00 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 an annual prescription drug deductible of $425.00. After meeting this deductible, your copay for Tier 1 preferred generics is $5.00 at preferred pharmacies and $12.00 at standard pharmacies. Other tiers require coinsurance during this initial coverage phase, including 25% for standard generics and 30% for preferred brands, until total drug costs reach $2,100.00. After reaching $2,100.00 in yearly out-of-pocket drug costs, you enter the catastrophic coverage phase and will have no copay for covered Part D drugs. Additionally, individuals who qualify for the Low-Income Subsidy (LIS) will pay no cost for their Part D coverage. You should consult the plan's formulary to verify how your specific prescription medications are categorized.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers comprehensive medical coverage with fixed copayments and no coinsurance for many core services. Inpatient hospital stays require a $200 daily copay for the first five days and no copay thereafter, while outpatient hospital visits have a $200 copay. Emergency care is available with a $150 copay, which is waived if admitted, and urgently needed services are covered with no copay. Preventive services and annual physicals are covered with no copay or coinsurance, and the plan includes a $60 quarterly over-the-counter allowance. Vision care is partially covered with low copays of $10 to $20, while skilled nursing facility stays feature no copay for the first 20 days. Specialized services like dialysis and durable medical equipment generally require a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are partially covered by Blue Shield 65 Plus (HMO) with no coinsurance, requiring a $200 daily copay for days 1 to 5 (no copay for days 6 and beyond) for acute care, and a $900 copay per stay for psychiatric care. Non-Medicare-covered stays, inpatient acute upgrades, and additional psychiatric hospital days are not covered.
Outpatient Services See details
Blue Shield 65 Plus (HMO) covers outpatient services with no coinsurance, including outpatient hospital visits for a $200 copay and ambulatory surgical center services for a $50 copay. Outpatient substance abuse sessions require a $30 copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Blue Shield 65 Plus (HMO) covers partial hospitalization services with a $55 copay and no coinsurance. To access these covered benefits, a doctor referral and prior authorization are required.
Ambulance and Transportation Services See details
Blue Shield 65 Plus (HMO) partially covers ambulance and transportation services, as transportation to plan-approved or any health-related locations is not covered. Covered ground ambulance services require a $325 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, with prior authorization required.
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, while urgently needed services are covered 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) with no coinsurance, as podiatry services are not covered. Covered services require a $10 copay for occupational, physical, and speech therapies, a $20 copay for opioid treatment, and a $30 copay for mental health and psychiatric sessions.
Preventive Services See details
Preventive services are covered by Blue Shield 65 Plus (HMO) with no copay and no coinsurance for Medicare-covered zero-dollar services, alongside covered annual physical exams and kidney disease education. However, additional preventive services are only partially covered; while memory fitness and remote access technologies are included, sub-services such as health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety modifications, and counseling are not covered.
Hearing Services See details
Hearing services are covered under Blue Shield 65 Plus (HMO) with no deductible, though a doctor referral is required for exams. While some services are covered, routine hearing exams, fitting and evaluation services, OTC hearing aids, and all types of prescription hearing aids (including inner ear, outer ear, and over the ear) are not covered.
Vision Services See details
Blue Shield 65 Plus (HMO) partially covers vision services, though upgrades and combined eyeglasses (lenses and frames) are not covered. Covered routine eye exams require a $10 copay with no coinsurance, while contact lenses, individual eyeglass lenses, and eyeglass frames carry a $20 copay with no coinsurance.
Dental Services See details
Blue Shield 65 Plus (HMO) partially covers dental services, providing coverage for Medicare dental services with a doctor referral. However, several sub-services are not covered, including restorative, endodontics, periodontics, prosthodontics, implants, oral and maxillofacial surgery, orthodontics, maxillofacial prosthetics, and adjunctive general services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Blue Shield 65 Plus (HMO) with prior authorization, featuring coinsurance ranging from no coinsurance to 20% for Medicare Part B drugs. Covered Part B insulin drugs require a $35 copay, while chemotherapy, radiation, and other Part B drugs have no copay.
Dialysis Services See details
Blue Shield 65 Plus (HMO) covers dialysis services with a 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, featuring no coinsurance to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetic devices. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Blue Shield 65 Plus (HMO), as diagnostic procedures, lab services, and outpatient X-ray services are not covered. Covered diagnostic radiological services require a $70 copay and no coinsurance, while therapeutic radiological services require a 20% coinsurance and no copay.
Home Health Services See details
Home Health Services are covered by Blue Shield 65 Plus (HMO), requiring a doctor referral and prior authorization for members to receive care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under Blue Shield 65 Plus (HMO) because none of the individual sub-services, including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are covered, meaning there is no copay or coinsurance.
Skilled Nursing Facility (SNF) See details
Blue Shield 65 Plus (HMO) partially covers Skilled Nursing Facility (SNF) services, as additional days beyond the Medicare-covered limit are not covered. Covered stays require prior authorization and a doctor referral, featuring no copay or coinsurance for days 1 through 20, and a $125 daily copay with no coinsurance for days 21 through 100.
Other Services See details
Other Services are partially covered by Blue Shield 65 Plus (HMO), featuring an Over-the-Counter (OTC) benefit with a $60 allowance every three months at no copay or coinsurance. Acupuncture, meal benefits, and dual eligible SNPs are not covered under this plan.
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