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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 Kern 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 no deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for your prescriptions. The copay varies depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $15 copay at preferred pharmacies and a $20 copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with a copay, and emergency services with a copay. It also covers primary care, preventive services, hearing services (routine exams), vision services (exams, contact lenses, and glasses), and dental services. Additional benefits include ambulance services, partial hospitalization, home health services, cardiac rehabilitation, and skilled nursing facility stays. The plan also provides coverage for home infusion services, dialysis, medical equipment, diagnostic and radiological services, and other services such as over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits for Blue Shield 65 Plus (HMO) include coverage for Inpatient Hospital-Acute with a $75 copay for days 1-5, and no copay for days 6-90, and also covers Inpatient Hospital Psychiatric with a $900 copay per admission or stay. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered stay and upgrades for Inpatient Hospital-Acute, and additional days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the Blue Shield 65 Plus (HMO) plan. Outpatient hospital services have a $150 copay, and individual and group sessions for outpatient substance abuse have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Shield 65 Plus (HMO) plan, requiring prior authorization and a doctor referral. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Blue Shield 65 Plus (HMO) plan. Ground ambulance services have a $280 copay, while air ambulance services have a 20% coinsurance. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a $140 copay with no coinsurance. 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 doctor referral), occupational therapy services (with a $10 copay), physician specialist services (with a doctor referral), and mental health specialty services (with a $30 copay for individual and group sessions). The plan also covers physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits, and opioid treatment program services. Podiatry services are not covered.
Preventive Services See details
The Blue Shield 65 Plus (HMO) plan covers various preventive services, including annual physical exams, with coverage for services not typically covered by Medicare plans. Other services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and others are not covered.
Hearing Services See details
Hearing Services, including routine hearing exams, are covered with no deductible and no coinsurance. However, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $10 copay, contact lenses with a $20 copay and a maximum plan benefit coverage amount of $160, eyeglass lenses with a $20 copay, and eyeglass frames with a $20 copay and a maximum plan benefit coverage amount of $160. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Shield 65 Plus (HMO) plan covers Medicare Dental Services with a doctor referral, but 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. For Medicare Part B Insulin Drugs, you pay a $35 copay, and the coinsurance is between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with prior authorization and a doctor's referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and coverage for Prosthetic Devices with 20% coinsurance, but Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Prosthetics/Medical Supplies - Non-Medicare benefit are covered with coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Blue Shield 65 Plus (HMO) plan. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $60.00, and Therapeutic Radiological Services have 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. Prior authorization and a referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Blue Shield 65 Plus (HMO) plan, but require prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $100.
Other Services See details
Other Services includes coverage for over-the-counter (OTC) items, with a maximum benefit of $70 every three months, and offers nicotine replacement therapy (NRT) as a Part C OTC benefit. Acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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.
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