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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 Luis Obispo and Santa Barbara Counties. 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 $54.00. 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 $3600.00 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. There is no deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for your prescriptions depending on the drug tier and pharmacy. For example, a preferred generic drug has a $10 copay at a preferred pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays for specific services. Emergency services and primary care visits also have copays. The plan includes coverage for preventive, hearing, vision, and dental services, with specific limitations and cost-sharing for each. Additionally, the plan covers home health, dialysis, and medical equipment, as well as other services like OTC items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization and a doctor referral. For Inpatient Hospital-Acute, you will pay a $275 copay for days 1-5, and no copay for days 6-90, while Inpatient Hospital Psychiatric has a $900 copay per stay.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a $150 copay for outpatient hospital services, and a $30 copay for individual and group sessions for outpatient substance abuse. Outpatient blood services are also covered with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered with a $55 copay, and requires prior authorization and a doctor's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Shield 65 Plus (HMO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a copay of $280.00, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a $5 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Shield 65 Plus (HMO) plan covers primary care services, including physician services, occupational therapy, physician specialist services, mental health specialty services, psychiatric services, physical therapy, and speech-language pathology services. Chiropractic services are partially covered, but routine chiropractic care is not covered. The plan has a $20 copay for occupational therapy, and a $20 copay for physical therapy and speech-language pathology services. Individual and group sessions for mental health and psychiatric services have a $30 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 EKGs following a welcome visit. Some services are not covered, including health education, in-home safety assessments, and several others.
Hearing Services See details
Hearing services are covered, including routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are limited to 1 in-person exam per year when performed by the network hearing aid vendor. Fitting/evaluation for hearing aids is limited to 2 visits per year. Prescription hearing aids have a copay between $449 and $699, and are limited to 2 per year. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
Vision Services include coverage for eye exams, contact lenses, eyeglass lenses, and eyeglass frames, but not for eyeglasses (lenses and frames) or upgrades. Routine eye exams are covered once per year, while contact lenses are covered up to $255 per year, eyeglass lenses are covered once per year, and eyeglass frames are covered up to $255 every two years.
Dental Services See details
The Blue Shield 65 Plus (HMO) plan covers various dental services including oral exams, dental x-rays, other diagnostic services, prophylaxis (cleaning), fluoride treatments, and other preventive services, with a coinsurance of 0% to 20%. However, orthodontic services, restorative services, and other specific dental services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is 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 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 benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20% and Prosthetic Devices with a 20% coinsurance, but does not cover Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, or Diabetic Therapeutic Shoes/Inserts. The plan also covers Prosthetics/Medical Supplies - Non-Medicare benefit, with no copay, and Diabetic Equipment.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Blue Shield 65 Plus (HMO), but Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay of at most $75.00, 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. This benefit requires authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. A doctor referral and prior authorization 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's referral. There is no copay for days 1-20, and a $200 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) items with a maximum benefit of $65 every three months, and Nicotine Replacement Therapy (NRT) is included as a Part C OTC benefit, but acupuncture, meal benefits, 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.
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