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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 Luis Obispo and Santa Barbara Counties. 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 $65.00. 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 $4100.00 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 a yearly prescription drug deductible of $425.00 before your initial coverage begins. During this initial phase, Tier 1 preferred generic drugs cost a $5.00 copay at preferred pharmacies and a $12.00 copay at standard pharmacies. For other tiers, you will pay a coinsurance of 25% for standard generics, 30% for preferred brands, and 28% for non-preferred drugs. After your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase where you pay nothing for covered Part D prescriptions. Additionally, individuals who qualify for the low-income subsidy will pay no copay for their Part D coverage. This enhanced alternative plan is designed to help lower your overall out-of-pocket medication expenses.
Additional Benefits
The Blue Shield 65 Plus (HMO) plan offers comprehensive coverage for essential medical services with predictable cost structures. Inpatient hospital stays require a $500 copay per day for the first four days and no copay for days five through 90, while outpatient hospital services carry a $200 copay. Additionally, emergency room visits have a $150 copay, which is waived if admitted, and urgent care visits require no copay. Preventive care, annual routine hearing exams, and routine eye exams are covered with no copay, coinsurance, or deductible. Routine dental services require no copay and 0% to 20% coinsurance, while skilled nursing facility stays incur a $10 daily copay for the first 20 days. However, this plan does not cover acupuncture, over-the-counter items, meal benefits, or transportation services.
Inpatient Hospital See details
Blue Shield 65 Plus (HMO) partially covers inpatient hospital stays with no coinsurance, requiring a $500 copay for days 1 through 4 of an acute stay (no copay for days 5 through 90) and a $900 copay per psychiatric stay. Unlimited additional acute days are covered with no copay, but acute upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Shield 65 Plus (HMO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital services and a $50 copay for both ambulatory surgical center and observation services. Outpatient substance abuse sessions require a $30 copay, and outpatient blood services are covered with no deductible.
Partial Hospitalization See details
Blue Shield 65 Plus (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Access to this covered benefit requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Blue Shield 65 Plus (HMO), as transportation services to health-related locations are not covered. Covered ground ambulance services require a $285 copay and no coinsurance, while air ambulance services require a 20% coinsurance and no copay, both requiring prior authorization.
Emergency Services See details
Blue Shield 65 Plus (HMO) covers emergency services with a $150 copay and no coinsurance (waived if admitted to the hospital within one day) and urgent care with no copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are covered by Blue Shield 65 Plus (HMO) with no coinsurance, featuring a $20 copay for occupational, physical, and speech therapies and a $30 copay for mental health and psychiatric sessions. Chiropractic services are partially covered as routine chiropractic care is not covered, and podiatry services are not covered.
Preventive Services See details
Blue Shield 65 Plus (HMO) covers preventive services, including annual physical exams and kidney disease education, with no copay or coinsurance. While memory fitness and remote access technologies are covered, other supplemental benefits such as health education, weight management, and alternative therapies are not covered.
Hearing Services See details
Hearing services are partially covered by Blue Shield 65 Plus (HMO), which provides one annual routine hearing exam and three fitting evaluations with no copay, coinsurance, or deductible. Prescription hearing aids (all types) are covered up to two per year with a $449 to $999 copay and no coinsurance, but inner ear, outer ear, over-the-ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Shield 65 Plus (HMO), though upgrades and complete eyeglasses (lenses and frames) are not covered. The plan requires no deductible and covers annual routine eye exams, eyeglass lenses, and up to $220 for contact lenses yearly and eyeglass frames every two years.
Dental Services See details
Dental services are partially covered by Blue Shield 65 Plus (HMO), with covered preventive and diagnostic care requiring no copay and 0% to 20% coinsurance. Specific sub-services including restorative, endodontic, periodontic, prosthodontic, implant, oral surgery, and orthodontic services are not covered.
Home Infusion bundled Services See details
Blue Shield 65 Plus (HMO) covers home infusion bundled services with prior authorization, requiring no copay and no coinsurance to 20% coinsurance for chemotherapy, radiation, and other Part B drugs. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Blue Shield 65 Plus (HMO) with no copay and a 20% coinsurance. 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, offering durable medical equipment (DME) with no copay and no coinsurance to 20% coinsurance, and prosthetic devices with no copay and 20% coinsurance, both requiring prior authorization. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under Blue Shield 65 Plus (HMO), requiring a doctor referral for covered treatments. Diagnostic radiological services incur a $100 copay with no coinsurance, and therapeutic radiological services require a 20% coinsurance with no copay, while diagnostic procedures, lab services, and outpatient X-ray services are not covered.
Home Health Services See details
Home health services are covered by Blue Shield 65 Plus (HMO), requiring prior authorization and a doctor referral for members to access care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Blue Shield 65 Plus (HMO), but in practice, some services are covered while Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. No copay or coinsurance is required since these services are not covered.
Skilled Nursing Facility (SNF) See details
Blue Shield 65 Plus (HMO) partially covers Skilled Nursing Facility (SNF) services, which require prior authorization and a doctor referral. Covered stays incur a $10 copay for days 1 to 20 and a $200 copay for days 21 to 100 with no coinsurance, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Blue Shield 65 Plus (HMO) plan, as acupuncture, over-the-counter items, meal benefits, and highly integrated dual eligible SNPs are all excluded from coverage.
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