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Blue Shield Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield Advantage (HMO) in 2026, please refer to our full plan details page.
Blue Shield Advantage (HMO) is a HMO plan offered by California Physicians' Service available for enrollment in 2026 to people living in San Joaquin County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Blue Shield Advantage (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 Advantage (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 Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $20.00. 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 $340.00 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 $2500.00 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 Advantage (HMO) Medicare plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $340.00. After meeting this deductible, you will pay copays or coinsurance until your yearly out-of-pocket drug costs reach $2,100.00, at which point you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, beneficiaries who qualify for the low-income subsidy can see their Part D premium reduced to $8.00. During the initial coverage phase, a 30-day supply of Tier 1 preferred generic drugs costs a $5.00 copay at preferred pharmacies or a $12.00 copay at standard pharmacies. For other tiers, costs are based on coinsurance, which includes 20% for Tier 2 standard generics, 25% for Tier 3 preferred brands, and 29% for Tier 4 non-preferred drugs.
Additional Benefits
The Blue Shield Advantage (HMO) plan features predictable cost-sharing with no copays for preventive care, annual physicals, and urgent care visits. For inpatient hospital stays, members pay a $225 daily copay for the first five days and no copay for days six through ninety. Outpatient hospital services require a $150 copay, while emergency room visits carry a $150 copay that is waived if you are admitted to the hospital within one day. This plan also includes key supplemental benefits to lower out-of-pocket expenses for dental, vision, and hearing services. Routine hearing and vision exams feature no copays, alongside a $275 allowance for eyewear and hearing aid coverage with copays between $449 and $999. Additionally, members receive dental coverage with copays up to $525 and a $45 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
Blue Shield Advantage (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $225 daily copay for days 1 to 5 (no copay for days 6 to 90) for acute care and a $900 copay per stay for psychiatric care. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Shield Advantage (HMO) covers outpatient services with no coinsurance, featuring a $150 copay for outpatient hospital services and a $30 copay for outpatient substance abuse sessions. Other covered benefits include ambulatory surgical center, observation, and outpatient blood services with no deductible.
Partial Hospitalization See details
Blue Shield Advantage (HMO) covers partial hospitalization benefits with a $55 copay and no coinsurance. Prior authorization and a doctor referral are required to access these covered services.
Ambulance and Transportation Services See details
Blue Shield Advantage (HMO) covers ground ambulance services with a $250 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Blue Shield Advantage (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within one day, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered, requiring a $150 copay and no coinsurance for emergency and urgent care, while worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are partially covered by Blue Shield Advantage (HMO), as podiatry services are not covered. Covered services require no coinsurance, featuring copays of $10 for physical, occupational, and speech therapy, $20 for opioid treatment, and $30 for mental health and psychiatric sessions.
Preventive Services See details
Blue Shield Advantage (HMO) covers preventive services, including annual physical exams and Medicare-covered zero-dollar preventive services with no copay or coinsurance. However, this benefit is only partially covered, as health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission 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 devices, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Blue Shield Advantage (HMO), which offers one routine hearing exam and three fitting evaluations annually with no copay and no coinsurance. Up to two prescription hearing aids (all types) are covered per year with a copay of $449 to $999 and no coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are covered by Blue Shield Advantage (HMO) with no deductible, offering one routine eye exam and up to $275 for contact lenses annually, as well as eyeglass lenses and a $275 frame allowance every two years. Eyewear is partially covered, as upgrades and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Shield Advantage (HMO) offers partially covered dental services with no coinsurance and copays ranging from no copay up to $525. Covered benefits include preventive, diagnostic, and restorative care, but maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Blue Shield Advantage (HMO) covers home infusion bundled services with prior authorization, requiring a $35 copay and no coinsurance to 20% coinsurance for Medicare Part B insulin. Other covered Part B drugs, including chemotherapy and radiation, have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Blue Shield Advantage (HMO) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to access these covered services.
Medical Equipment See details
Medical Equipment is partially covered by Blue Shield Advantage (HMO), offering no copays alongside 0% to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetic devices. While prior authorization is required for these covered items, medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Blue Shield Advantage (HMO) partially covers diagnostic and radiological services with a doctor referral, though diagnostic procedures/tests, lab services, and outpatient X-ray services are not covered. Covered diagnostic services have no copay and no coinsurance, while diagnostic radiological services require a $75 copay with no coinsurance, and therapeutic radiological services require a copay and 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Blue Shield Advantage (HMO) but require prior authorization and a doctor referral, while specific copay and coinsurance details are not specified.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Blue Shield Advantage (HMO) plan, meaning there is no coverage, copay, or coinsurance for intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Blue Shield Advantage (HMO) partially covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor referral, though additional days beyond the Medicare-covered limit are not covered. There is no copay or coinsurance for days 1 through 20, and a $150 copay with no coinsurance for days 21 through 100 per stay.
Other Services See details
Blue Shield Advantage (HMO) partially covers Other Services, including up to 12 acupuncture treatments per year and a $45 quarterly allowance for over-the-counter items. Meal benefits, Dual Eligible SNPs, and Naloxone coverage are not covered under this plan.
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Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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