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Blue Shield TotalDual Plan (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield TotalDual Plan (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield TotalDual Plan (HMO D-SNP) in 2025, please refer to our full plan details page.
Blue Shield TotalDual Plan (HMO D-SNP) is a HMO D-SNP plan offered by California Physicians' Service available for enrollment in 2025 to people living in Los Angeles and San Diego Counties. The overall rating for this plan is not yet available for 2025.
It's important to know that Blue Shield TotalDual Plan (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Blue Shield TotalDual Plan (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Shield TotalDual Plan (HMO D-SNP).
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 TotalDual Plan (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $28.30. 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 $589.00 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 $9350.00 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 TotalDual Plan (HMO D-SNP) has a $589.00 deductible for prescription drugs. After the deductible, you pay 25% coinsurance for most drugs at a standard pharmacy. If you qualify for the low-income subsidy, you will pay $28.30. Once your total drug costs reach $2,000.00, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Blue Shield TotalDual Plan (HMO D-SNP) offers a variety of benefits, including inpatient and outpatient services, with a coinsurance of 20% for most services. Emergency services have no copay, and the plan also covers preventive, hearing, vision, and dental services, each with its own cost-sharing structure. Additional benefits include coverage for ambulance, transportation, and home health services, as well as medical equipment and home infusion services. The plan also offers an over-the-counter (OTC) allowance and a meal benefit for chronic illness. Prior authorization and referrals are often required for coverage, and some services have limitations or are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. The plan requires prior authorization and a doctor's referral, and the coinsurance amount is based on the original Medicare cost share; however, additional days, non-Medicare stays, and upgrades for both are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services and Observation Services, are covered under the Blue Shield TotalDual Plan (HMO D-SNP) with a 20% coinsurance. Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services are also covered, with a coinsurance of 20%. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Shield TotalDual Plan (HMO D-SNP) with prior authorization and a doctor referral. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a 20% coinsurance, and transportation services to a plan-approved health-related location are covered for up to 48 one-way trips per year, but 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 by the Blue Shield TotalDual Plan (HMO D-SNP) with a 20% coinsurance, and no copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. For Primary Care Physician Services and Chiropractic Services, you pay 20% coinsurance. For Occupational Therapy Services, Individual and Group Sessions for Mental Health Specialty Services, Routine Foot Care, Other Health Care Professional, Individual and Group Sessions for Psychiatric Services, and Opioid Treatment Program Services, you pay 20% coinsurance. For Physical Therapy and Speech-Language Pathology Services, you pay 20% coinsurance.
Preventive Services See details
The Blue Shield TotalDual Plan (HMO D-SNP) covers preventive services, including Medicare-covered services, an annual physical exam, health education, personal emergency response systems, remote access technologies, and fitness benefits. Kidney disease education services are covered with 20% coinsurance, and other preventive services, such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, are covered with a referral. However, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing services are covered, including hearing exams with a coinsurance of at most 20% and a limit of $1500 per year for prescription hearing aids. Fitting/evaluation for hearing aids is covered for 2 visits every year, and inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams and eyewear. Eye exams have a 20% coinsurance, and routine eye exams are limited to one per year. Eyewear has a 20% coinsurance, and contact lenses are covered with a maximum benefit of $200 per year. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with 20% coinsurance, Orthodontic Services, Restorative Services, Prosthodontics (removable and fixed). Adjunctive General Services, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Blue Shield TotalDual Plan (HMO D-SNP), including Medicare Part B Insulin Drugs with a $35 copay and between 0% and 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with between 0% and 20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Blue Shield TotalDual Plan (HMO D-SNP) with a coinsurance of 20%. Prior authorization and a doctor referral are required for coverage.
Medical Equipment See details
Medical Equipment benefits are covered by the Blue Shield TotalDual Plan (HMO D-SNP), including Durable Medical Equipment (DME) with 0-20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with 20% coinsurance for diabetic supplies and therapeutic shoes/inserts. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. There is no copay for diagnostic services or radiological services, but you may have to pay up to 20% coinsurance for Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services.
Home Health Services See details
Home Health Services are covered by the Blue Shield TotalDual Plan (HMO D-SNP) with no copay or coinsurance; however, 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 not covered by the Blue Shield TotalDual Plan (HMO D-SNP). Prior authorization and a doctor referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Shield TotalDual Plan (HMO D-SNP) with prior authorization and a doctor referral required. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with a maximum benefit of $70.00 every month, and a meal benefit for a chronic illness, but acupuncture, 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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