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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 Orange and San Bernardino 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 $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 a $590.00 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 $590 deductible for prescription drugs. After the deductible, you will pay 25% coinsurance for your drugs in the initial coverage phase. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you will pay nothing for your Part D covered drugs. This plan may have a reduced premium if you qualify for the low-income subsidy, also known as LIS or "Extra help".
Additional Benefits
The Blue Shield TotalDual Plan (HMO D-SNP) offers a variety of additional benefits to supplement your Medicare coverage. Many services, such as outpatient services, emergency services, preventive services, and home health services, have no copay. You will pay a 20% coinsurance for many services, including outpatient hospital services, ambulance services, primary care, and vision services. This plan also covers hearing aids up to $2,000 per year and provides dental coverage, including restorative services and prosthodontics. Additionally, the plan includes benefits for transportation, medical equipment, and over-the-counter items, with a maximum of $170 every three months. Note that some services may require prior authorization or a doctor's referral.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered under the Blue Shield TotalDual Plan (HMO D-SNP). However, additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered; coinsurance applies to covered services, and a doctor referral and prior authorization are required.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient substance abuse services. Outpatient hospital and observation services have a 20% coinsurance, while outpatient substance abuse individual and group sessions have a minimum of 20% and a maximum of 20% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a 20% coinsurance, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not usually covered by Medicare, are covered by the Blue Shield TotalDual Plan (HMO D-SNP). 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. 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 under the Blue Shield TotalDual Plan (HMO D-SNP), each with a 20% coinsurance, with no copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services are covered with a 20% coinsurance, Chiropractic Services are covered with a 20% coinsurance, Occupational Therapy Services are covered with a 20% coinsurance, and Physician Specialist Services are covered with 0% to 20% coinsurance. Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services are covered with a minimum coinsurance of 20% and a maximum coinsurance of 20%. Physical Therapy and Speech-Language Pathology Services are covered with a 20% coinsurance. Additional Telehealth Benefits are covered.
Preventive Services See details
The Blue Shield TotalDual Plan (HMO D-SNP) covers preventive services, including an annual physical exam, and other services like health education, personal emergency response systems, remote access technologies, and a fitness benefit, all with no copay. Kidney disease education services are covered with 20% coinsurance. Other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit are covered with a referral.
Hearing Services See details
Hearing services with the Blue Shield TotalDual Plan (HMO D-SNP) include coverage for hearing exams with a coinsurance of at most 20% and routine hearing exams with no coinsurance. The plan also covers fitting and evaluation for hearing aids, but only two visits per year, and prescription hearing aids up to $2,000 per year. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
The Blue Shield TotalDual Plan (HMO D-SNP) covers vision services including routine eye exams and eyewear. Routine eye exams and eyewear each have a 20% coinsurance, and contact lenses have a maximum plan benefit coverage amount of $295.00 every year.
Dental Services See details
Dental services are covered, including Medicare dental services with 20% coinsurance. Restorative services, Prosthodontics (removable and fixed) are covered, but Adjunctive General Services, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Orthodontics, and Oral and Maxillofacial Surgery are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. For Medicare Part B insulin drugs, you will pay a $35 copay, and the coinsurance will be between 0% and 20%. For other Medicare Part B drugs, and Medicare Part B Chemotherapy/Radiation Drugs, the coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization and a doctor referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Blue Shield TotalDual Plan (HMO D-SNP). Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a coinsurance, with no copay, and Diabetic Equipment has a coinsurance of 20% for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts, with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Blue Shield TotalDual Plan (HMO D-SNP). You will pay no copay for all diagnostic and radiological services, but you may 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 and no coinsurance, but prior authorization and a referral are required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Shield TotalDual Plan (HMO D-SNP). Note that 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), but require prior authorization and a doctor's referral. The plan does not cover additional days beyond Medicare-covered SNF stays, or non-Medicare-covered SNF stays.
Other Services See details
Other Services include Over-the-Counter (OTC) Items and a Meal Benefit. Over-the-Counter (OTC) Items are covered with a maximum of $170 every three months. The Meal Benefit is covered for chronic illnesses. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and other services are not covered.
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