A non-government entity
California Physicians' Service
Plan ID: H0504-21-0
Plan Summary PageBlue Shield 65 Plus Plan 2 (HMO)
2026 Blue Shield 65 Plus Plan 2 (HMO) H0504 — 021 — 0 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2026.
Learn more about Blue Shield 65 Plus Plan 2 (HMO) H0504 - 021 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
4 / 5 stars for 2026
$0.00 /mo
Monthly premium
$340.00
Drug deductible
$2200.00
Out-of-pocket maximum (Out-of-Network)
Enroll online
Call to enroll
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
About This Plan
The Blue Shield 65 Plus Plan 2 (HMO) offers comprehensive medical coverage with no copay or coinsurance for annual physicals and Medicare-covered preventive services. Emergency room and outpatient hospital visits require a $150 copay, while urgently needed care is available with no copay. Inpatient psychiatric stays require a $900 copay, and skilled nursing facility stays feature no copay for the first 20 days before a $100 daily copay applies. This plan also features key supplemental benefits, including routine eye exams with no copay and dental care with copays ranging from no copay up to $525. Eligible members can also utilize up to 14 one-way transportation trips per year to plan-approved locations at no cost. Please note that certain services, such as cardiac rehabilitation, acupuncture, and over-the-counter items, are not covered.
The Blue Shield 65 Plus Plan 2 (HMO) prescription drug coverage features an annual deductible of $340. During the initial coverage phase, you will pay a $10 copay for preferred generics at preferred pharmacies, while standard pharmacies charge an $18 copay. Standard generics, preferred brands, and non-preferred drugs require coinsurance ranging from 20% to 29%. Individuals who qualify for the low-income subsidy will benefit from a premium reduction with no copay for Part D coverage. Once your yearly out-of-pocket costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. This structured plan helps beneficiaries easily anticipate their medication costs throughout the year.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 Blue Shield 65 Plus Plan 2 (HMO) H0504 — 021 — 0 is a HMO offered in Los Angeles and Orange Counties by California Physicians' Service. It has a monthly premium of $0.00.
Premium Breakdown
Monthly plan premium
$0.00
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
No
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$2200.00
Out-of-pocket maximum (Combined)
N/A
Plan Organization:
California Physicians' Service
Plan Type:
HMO
Location:
Los Angeles and Orange Counties
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$340
Note:
This plan does not charge an annual deductible for all drugs. The $340.00 annual deductible only applies to drugs in certain tiers.
Sign up for Blue Shield 65 Plus Plan 2 (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
Blue Shield 65 Plus Plan 2 (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$340.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you pay your $340.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | $0.00 copay | $5.00 copay | - | - |
2. Generic | $10.00 copay | $18.00 copay | - | - |
3. Preferred Brand | 20% coinsurance | 20% coinsurance | - | - |
4. Non-Preferred Drug | 25% coinsurance | 25% coinsurance | - | - |
5. Specialty Tier | 29% coinsurance | 29% coinsurance | - | 29% coinsurance |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
Blue Shield 65 Plus Plan 2 (HMO) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization and a doctor referral are required.
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
900.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Observation Services
Observation Services benefits are covered. A doctor referral is required.
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization and a doctor referral are required.
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Outpatient Blood Services
Outpatient Blood Services benefits are covered. A doctor referral is required.
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
Yes
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
Yes
Which Services have a Copayment
Medicare-covered Air Ambulance Services
Is this Copayment waived if admitted to hospital?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit (10b)
Plan Approved Health-related Location
Is there a service specific maximum plan benefit coverage amount?
No
Transportation Services - Plan Approved Health-related Location
Transportation Services - Plan Approved Health-related Location benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of trips
14
Periodicity
Every year
Type of transportation
One-way
Mode of Transportation
Rideshare Services, Bus/Subway, Medical Transport, Other, Describe
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
1
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Worldwide Services have a Copayment
Worldwide Urgent Coverage, Worldwide Emergency Transportation
Is there a maximum plan benefit coverage?
Yes
Is the maximum plan benefit coverage amount unlimited?
No
Maximum amount
50000.00
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Chiropractic Services
Chiropractic Services benefits are covered. A doctor referral is required.
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered. Prior Authorization and a doctor referral are required.
Physician Specialist Services
Physician Specialist Services benefits are covered. A doctor referral is required.
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Podiatry Services
Podiatry Services benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
Yes
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional
Other Health Care Professional benefits are covered. A doctor referral is required.
Psychiatric Services
Psychiatric Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Psychiatric Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
30.00
Maximum copayment
30.00
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered. Prior Authorization and a doctor referral are required.
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
7a: Primary Care Physician Services
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum copayment
10.00
Maximum copayment
10.00
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education
Not covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered. A doctor referral is required.
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
Yes
Which Services require a Referral
Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered. A doctor referral is required.
More Details:
Is there a deductible?
No
Routine Hearing Exams
Not covered.
Fitting/Evaluation for Hearing Aid
Not covered.
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered.
Prescription Hearing Aids (all types)
Not covered.
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
Cost Sharing:
More Details:
Type of Eyewear with Individual Max Plan Benefit Coverage amount
Eyeglasses (lenses and frames), Upgrades
Which Eyewear Benefits have a Copayment
Eyeglasses (lenses and frames), Eyeglass frames, Upgrades
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
No
Contact Lenses
Contact Lenses benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Maximum plan benefit coverage amount
175.00
Periodicity
Every year
Eyeglasses (lenses and frames)
Not covered.
Eyeglass lenses
Eyeglass lenses benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass frames
Eyeglass frames benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Every two years
Maximum plan benefit coverage amount
175.00
Periodicity
Every two years
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. A doctor referral is required.
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Oral Exams
Oral Exams benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
No frequency limit for limited oral evaluation � problem focused, periodic oral evaluation � established patient covered twice every 12 months from last date of service, comprehensive oral evaluation � new or established patient covered once every 36 months from last date of service.
Dental X-Rays
Dental X-Rays benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for intraoral - periapical first radiographic image, bitewing - single radiographic image covered once every 6 months from last date of service, panoramic radiographic image covered once every 24 months from last date of service.
Other Diagnostic Dental Services
Other Diagnostic Dental Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Fluoride Treatment
Fluoride Treatment benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Other Preventive Dental Services
Other Preventive Dental Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for oral hygiene instructions, sealant - per tooth covered once every 36 months (exact tooth) from last date of service.
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Restorative Services
Restorative Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for amalgam - one surface, primary or permanent, crown - resin-based composite (indirect) covered once every 5 years (exact tooth) from last date of service.
Adjunctive General Services
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Endodontics
Endodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for pulp cap - direct (excluding final restoration), endodontic therapy - anterior tooth (excluding final restoration) covered once per lifetime (exact tooth).
Periodontics
Periodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity varies by the covered benefit. See Notes for more details.
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity varies by the covered benefit. See Notes for more details.
Maxillofacial Prosthetics
Not covered.
Implant Services
Implant Services benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for re-cement or re-bond fixed partial denture, pontic � indirect resin-based composite covered once every 5 years (exact tooth) from last date of service.
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity range: No frequency limit for incision and drainage of abscess - extraoral soft tissue, removal of impacted tooth - soft tissue covered once per lifetime (exact tooth).
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
No
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
Yes
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Not covered.
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
More Details:
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Not covered.
Diabetic Therapeutic Shoes/Inserts
Not covered.
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. A doctor referral is required.
More Details:
Is there a copayment?
No
Diagnostic Procedures/Tests
Not covered.
Lab Services
Not covered.
All Radiological Services
All Radiological Services benefits are covered. A doctor referral is required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance
Medicare-covered X-Ray Services
Is there a copayment?
No
Diagnostic Radiological Services
Not covered.
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services
Not covered.
Home Health Services
Home Health Services benefits are covered. Prior Authorization and a doctor referral are required.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Copayment
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
| Days 1-20: | Days 21-100: | |
|---|---|---|
| Copayment | 0.00 | 100.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Not covered.
Over-the-Counter (OTC) Items
Not covered.
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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