A non-government entity
California Physicians' Service
Plan ID: H0504-39-0
Plan Summary PageBlue Shield 65 Plus (HMO)
2026 Blue Shield 65 Plus (HMO) H0504 — 039 — 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 (HMO) H0504 - 039 - 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
$65.00 /mo
Monthly premium
$425.00
Drug deductible
$4100.00
Out-of-pocket maximum (Out-of-Network)
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About This Plan
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.
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.
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 (HMO) H0504 — 039 — 0 is a HMO offered in San Luis Obispo and Santa Barbara Counties by California Physicians' Service. It has a monthly premium of $65.00.
Premium Breakdown
Monthly plan premium
$65.00
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)
$4100.00
Out-of-pocket maximum (Combined)
N/A
Plan Organization:
California Physicians' Service
Plan Type:
HMO
Location:
San Luis Obispo and Santa Barbara 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
$425
Note:
This plan does not charge an annual deductible for all drugs. The $425.00 annual deductible only applies to drugs in certain tiers.
Sign up for Blue Shield 65 Plus (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 (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
$425.00
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 $425.00 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 | $5.00 copay | $12.00 copay | - | - |
3. Preferred Brand | 25% coinsurance | 25% coinsurance | - | - |
4. Non-Preferred Drug | 30% coinsurance | 30% coinsurance | - | - |
5. Specialty Tier | 28% coinsurance | 28% coinsurance | - | 28% 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 (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.
Cost Sharing:
| Days 1-4: | Days 5-90: | |
|---|---|---|
| Copayment | 500.00 | 0.00 |
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
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
Number of day intervals for Additional Days
Zero (No Copayment per Day)
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 Outpatient Hospital Services, 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.
Cost Sharing:
More Details:
Periodicity
Per stay
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization and a doctor referral are required.
Cost Sharing:
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.
Transportation Services - Plan Approved Health-related Location
Not covered.
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.
Cost Sharing:
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
Not covered.
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.
Cost Sharing:
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
20.00
Maximum copayment
20.00
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 – 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 Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
3
Periodicity
Every year
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every year
Minimum copayment
449.00
Maximum copayment
999.00
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.
More Details:
Type of Eyewear with Individual Max Plan Benefit Coverage amount
Eyeglasses (lenses and 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.
More Details:
Is this benefit unlimited?
Yes
Maximum plan benefit coverage amount
220.00
Periodicity
Every year
Eyeglasses (lenses and frames)
Not covered.
Eyeglass lenses
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Every two years
Maximum plan benefit coverage amount
220.00
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
Periodicity range: No frequency limit for re-evaluation - limited, problem focused (established patient, not post-operative visit), periodic oral evaluation - established patient covered once every 6 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?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodicity varies by the covered benefit. See Notes for more details
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Fluoride Treatment
Fluoride Treatment benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
2
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, caries preventive medicament application � per tooth covered twice every 12 months from last date of service, sealant � per tooth covered twice every 36 months (exact tooth) from last date of service.
Orthodontic Services
Not covered.
Restorative Services
Not covered.
Adjunctive General Services
Not covered.
Endodontics
Not covered.
Periodontics
Not covered.
Prosthodontics, removable
Not covered.
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Not covered.
Oral and Maxillofacial Surgery
Not covered.
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?
Yes
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Copayment
Medicare-covered Therapeutic Radiological Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
No
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
100.00
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 | 10.00 | 200.00 |
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
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