Blue Shield 65 Plus (HMO)

Blue Shield 65 Plus (HMO) H0504-017 Plan Details
4 out of 5 stars

Blue Shield 65 Plus (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0504-017.

$0.00
Monthly Premium

Blue Shield 65 Plus (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0504-017.

Blue Shield 65 Plus (HMO) H0504-017 Plan Details
4 out of 5 stars

Blue Shield 65 Plus (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0504-017.

$0.00
Monthly Premium

California Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $2799
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00
Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Your plan covers an unlimited number of days for an inpatient stay.
Referral Required for Acute Hospital Services
Urgent Care
Copayment for Urgent Care $5.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $85.00
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $85.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $85.00
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $150.00

Air Ambulance:
Copayment for Air Ambulance Services $150.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Blue Shield 65 Plus (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $0.00
Referral Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $20.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Referral Required for Outpatient Diag/Therapeutic Rad Services
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $900.00
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Referral Required for Outpatient Mental Health Services
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $150.00
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Referral Required for Ambulatory Surgical Center Services
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Referral Required for Outpatient Substance Abuse Services
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Referral Required for Podiatry Services
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$75.00 per day for days 21 to 100
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $5.00 to $16.00
Copayment for Prophylaxis (Cleaning) $20.00
  • Maximum 1 visit every six months
Copayment for Fluoride Treatment $5.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00 to $10.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Diagnostic Services $0.00 to $16.00
Copayment for Restorative Services $19.00 to $430.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $25.00 to $373.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $40.00 to $80.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $23.00 to $80.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 to $525.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Prior Authorization Required for Comprehensive Dental
Referral Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $20.00
  • Maximum plan benefit of $65.00 every year for Contact Lenses
Copayment for Eyeglass Lenses $20.00
  • Maximum 1 Pair every year
Copayment for Eyeglass Frames $20.00
  • Maximum 1 Pair every two years
  • Maximum plan benefit of $65.00 every two years for Eyeglass Frames
Referral Required for Eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every two years
Referral Required for Hearing Exams

Hearing Aids:
Maximum Plan Allowance of $500.00 every two years both ears combined
For hearing aids, member may self-refer to any provider of their choice.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit