Blue Shield Vital (HMO)
Blue Shield Vital (HMO) H0504-045 Plan Details
Blue Shield Vital (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by California Physicians' Service.
Plan ID: H0504-045.
$0.00
Monthly Premium
Blue Shield Vital (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by California Physicians' Service.
Plan ID: H0504-045.
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3400 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 to $10.00 Referral Required for Doctor Specialty Visit |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $120.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Referral Required for Acute Hospital Services |
| Urgent Care | Copayment for Urgent Care $10.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 1 days Worldwide Coverage: Copayment for Worldwide Urgent Coverage $120.00 Maximum Plan Benefit of $10,000 |
| Emergency Room Visit | Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Maximum Plan Benefit of $10,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $100.00 Air Ambulance: Copayment for Air Ambulance Services $100.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Blue Shield Vital (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 $10.00 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 $5.00 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: $250 copay per Medicare-covered stay plus: $120.00 per day for days 1 to 10 $0.00 per day for days 11 to 90 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 $20.00 Copayment for Medicare-covered Group Sessions $20.00 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 $50.00 Referral Required for Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Referral Required for Outpatient Substance Abuse Services |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $10.00 Referral Required for Podiatry Services |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $20.00 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
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 to $10.00 Copayment for Diagnostic Services $0.00 to $16.00 Copayment for Restorative Services $19.00 to $430.00
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 $10.00 Copayment for Routine Eye Exams $10.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Eyeglass Lenses $20.00
|
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 to $10.00 Copayment for Routine Hearing Exams $0.00 to $10.00 Referral Required for Hearing Exams |
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:
Yearly "Wellness" visit |
