Blue Shield 65 Plus
Medicare Advantage Plans (Part C)
- Blue Shield 65 Plus
- 2013 Plan
|Office Visit for Primary Doctor||$0|
|Office Visit for Specialist||$10|
|Doctor Choice||Network applies|
|Prescription Drug Coverage||Yes|
|Hospital Services Coverage|
|Emergency Room||$65 Copay.
$10,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.
|Ambulance Services||$250 copay|
|Outpatient Lab/X-Ray||$0 copay|
|Outpatient Surgery||$50 copay for each ambulatory surgical center visit.
$150 copay for each outpatient hospital facility visit
|Urgent Care||$10 Copay|
|Hospitalization||Days 1-10: $50 copay per day.
Days 11+: $0 copay per day.
$500 out-of-pocket limit every year.
|Outpatient Rehabilitation Services||$25 copay for Occupational Therapy visits and Physical Therapy and/or Speech and Language Pathology visits.|
|Skilled Nursing Facility||Days 1-10: $50 copay per day.
Days 11-100: $100 copay per day.
Plan covers up to 100 days each benefit period.
No prior hospital stay is required.
|Home Health Care||$10 Copay|
|Hospice||You must get care from a Medicare-certified hospice.
Your plan will pay for a consultative visit before you select hospice.
|Prescription Drug Coverage|
|Prescription Drug Deductible||$0|
|Retail Pharmacy for Prescription Drugs|
|$6 copay for a one-month (30-day) supply;
$12 copay for a three-month (90-day) supply.
|$45 copay for a one-month (30-day) supply;
$90 copay for a three-month (90-day) supply.
|$90 copay for a one-month (30-day) supply;
$180 copay for a three-month (90-day) supply.
|Mail Order Pharmacy for Prescription Drugs|
|$12 copay for a three-month (90-day) supply|
|$90 copay for a three-month (90-day) supply|
|$180 copay for a three-month (90-day) supply|
|33% coinsurance for a three-month (90-day) supply|
|Dental Services||$0 to $10 copay for dental benefits.
In general, preventive dental benefits (such as cleaning) not covered.
|Hearing Services||$0 copay for diagnostic hearing exams.
$0 to $10 copay for supplemental routine hearing exams.
Hearing aids not covered.
|Vision Services||$0 copay for one pair of eyeglasses or contact lenses after cataract surgery, exams to diagnose and treat diseases and conditions of the eye.
$20 copay for up to 1 supplemental routine eye exam(s) and 1 pair(s) of lenses every year, up to 1 frame(s) every two years.
If the doctor provides you services in addition to eye exams, separate cost sharing of $0 to $10 may apply.
$75 plan coverage limit for eye glass frames every two years.
|Chiropractic Coverage||$10 Copay|
|Outpatient Mental Health Coverage||$30 Copay|
(See more benefit details,
including Out of Network coverage)
|See more benefit details:
Summary of Benefits
|Medicare Brochure(s)||Medicare & You|
- You can always call our licensed agents at 1 -800-299-3116 (TTY User: 711) Mon - Fri 8AM - 8PM ET, Sat 9AM - 6PM ET if you have questions, need help comparing plans, or to complete your enrollment.
- Blue Shield of California - Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal.
- Blue Shield of California - For more information about Blue Shield Medicare plans, contact Blue Shield of California at (800) 963-8008; TTY: (888) 595-0000, seven days a week, 8 a.m. - 8 p.m. PST, from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on weekends and holidays.
- Limitations, copayments, and restrictions may apply.
- Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
- You must continue to pay your Medicare Part B premium.
- You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your Medicaid Office.
- Medicare beneficiaries may also enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
- Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
- Not every plan is available statewide or in all service areas.