2019 Blue Shield 65 Plus Choice Plan (HMO) H0504-40-0 in CA from Blue Shield of California | HealthPocket

Blue Shield 65 Plus Choice Plan (HMO)

$0/mo

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Zip Code90011
Applicant3/20/1984 Male
Coverage Start3/22/2019
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderBlue Shield of California
Plan IDH0504-40-0
Plan Year2019
CMS Rating
Plan TypeHMO
Annual Deductible$0.00

What To Know About This Plan
  • This plan has health and drug coverage

Why We Like This Plan
  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$0.00
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$999 In-network
Optional Supplemental BenefitsYes

Benefits

SERVICECOST
Inpatient hospital coverage$0 copay
Outpatient hospital coverage$150 per visit
Doctor visitsPrimary:$0 copay
Specialist:$0 copay
Preventive care$0 copay
Emergency care/Urgent careEmergency:$85 per visit (always covered)
Urgent care:$5 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:$0 copay
Lab services:$0 copay
Diagnostic radiology services (e.g., MRI):$40
Outpatient x-rays:$0 copay
Mental health servicesInpatient hospital - psychiatric:$900 per stay
Outpatient group therapy visit with a psychiatrist:$30
Outpatient individual therapy visit with a psychiatrist:$30
Outpatient group therapy visit:$30
Outpatient individual therapy visit:$30
Skilled Nursing Facility$0 per day for days 1 through 20
$50 per day for days 21 through 100
Rehabilitation servicesOccupational therapy visit:$0 copay
Physical therapy and speech and language therapy visit:$0 copay
Ground ambulance$150
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:$0 copay
Routine foot care:$0 copay. There may be limits on how much the plan will provide.
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):0-20% per item
Prosthetics (e.g., braces, artificial limbs):$0 copay
Diabetes supplies:$0 copay
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:20%
Other Part B drugs:20%

Benefits Services

Hearing
Hearing exam$0 copay
Fitting/evaluation$0 copay. There may be limits on how much the plan will provide.
Hearing aids$499-799There may be limits on how much the plan will provide.
Preventive Dental
Oral exam$5-16
Cleaning$20There may be limits on how much the plan will provide.
Fluoride treatment$5There may be limits on how much the plan will provide.
Dental x-ray(s)$0-10There may be limits on how much the plan will provide.
Comprehensive Dental
Non-routine servicesNot covered
Diagnostic services$0-16
Restorative services$19-430There may be limits on how much the plan will provide.
Endodontics$25-373There may be limits on how much the plan will provide.
Periodontics$40-80There may be limits on how much the plan will provide.
Extractions$23-80There may be limits on how much the plan will provide.
Prosthodontics, other oral/maxillofacial surgery, other services$0-525There may be limits on how much the plan will provide.
Vision
Routine eye exam$0 copay. There may be limits on how much the plan will provide.
OtherNot covered
Contact lenses$0 copay. There may be limits on how much the plan will provide.
Eyeglasses (frames and lenses)Not covered
Eyeglass frames$0 copay. There may be limits on how much the plan will provide.
Eyeglass lenses$0 copay. There may be limits on how much the plan will provide.
UpgradesNot covered

Coverage Area for Blue Shield 65 Plus Choice (HMO)

StateCalifornia
CountyLos Angeles

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$7 copayNot offered
Tier 2: Non-Preferred Generic$5 copay$12 copayNot offered
Tier 3: Preferred Brand Name$40 copay$47 copayNot offered
Tier 4: Non-Preferred Brand Name$95 copay$100 copayNot offered
Tier 5: Specialty Tier31% coinsurance31% coinsuranceNot offered

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$14 copayNot offered
Tier 2: Non-Preferred Generic$10 copay$24 copayNot offered
Tier 3: Preferred Brand Name$80 copay$94 copayNot offered
Tier 4: Non-Preferred Brand Name$190 copay$200 copayNot offered
Tier 5: Specialty Tier31% coinsurance31% coinsuranceNot offered
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$0 copay$21 copayNot offered
Tier 2: Non-Preferred Generic$7.5 copay$36 copayNot offered
Tier 3: Preferred Brand Name$100 copay$141 copayNot offered
Tier 4: Non-Preferred Brand Name$237.5 copay$300 copayNot offered
Tier 5: Specialty Tier31% coinsurance31% coinsuranceNot offered

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physicians that accept Blue Shield 65 Plus Choice (HMO) for California

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Yacomotti, Luciana
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Lawrence, Patrick
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Aron, Monish
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Selsted, Michael E
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Chang, Eric
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Bandarpalle, Sushant
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Germain, Beatrice
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Sweeny, Alfredo
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Paiz, Aela
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Kashanian, Alona
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Duplessis, Helen
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Powell, Cheryl
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Lin, Xiaomei
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Saulsberry, Vallorie
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Zarrinpar, David
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Tesoro, Kent
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Shadpour, Joseph
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Ware, Kirsten
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Tehrani, Faramarz
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Merritt, Helen
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Acosta-padron, Cristina
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Cabral, Marissa
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Morrissey, Darlene
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Bendana, Raul
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Luciana Yacomotti
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  • Phone Number
    (323) 908-4200
  • Office Locations
    4425 S Central Ave
    Los Angeles, CA 90011
4425 S Central Ave Los Angeles CA, 90011

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.