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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Blue Shield 65 Plus Choice Plan (HMO)

2015 Medicare Advantage Plan Details
Plan Name:Blue Shield 65 Plus Choice Plan (HMO)
Location (County, State ZIP):Los Angeles (Partial), California
Plan ID:H0504 - 021     Click to see other plans

Click here for the Blue Shield 65 Plus Choice Plan (HMO) enrollment options and to have a copy of this chart sent to your email. Enroll in Blue Shield 65 Plus Choice Plan (HMO)

— Plan Features —
Monthly Premium:$0.00
Monthly Premium with Low-Income Subsidy:100%75%50%25%
$0.00$0.00$0.00$0.00
Annual Rx Deductible:$0
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$2,000
Gap Coverage:Yes
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$0.00$3.00$30.00$65.0025%
Number of Members enrolled in this plan in your County:11,318 members
Plan’s Summary Star Rating: 4.00 out of 5 Stars.
   - Customer Service Rating: 4 out of 5 Stars.
   - Member Experience Rating: 4 out of 5 Stars.
   - Drug Cost Accuracy Rating: 4 out of 5 Stars.

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$0 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $2 000 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
Not covered
** Extra Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  20% of the cost
Other Part B drugs1:  20% of the cost
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Preferred Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0$0
Tier 2 (Non-Preferred Generic)$3 copay$6 copay$6 copay
Tier 3 (Preferred Brand)$30 copay$60 copay$60 copay
Tier 4 (Non-Preferred Brand)$65 copay$130 copay$130 copay
Tier 5 (Injectable Drugs)25% of the cost25% of the cost25% of the cost
Tier 6 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$3 copay$6 copay$9 copay
Tier 2 (Non-Preferred Generic)$7 copay$14 copay$21 copay
Tier 3 (Preferred Brand)$35 copay$70 copay$105 copay
Tier 4 (Non-Preferred Brand)$70 copay$140 copay$210 copay
Tier 5 (Injectable Drugs)25% of the cost25% of the cost25% of the cost
Tier 6 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Mail Order Cost-Sharing
TierThree-month supply
Tier 1 (Preferred Generic)$0
Tier 2 (Non-Preferred Generic)$6 copay
Tier 3 (Preferred Brand)$60 copay
Tier 4 (Non-Preferred Brand)$130 copay
Tier 5 (Injectable Drugs)25% of the cost
Tier 6 (Specialty Tier)33% of the cost
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Preferred Retail Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)All$0$0$0
Tier 2 (Non-Preferred Generic)All$3 copay$6 copay$6 copay
Tier 3 (Preferred Brand)Some$30 copay$60 copay$60 copay
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)All$3 copay$6 copay$9 copay
Tier 2 (Non-Preferred Generic)All$7 copay$14 copay$21 copay
Tier 3 (Preferred Brand)Some$35 copay$70 copay$105 copay
Standard Mail Order Cost-Sharing
TierDrugs CoveredThree-month supply
Tier 1 (Preferred Generic)All$0
Tier 2 (Non-Preferred Generic)All$6 copay
Tier 3 (Preferred Brand)Some$60 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$0 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $2 000 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
Not covered
Ambulance Services
$100 copay
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  You pay nothing
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  You pay nothing
Preventive dental services:
  • Cleaning (for up to 1 every six months):  $20 copay
  • Dental x-ray(s) (for up to 1):  $0-10 copay depending on the service
  • Fluoride treatment (for up to 2):  $5 copay
  • Oral exam:  $5-16 copay depending on the service
  • Diabetes Supplies and Services
    Diabetes monitoring supplies:  You pay nothing
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  You pay nothing
    Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):  You pay nothing
    Diagnostic tests and procedures:  You pay nothing
    Lab services:  You pay nothing
    Outpatient x-rays:  You pay nothing
    Therapeutic radiology services (such as radiation treatment for cancer):  20% of the cost
    Doctor&rsuo;s Office Visits
    Primary care physician visit:  You pay nothing
    Specialist visit:  You pay nothing
    Durable Medical Equipment (wheelchairs, oxygen, etc.)
    20% of the cost
    Emergency Care
    $65 copay
    Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
    Routine foot care (for up to 12 visit(s) every year):  You pay nothing
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:  You pay nothing
    Routine hearing exam:  You pay nothing
    Hearing aid fitting/evaluation (for up to 1 every two years):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $500 every two years for hearing aids.
    Home Health Care
    You pay nothing
    Mental Health Care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • $900 copay per stay
    • Outpatient group therapy visit:  $30 copay
      Outpatient individual therapy visit:  $30 copay
      Outpatient Rehabilitation Services
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $15 copay
      Occupational therapy visit:  $10 copay
      Physical therapy and speech and language therapy visit:  $10 copay
      Outpatient Substance Abuse
      Group therapy visit:  $30 copay
      Individual therapy visit:  $30 copay
      Outpatient Surgery
      Ambulatory surgical center:  You pay nothing
      Outpatient hospital:  $50 copay
      Over-the-Counter Items
      Not Covered
      Prosthetic Devices (braces, artificial limbs, etc.)
      Prosthetic devices:  You pay nothing
      Related medical supplies:  You pay nothing
      Renal Dialysis
      $25 copay
      Transportation
        You pay nothing
      Urgently Needed Care
      You pay nothing
      Vision Services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  You pay nothing
      Routine eye exam (for up to 1 every year):  $10 copay
      Eyeglasses frames (for up to 1 every two years):  $20 copay
      Our plan pays up to $90 every two years for eyeglass frames.
      Eyeglasses lenses (for up to 1 every year):  $20 copay
      Eyeglasses or contact lenses after cataract surgery:  You pay nothing
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive Care
      You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colonoscopy
      • Colorectal cancer screenings
      • Depression screening
      • Diabetes screenings
      • Fecal occult blood test
      • Flexible sigmoidoscopy
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      ** Inpatient Care **
      Inpatient Hospital Care
      Our plan covers an unlimited number of days for an inpatient hospital stay.
      You pay nothing
      Inpatient Mental Health Care
      For inpatient mental health care see the "Mental Health Care" section.
      Skilled Nursing Facility (SNF)
      Our plan covers up to 100 days in a SNF.
        • $0 copay per day for days 1 through 20
        • $50 copay per day for days 21 through 100
        Outpatient Prescription Drugs
        For Part B drugs such as chemotherapy drugs1:  20% of the cost
        Other Part B drugs1:  20% of the cost
        You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
        You may get your drugs at network retail pharmacies and mail order pharmacies.
        Preferred Retail Cost-Sharing
        TierOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)$0$0$0
        Tier 2 (Non-Preferred Generic)$3 copay$6 copay$6 copay
        Tier 3 (Preferred Brand)$30 copay$60 copay$60 copay
        Tier 4 (Non-Preferred Brand)$65 copay$130 copay$130 copay
        Tier 5 (Injectable Drugs)25% of the cost25% of the cost25% of the cost
        Tier 6 (Specialty Tier)33% of the cost33% of the cost33% of the cost
        Standard Retail Cost-Sharing
        TierOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)$3 copay$6 copay$9 copay
        Tier 2 (Non-Preferred Generic)$7 copay$14 copay$21 copay
        Tier 3 (Preferred Brand)$35 copay$70 copay$105 copay
        Tier 4 (Non-Preferred Brand)$70 copay$140 copay$210 copay
        Tier 5 (Injectable Drugs)25% of the cost25% of the cost25% of the cost
        Tier 6 (Specialty Tier)33% of the cost33% of the cost33% of the cost
        Standard Mail Order Cost-Sharing
        TierThree-month supply
        Tier 1 (Preferred Generic)$0
        Tier 2 (Non-Preferred Generic)$6 copay
        Tier 3 (Preferred Brand)$60 copay
        Tier 4 (Non-Preferred Brand)$130 copay
        Tier 5 (Injectable Drugs)25% of the cost
        Tier 6 (Specialty Tier)33% of the cost
        If you reside in a long-term care facility you pay the same as at a retail pharmacy.
        You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
        Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

        After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

        Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
        Preferred Retail Cost-Sharing
        TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)All$0$0$0
        Tier 2 (Non-Preferred Generic)All$3 copay$6 copay$6 copay
        Tier 3 (Preferred Brand)Some$30 copay$60 copay$60 copay
        Standard Retail Cost-Sharing
        TierDrugs CoveredOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)All$3 copay$6 copay$9 copay
        Tier 2 (Non-Preferred Generic)All$7 copay$14 copay$21 copay
        Tier 3 (Preferred Brand)Some$35 copay$70 copay$105 copay
        Standard Mail Order Cost-Sharing
        TierDrugs CoveredThree-month supply
        Tier 1 (Preferred Generic)All$0
        Tier 2 (Non-Preferred Generic)All$6 copay
        Tier 3 (Preferred Brand)Some$60 copay
        After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
        • 5% of the cost or
        • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
        ** Outpatient Care **
        Diabetes Supplies and Services
        Diabetes monitoring supplies:  You pay nothing
        Diabetes self-management training:  You pay nothing
        Therapeutic shoes or inserts:  You pay nothing
        Foot Care (podiatry services)
        Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
        Routine foot care (for up to 12 visit(s) every year):  You pay nothing
        Hearing Services
        Exam to diagnose and treat hearing and balance issues:  You pay nothing
        Routine hearing exam:  You pay nothing
        Hearing aid fitting/evaluation (for up to 1 every two years):  You pay nothing
        Hearing aid:  You pay nothing
        Our plan pays up to $500 every two years for hearing aids.
        ** Outpatient Medical Services and Supplies **
        Outpatient Substance Abuse
        Group therapy visit:  $30 copay
        Individual therapy visit:  $30 copay
        Prosthetic Devices (braces, artificial limbs, etc.)
        Prosthetic devices:  You pay nothing
        Related medical supplies:  You pay nothing
        ** Additional Benefits **
        Inpatient Mental Health Care
        For inpatient mental health care see the "Mental Health Care" section.
        ** Cost **
        Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
        Package 1: Dental
        Benefits include:
        • Preventive Dental
        • Comprehensive Dental
        Additional $12.20 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium.
        This package does not have a deductible.
        No. There is no limit to how much our plan will pay for benefits in this package.
        ** Important Information **
        Package 1: Dental
        Benefits include:
        • Preventive Dental
        • Comprehensive Dental
        Additional $12.20 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium.
        This package does not have a deductible.
        No. There is no limit to how much our plan will pay for benefits in this package.

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