Blue Shield 65 Plus Choice Plan (HMO)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – 0.00-80.00 Copay (Limits Apply)
• Endodontics
  • In-Network: No Coins – 25.00-373.00 Copay
• Oral and Maxillofacial Surgery
  • In-Network: No Coins – 23.00-80.00 Copay
• Periodontics
  • In-Network: No Coins – 40.00-60.00 Copay
• Prosthodontics, fixed
  • In-Network: No Coins – 40.00-430.00 Copay
• Prosthodontics, removable
  • In-Network: No Coins – 28.00-525.00 Copay
• Restorative Services
  • In-Network: No Coins – 19.00-430.00 Copay

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – 0.00-10.00 Copay
• Fluoride Treatment
  • In-Network: No Coins – 5.00 Copay
• Oral Exams
  • In-Network: No Coins – 0.00-16.00 Copay
• Other Diagnostic Dental Services
  • In-Network: No Coins – 0.00-15.00 Copay (Limits Apply)
• Other Preventive Dental Services
  • In-Network: No Coins – 0.00-80.00 Copay
• Prophylaxis (cleaning)
  • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • $0 copay (Referral Required)
• Outpatient x-rays
  • $0 copay (Referral Required)
• Diagnostic tests and procedures
  • $0 copay (Referral Required)
• Lab services
  • $0 copay (Referral Required)

Doctor visits

• Specialist
  • $0 copay (Referral Required)
• Primary
  • $0 copay

Emergency care/Urgent care

• Emergency
  • $140 copay per visit (always covered)
• Urgent care
  • $0 copay

Foot care (podiatry services)

• Foot exams and treatment
  • $0 copay (Referral Required)
• Routine foot care
  • $0 copay (Referral Required)

Ground ambulance

• • $250 copay

Health plan deductible

• • $0

Hearing

• Hearing aids OTC
  • Not covered
• Fitting/evaluation
  • $0 copay (Limits Apply, Referral Required)
• Hearing aids
  • $449-699 copay (Limits Apply)
• Medicare-Covered Hearing Exam
  • $0 copay (Referral Required)

Inpatient hospital coverage

• • $0 copay (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $800 In-network

Medical equipment/supplies

• Prosthetics (e.g., braces, artificial limbs)
  • 20% coinsurance per item (Authorization Required)
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • 0-20% coinsurance per item (Authorization Required)
• Diabetes supplies
  • $0 copay (Authorization Required)

Medicare Part B drugs

• Other Part B drugs
  • 0-20% coinsurance (Authorization Required)
• Chemotherapy
  • 0-20% coinsurance (Authorization Required)

Mental health services

• Inpatient hospital – psychiatric
  • $900 per stay (Authorization Required, Referral Required)
• Outpatient group therapy visit with a psychiatrist
  • $30 copay (Authorization Required, Referral Required)
• Outpatient individual therapy visit with a psychiatrist
  • $30 copay (Authorization Required, Referral Required)
• Outpatient group therapy visit
  • $30 copay (Authorization Required, Referral Required)
• Outpatient individual therapy visit
  • $30 copay (Authorization Required, Referral Required)

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $150 copay per visit (Authorization Required, Referral Required)

Preventive care

• • $0 copay

Rehabilitation services

• Occupational therapy visit
  • $0 copay (Authorization Required, Referral Required)
• Physical therapy and speech and language therapy visit
  • $0 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $75 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

• • $0 copay (Limits Apply)

Vision

• Eyeglasses (frames and lenses)
  • Not covered
• Contact lenses
  • $0 copay (Limits Apply, Referral Required)
• Eyeglass lenses
  • $0 copay (Limits Apply, Referral Required)
• Eyeglass frames
  • $0 copay (Limits Apply, Referral Required)
• Other
  • Not covered
• Routine eye exam
  • $0 copay (Limits Apply, Referral Required)
• Upgrades
  • Not covered

Wellness programs (e.g., fitness, nursing hotline)

• • Covered

Dental PPO

Comprehensive Dental

• Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, Adjunctive General Services
  • Monthly Premium: $47.00
  • Max Coverage: $1500.00
  • Coverage Periodicity: Other, Describe
  • Deductible Services: 16c1: Restorative Services, 16c2: Endodontics, 16c3: Periodontics, 16c4: Prosthodontics, removable, 16c6: Implant Services, 16c7: Prosthodontics, fixed, 16c8: Oral and Maxillofacial Surgery, 16c10: Adjunctive General Services
  • Deductible: $50.00

Diagnostic and Preventive Dental

• Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services
  • Monthly Premium: $47.00
  • Max Coverage: $1500.00
  • Coverage Periodicity: Other, Describe