Blue Shield Coordinated Choice Plan (HMO)
H5928 - 037 - 0
(3.5 / 5)
Blue Shield Coordinated Choice Plan (HMO) is a Medicare Advantage (Part C) Plan by Blue Shield of California.
This page features plan details for 2022 Blue Shield Coordinated Choice Plan (HMO) H5928 – 037 – 0 available in Counties: LA, OR, SD, SB, RV, SC, FR, ME, SJ, ST.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Blue Shield Coordinated Choice Plan (HMO) is offered in the following locations.
Plan Overview
Blue Shield Coordinated Choice Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Blue Shield of California |
| Health Plan Deductible: | $0 |
| MOOP: | $6,700.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $480 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Blue Shield Coordinated Choice Plan (HMO) ?
Premium Breakdown
Blue Shield Coordinated Choice Plan (HMO) has a monthly premium of $33.2. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $33.20 | $0.00 | $203.30 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Blue Shield Coordinated Choice Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $480.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $33.20 | $24.90 | $16.60 | $8.30 | $0.00 |
Initial Coverage Phase
After you pay your $480.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Blue Shield Coordinated Choice Plan (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0-5 copay (authorization required) (referral required) |
| Endodontics: | $0-380 copay (authorization required) (referral required) |
| Extractions: | $5-130 copay (authorization required) (referral required) |
| Non-routine services: | Not covered |
| Periodontics: | $0-345 copay (authorization required) (referral required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0-2,100 copay (authorization required) (referral required) |
| Restorative services: | $0-380 copay (authorization required) (referral required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) (referral required) |
| Diagnostic tests and procedures: | 20% coinsurance (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | 20% coinsurance (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | 0-20% coinsurance per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | 20% coinsurance per visit (always covered) |
| Urgent care: | 20% coinsurance per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | 20% coinsurance (referral required) |
| Routine foot care: | $0 copay (limits may apply) (referral required) |
Ground ambulance
| 20% coinsurance |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (referral required) |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | 20% coinsurance (referral required) |
Hospital coverage (inpatient)
| Contact plan for details (authorization required) (referral required) |
Hospital coverage (outpatient)
| 20% coinsurance per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,700 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | Contact plan for details (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance (referral required) |
| Outpatient group therapy visit: | 20% coinsurance (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance (referral required) |
| Outpatient individual therapy visit: | 20% coinsurance (referral required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization required) (referral required) |
Rehabilitation services
| Occupational therapy visit: | 20% coinsurance (referral required) |
| Physical therapy and speech and language therapy visit: | 20% coinsurance (referral required) |
Skilled Nursing Facility
| Contact plan for details (authorization required) (referral required) |
Transportation
| $0 copay (authorization required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization required) |
| Other: | $0 copay (limits may apply) (authorization required) |
| Routine eye exam: | $0 copay (limits may apply) (authorization required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for Blue Shield Coordinated Choice Plan (HMO) ?