Blue Shield Vital (HMO)
H0504 - 045 - 0
(4 / 5)
Blue Shield Vital (HMO) is a Medicare Advantage (Part C) Plan by Blue Shield of California.
This page features plan details for 2022 Blue Shield Vital (HMO) H0504 – 045 – 0 available in Counties: LA, OR, SB, RIV.
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 Vital (HMO) is offered in the following locations.
Plan Overview
Blue Shield Vital (HMO) offers the following coverage and cost-sharing.
| Insurer: | Blue Shield of California |
| Health Plan Deductible: | $0 |
| MOOP: | $3,400.00 |
| Drugs Covered: | Yes |
Ready to sign up for Blue Shield Vital (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Blue Shield Vital (HMO) qualifies for a monthly Medicare Give Back Benefit of $49.00.
| Premium Reduction: | $49.00 |
Premium Breakdown
Blue Shield Vital (HMO) has a monthly premium of $0. 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 | $0.00 | $49.00 | $121.10 |
- 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 Vital (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| 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 |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $0.00 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 | $5.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $5.00 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 Vital (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: | $0-16 copay (authorization required) (referral required) |
| Endodontics: | $25-373 copay (limits may apply) (authorization required) (referral required) |
| Extractions: | $23-80 copay (limits may apply) (authorization required) (referral required) |
| Non-routine services: | Not covered |
| Periodontics: | $40-80 copay (limits may apply) (authorization required) (referral required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0-525 copay (limits may apply) (authorization required) (referral required) |
| Restorative services: | $19-430 copay (limits may apply) (authorization required) (referral required) |
Dental (preventive)
| Cleaning: | $20 copay (limits may apply) |
| Dental x-ray(s): | $0-10 copay (limits may apply) |
| Fluoride treatment: | $5 copay (limits may apply) |
| Oral exam: | $5-16 copay |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $5 copay (referral required) |
| Diagnostic tests and procedures: | $0 copay (referral required) |
| Lab services: | $0 copay (referral required) |
| Outpatient x-rays: | $0 copay (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0-10 copay per visit (referral required) |
Emergency care/Urgent care
| Emergency: | $120 copay per visit (always covered) |
| Urgent care: | $10 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $10 copay (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $100 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered |
| Hearing aids – inner ear: | Not covered |
| Hearing aids – outer ear: | Not covered |
| Hearing aids – over the ear: | Not covered |
| Hearing exam: | $0-10 copay (referral required) |
Hospital coverage (inpatient)
| $120 per day for days 1 through 5 $0 per day for days 6 through 90 (referral required) |
Hospital coverage (outpatient)
| $150 copay per visit (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,400 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: | $250 per stay $120 per day for days 1 through 10 $0 per day for days 11 through 90 (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $20 copay (referral required) |
| Outpatient group therapy visit: | $20 copay (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $20 copay (referral required) |
| Outpatient individual therapy visit: | $20 copay (referral required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay |
Rehabilitation services
| Occupational therapy visit: | $0 copay (referral required) |
| Physical therapy and speech and language therapy visit: | $0 copay (referral required) |
Skilled Nursing Facility
| $20 per day for days 1 through 20 $75 per day for days 21 through 100 (referral required) |
Transportation
| Not covered |
Vision
| Contact lenses: | Not covered |
| Eyeglass frames: | $20 copay (limits may apply) (referral required) |
| Eyeglass lenses: | $20 copay (limits may apply) (referral required) |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | Not covered |
| Routine eye exam: | $10 copay (limits may apply) (referral required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $12.40 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $12.40 |
| Comprehensive dental: | Deductible: | N/A |
Package #2
| Preventive dental: | Monthly Premium: | $41.90 |
| Preventive dental: | Deductible: | $50.00 |
| Comprehensive dental: | Monthly Premium: | $41.90 |
| Comprehensive dental: | Deductible: | $50.00 |
Ready to sign up for Blue Shield Vital (HMO) ?