Blue Shield 65 Plus (HMO) Medicare Advantage Plan H0504-028 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $1800.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $300.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 1,931 beneficiaries
Blue Shield 65 Plus (HMO) Introduction
CMS Plan ID H0504-028 identifies Blue Shield 65 Plus, a Medicare Advantage HMO plan offered by Blue Shield of California. The plan uses a Health Maintenance Organization (HMO) provider network and comes with prescription drug coverage. Its costs for the 2027 plan year include a $0.00 monthly premium, $0.00 medical deductible, and $1800.00 in-network maximum out-of-pocket. The 2027 Part D prescription drug deductible is $300.00.
Plan Benefits
Blue Shield 65 Plus has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H0504-028.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay | In-network: $0 copay |
| Specialist | In-network: $0 copay | In-network: $0 copay |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | Not covered | In-network: $0 copay |
| Telehealth benefit | In-network: $0 copay | In-network: $0 copay |
| Routine chiropractic | In-network: $0 copay | In-network: $0 copay |
| Fitness benefits | Coming soon | In-network: $0 copay |
| Health education | Not covered | Not covered |
| Counseling services | Not covered | Not covered |
| Over-the-counter drug benefits | In-network: $0 copay | In-network: $0 copay |
| Health transportation (non-emergency) | Coming soon | In-network: $0 copay |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $50 copay | In-network: $50 copay |
| Lab services | In-network: $0 copay | In-network: $0 copay |
| Outpatient x-rays | In-network: $0 copay | In-network: $0 copay |
| Diagnostic tests and procedures | In-network: $0 copay | In-network: $0 copay |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $150 copay | $150 copay |
| Worldwide emergency care | Coming soon | $150 copay |
| Urgent care | $0 copay | $0 copay |
| Inpatient hospital care | Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
| Skilled Nursing Facility | Tier 1 $0 per day for days 1-20 $220 per day for days 21-100 |
Tier 1 $0 per day for days 1-20 $140 per day for days 21-100 |
| Ground ambulance | In-network: $275 copay | In-network: $275 copay |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $20 copay | In-network: $20 copay |
| Outpatient group therapy | In-network: $20 copay | In-network: $20 copay |
| Inpatient psychiatric hospital care | Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Tier 1 $150 per day for days 1-7 $0 per day for days 8-90 $0 per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $40 copay | In-network: $40 copay |
| Occupational therapy | In-network: $40 copay | In-network: $40 copay |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay | In-network: $0 copay |
| Durable medical equipment | In-network: 20% coinsurance | In-network: 0%-20% coinsurance |
| Prosthetics | In-network: 20% coinsurance | In-network: 20% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance | In-network: 0%-20% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0-$16 copay | In-network: $0-$16 copay |
| Dental x-rays | In-network: $0-$10 copay | In-network: $0-$10 copay |
| Cleaning | In-network: $0 copay | In-network: $0 copay |
| Periodontics | In-network: $40-$60 copay | In-network: $40-$60 copay |
| Endodontics | In-network: $25-$373 copay | In-network: $25-$373 copay |
| Restorative services | In-network: $19-$430 copay | In-network: $19-$430 copay |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: $23-$80 copay | In-network: $23-$80 copay |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay | In-network: $0 copay |
| Contact lenses | In-network: $0 copay | In-network: $0 copay |
| Eyeglass frames only | In-network: $0 copay | In-network: $0 copay |
| Eyeglass lenses only | In-network: $0 copay | In-network: $0 copay |
| Eyeglasses (frames & lenses) | Not covered | Not covered |
| Upgrades | Not covered | Not covered |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay | In-network: $0 copay |
| Fitting/evaluation | In-network: $0 copay | In-network: $0 copay |
| Prescription hearing aids | In-network: $449-$999 copay | In-network: $449-$999 copay |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | In-network: $0 copay |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | Not covered | Not covered |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | Not covered | Not covered |
Certain preventive services are covered 100% by Blue Shield 65 Plus as a Part B benefit.
Prescription Drug Coverage
Blue Shield 65 Plus includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | $7.28 |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $300.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Shield of California starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Blue Shield 65 Plus may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | 20% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 30% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H0504)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Blue Shield of California
- Website
- Blue Shield of California Plan Page
- Providers
- Blue Shield of California Providers Page
- Formulary
- Blue Shield of California Formulary Page
- Pharmacy
- Blue Shield of California Pharmacy Page
- New Member Health Plan Help
- (888)534-4263
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (888)534-4263
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Blue Shield 65 Plus (H0504-028-0) is available in the following locations:
California Counties Served
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Blue Shield 65 Plus (HMO)
How much does plan H0504-028 cost per month?
For 2027, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the annual out-of-pocket maximum (MOOP) for this plan?
The annual in-network MOOP is $1800.00 for 2027. After this limit is reached, covered in-network services are fully paid.
What is the CMS star rating for this plan?
For 2027, plan H0504-028 has a CMS star rating of ★0.0 out of 5 stars.
What is the total enrollment for plan H0504-028?
Total enrollment is 1,931 beneficiaries based on the latest CMS data.
What is the prescription drug deductible for 2027?
The plan’s Part D deductible is $300.00, applied to covered prescription drug costs.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Blue Shield of California (official source) | http://blueshieldca.com/medicare | October 4, 2026 |
| Medicare.gov | Compare types of Medicare Advantage Plans | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Compare Original Medicare & Medicare Advantage | 25 May, 2025 |
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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.