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Medicare Advantage · HMO
Blue Shield of California
Plan year 2026

Blue Shield 65 Plus H0504-039 (HMO)

4.0 · 2026 Star Rating · source: CMS · Ratings are updated annually
Monthly premium
$65
+ your Part B premium
Max out-of-pocket
$4,100
in-network annual cap
Primary care
$0
per visit copay
Specialist
$0
per visit

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$425
Inpatient hospital
Days 1-4: $500/day, Days 5-90: $0/day
no limit on covered hospital days
Inpatient mental health
$900
per stay
Outpatient surgery
$200
Emergency room
$150
Urgent care
$0

What's included, and what it's actually worth3 benefits included. Tap any card for the detail

Hearing

$449–$999copay per hearing aid
Details$449–$999 copay per hearing aid
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$220eyewear allowance
Eyewear allowance$220 eyewear allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$0 copay
In-network$0 copay per visit
Inpatient Hospital$500/day, days 1–4
In-networkDays 1-4: $500/day, Days 5-90: $0/day
Benefit limitNone — additional covered days are unlimited
Outpatient Surgery$200 copay
In-network$200 copay per procedure
Mental Health$900 per stay
Inpatient psychiatric$900 per stay
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$0
Preferred Generic
Tier 2
$5
Generic
Tier 3
25%
Preferred Brand· after deductible
Tier 4
30%
Non-Pref Brand· after deductible
Tier 5
28%
Specialty· after deductible

Our take

Where this plan shines

This plan’s out-of-pocket maximum is below the national median.
See your primary doctor for $0.
The specialist copay ($0) is among the more affordable options.
Highly rated by CMS (4 stars).

Things to know before you enroll

Network restriction — you’ll need to use in-network providers except in emergencies.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits
No online copy available — call the plan at (888)534-4263 to request the Summary of Benefits
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (888)534-4263 (TTY: 711) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Every year, Medicare evaluates plans based on a 5-star rating system. Star ratings are based on 2026 data and may change annually.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

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