Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5928-004-000
Plan Organization Blue Shield of California
Plan Type Local HMO
Plan Name Blue Shield AdvantageOptimum Plan (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $999.00
Gap Coverage Yes

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - Yes Yes $0-8 copay
Endodontics No - Yes Yes $15-475 copay
Extractions No - Yes Yes $20-150 copay
Non-routine services No - Yes Yes $0 copay
Periodontics No - Yes Yes $0-375 copay
Prosthodontics, other oral/maxillofacial surgery, other services No - Yes Yes $0-1,800 copay
Restorative services No - Yes Yes $16-300 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - No Yes $0 copay
Diagnostic tests and procedures - - No Yes $0 copay
Lab services - - No Yes $0 copay
Outpatient x-rays - - No Yes $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No Yes $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $85 copay per visit (always covered)
Urgent care - - - - $0-45 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No Yes $0 copay
Routine foot care No - No Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $125 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No Yes $0 copay
Hearing aids Yes - No No $0 copay
Hearing exam - - No Yes $10 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No Yes $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $999 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $100 per day for days 1 through 8$0 per day for days 9 through 90
Outpatient group therapy visit - - No Yes $25 copay
Outpatient group therapy visit with a psychiatrist - - No Yes $25 copay
Outpatient individual therapy visit - - No Yes $25 copay
Outpatient individual therapy visit with a psychiatrist - - No Yes $25 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No Yes $100 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0-5 copay
Fluoride treatment Yes - No No $5 copay
Oral exam No - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - No Yes $10 copay
Physical therapy and speech and language therapy visit - - No Yes $10 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No Yes $0 per day for days 1 through 20$80 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other Yes - No No $0 copay
Routine eye exam Yes - No No $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Los Angeles County, California, Orange County, California

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