summary of benefits San Bernardino (partial) & Riverside (partial) Counties January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for Evidence of Coverage. H0504_15_257_017_026 CMS Accepted 09092015
You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by Federal government. Anor choice is to get your Medicare benefits by joining a Medicare health plan (such as Blue Shield 65 Plus (HMO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what covers and what you pay. If you want to compare our plan with or Medicare health plans, ask or plans for ir Summary of Benefits booklets. Or, use Medicare Plan Finder on http://www.medicare.gov. If you want to know more about coverage and s of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet Things to Know About Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for se benefits) This document is available in or formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (800) 776-4466 (TTY: 711). Este documento puede estar disponible en otro idioma que no sea el inglés. Para obtener más información, llámenos al (800) 776-4466 (TTY: 711). A-2
Things to Know About Hours of Operation From October 1 to February 14, you can call us 7 days a week from 7:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 7:00 a.m. to 8:00 p.m. Pacific time. Phone Numbers and Website If you are a member of this plan, call toll-free (800) 776-4466 [TTY: 711]. If you are not a member of this plan, call toll-free (800) 488-8000 [TTY: 711]. Our website: http://www.blueshieldca.com/findamedicareplan Who can join? To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes following counties in California: San Bernardino* and Riverside*. * denotes partial county The service area for San Bernardino County includes only ZIP codes listed below. You must live in one of se ZIP codes to join plan: 91701 91763 92314 92334 92352 92376 92401 92415 91708 91709 91710 91729 91764 91784 91785 92315 92316 92317 92335 92336 92337 92354 92356 92357 92377 92378 92382 92402 92403 92404 92418 92420 92424 91730 91737 91739 91743 91758 91759 91761 91762 91786 91798 92301 92305 92307 92308 92311 92312 92313 92318 92321 92322 92324 92325 92326 92327 92329 92333 92339 92340 92341 92342 92344 92345 92346 92347 92350 92358 92359 92368 92369 92371 92372 92373 92374 92375 92385 92386 92391 92392 92393 92394 92395 92397 92399 92405 92406 92407 92408 92410 92411 92412 92413 92414 92427 The service area for Riverside County includes only ZIP codes listed below. You must live in one of se ZIP codes to join plan: 91752 92220 92223 92320 92501 92502 92503 92504 92505 92506 92507 92508 92509 92513 92514 92515 92516 92517 92518 92519 92521 92522 92530 92531 92532 92543 92544 92545 92546 92548 92551 92552 92553 92554 92555 92556 92557 92562 92563 92564 92567 92570 92571 92572 92581 92582 92583 92584 92585 92586 92587 92589 92590 92591 92592 92593 92595 92596 92599 92860 92877 92878 92879 92880 92881 92882 92883 A-3
Which doctors, hospitals, and pharmacies can I use? has a network of doctors, hospitals, pharmacies, and or providers. If you use providers that are not in our network, plan may not pay for se services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred -sharing. You may pay less if you use se pharmacies. You can see our plan's provider directory at our website (www.blueshieldca.com/findaprovider). You can see our plan's pharmacy directory at our website (www.blueshieldca.com/med_pharmacy). Or, call us and we will send you a copy of provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of benefits covered by Original Medicare. For some of se benefits, you may pay more in our plan than you would in Original Medicare. For ors, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemorapy and some drugs administered by your provider. You can see complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.blueshieldca.com/med_formulary. Or, call us and we will send you a copy of formulary. How will I determine my drug s? Our plan groups each medication into one of six "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will you. The amount you pay depends on drug's tier and what stage of benefit you have reached. Later in this document we discuss benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. A-4
SUMMARY OF BENEFITS January 1, 2016 December 31, 2016 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. How much is deductible? These plans do not have a deductible. Is re any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plans protect you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in se plans: $3,200 for services you receive from in-network providers If you reach limit on out-of-pocket s, you keep getting covered hospital and medical services and we will pay full for rest of year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Is re a limit on how much plan will pay? Our plans have a coverage limit every year for certain in-network benefits. Contact us for services that apply. Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. COVERED MEDICAL AND HOSPITAL BENEFITS Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. A-5
OUTPATIENT CARE AND SERVICES Acupuncture Not Covered Not Covered Ambulance 1 $250 $250 Chiropractic Care 1,2 Manipulation of spine to correct a subluxation (when 1 or more of bones of your spine move out of position): $5 Dental Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-5, depending on service This plan covers preventive and comprehensive dental services for an extra plan premium. See Optional Benefits Package 1: Dental on page A-18 for more information. Diabetes Supplies and Services 1,2 Diagnostic Tests, Lab and Radiology Services, and X- Rays (Costs for se services may vary based on place of service) 1,2 Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing For blood glucose monitors, please see Durable Medical Equipment below. Diagnostic radiology services (such as MRIs, CT scans): $40 Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Manipulation of spine to correct a subluxation (when 1 or more of bones of your spine move out of position): $5 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-5, depending on service This plan covers preventive and comprehensive dental services for an extra plan premium. See Optional Benefits Package 1: Dental on page A-18 for more information. Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing For blood glucose monitors, please see Durable Medical Equipment below. Diagnostic radiology services (such as MRIs, CT scans): $60 Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing A-6
OUTPATIENT CARE AND SERVICES Therapeutic radiology services (such as radiation treatment for cancer): 20% of Therapeutic radiology services (such as radiation treatment for cancer): 20% of While you pay 20% of for rapeutic radiology services, you will never pay more than your $3,200 total outof-pocket maximum for year. Doctor's Office Visits 1,2 Primary care physician visit: You pay nothing While you pay 20% of for rapeutic radiology services, you will never pay more than your $3,200 total outof-pocket maximum for year. Primary care physician visit: You pay nothing Durable Medical Equipment (wheelchairs, oxygen, etc.)1 Specialist visit: $5 Specialist visit: $5 20% of 20% of Emergency Care $75 $75 You pay regardless of wher You pay regardless of wher or not you are admitted to a hospital for or not you are admitted to a hospital for same condition. same condition. World-wide coverage. You have a,000 combined annual limit for covered emergency care or urgently needed services outside United States and its territories. World-wide coverage. You have a,000 combined annual limit for covered emergency care or urgently needed services outside United States and its territories. Foot Care (podiatry services) 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $5 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $5 Hearing Services 1,2 Exam to diagnose and treat hearing and balance issues: $0-5, depending on service Exam to diagnose and treat hearing and balance issues: $0-5, depending on service A-7
OUTPATIENT CARE AND SERVICES Routine hearing exam: $0-5, depending on service Routine hearing exam: $0-5, depending on service Home Health 1,2 You pay nothing Mental Health Care 1,2 Inpatient visit: Inpatient visit: Our plan covers up to 190 days in a lifetime Our plan covers up to 190 days in a lifetime for inpatient mental health care in a for inpatient mental health care in a psychiatric hospital. The inpatient hospital psychiatric hospital. The inpatient hospital care limit does not apply to inpatient care limit does not apply to inpatient mental services provided in a general mental services provided in a general hospital. hospital. The s for hospital and skilled nursing The s for hospital and skilled nursing facility (SNF) benefits are based on benefit facility (SNF) benefits are based on benefit periods. A benefit period begins day periods. A benefit period begins day you're admitted as an inpatient and ends you're admitted as an inpatient and ends when you haven't received any inpatient when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF a row. If you go into a hospital or a SNF after one benefit period has ended, a new after one benefit period has ended, a new benefit period begins. You must pay benefit period begins. You must pay inpatient hospital deductible for each inpatient hospital deductible for each benefit period. There's no limit to benefit period. There's no limit to number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, If your hospital stay is longer than 90 days, you can use se extra days. But once you can use se extra days. But once you have used up se extra 60 days, your you have used up se extra 60 days, your inpatient hospital coverage will be limited inpatient hospital coverage will be limited to 90 days. to 90 days. $900 per stay $900 per stay A-8
OUTPATIENT CARE AND SERVICES Outpatient group rapy visit: $30 Outpatient group rapy visit: $30 Outpatient individual rapy visit: $30 Outpatient individual rapy visit: $30 Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $20 Occupational rapy visit: $20 Physical rapy and speech and language rapy visit: $20 Outpatient Substance Abuse 1,2 Group rapy visit: $30 Individual rapy visit: $30 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $25 Occupational rapy visit: $25 Physical rapy and speech and language rapy visit: $25 Group rapy visit: $30 Individual rapy visit: $30 Outpatient Surgery 1,2 Ambulatory surgical center: You pay nothing Ambulatory surgical center: $50 Outpatient hospital: 0 Outpatient hospital: $150 Over--Counter Items Not Covered Not Covered Prostic Devices (braces, Prostic devices: You pay nothing Prostic devices: You pay nothing artificial limbs, etc.) 1 Related medical supplies: You pay nothing Related medical supplies: You pay nothing Renal Dialysis 1,2 10% of 10% of Transportation Not Covered Not Covered Urgently Needed Services You pay regardless of wher You pay regardless of wher or not you are admitted to a hospital for or not you are admitted to a hospital for same condition. same condition. World-wide coverage. You pay a $75 and have a,000 combined annual limit for covered emergency care World-wide coverage. You pay a $75 and have a,000 combined annual limit for covered emergency care A-9
OUTPATIENT CARE AND SERVICES or urgently needed services outside United States and its territories. or urgently needed services outside United States and its territories. Vision Services 1,2 Exam to diagnose and treat diseases and conditions of eye (including yearly glaucoma screening): $0-5, depending on service Routine eye exam (for up to 1 every year): Eyeglass frames (for up to 1 every two years): $20 Our plan pays up to $75 every two years for eyeglass frames. Eyeglass lenses (for up to 1 every year): $20 Eyeglasses or contact lenses after cataract surgery: You pay nothing Exam to diagnose and treat diseases and conditions of eye (including yearly glaucoma screening): $0-5, depending on service Routine eye exam (for up to 1 every year): Eyeglass frames (for up to 1 every two years): $20 Our plan pays up to $75 every two years for eyeglass frames. Eyeglass lenses (for up to 1 every year): $20 Eyeglasses or contact lenses after cataract surgery: You pay nothing For routine eye exams, no authorization or referral is required. See plan Evidence of Coverage for a full description of covered services as well as -sharing amounts for services obtained from nonnetwork providers. For routine eye exams, no authorization or referral is required. See plan Evidence of Coverage for a full description of covered services as well as -sharing amounts for services obtained from nonnetwork providers. Preventive Care 1 You pay nothing You pay nothing Our plan covers many preventive services, including: Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Abdominal aortic aneurysm screening Alcohol misuse counseling Alcohol misuse counseling Bone mass measurement Bone mass measurement A-10
OUTPATIENT CARE AND SERVICES Breast cancer screening (mammogram) Breast cancer screening (mammogram) Cardiovascular disease (behavioral rapy) Breast cancer screening (mammogram) Breast cancer screening (mammogram) Cardiovascular disease (behavioral rapy) Cardiovascular screenings Cardiovascular screenings Cervical and vaginal cancer screening Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Depression screening Diabetes screenings Diabetes screenings HIV screening HIV screening Medical nutrition rapy services Medical nutrition rapy services Obesity screening and counseling Obesity screening and counseling Prostate cancer screenings (PSA) Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during contract year will be covered. Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during contract year will be covered. You pay nothing for hospice care from a Medicare-certified hospice. You may have A-11
OUTPATIENT CARE AND SERVICES to pay part of for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care 1,2 Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing The Original Medicare benefit period does not apply. Inpatient Mental Health Care For inpatient mental health care, see "Mental Health Care" section of this booklet. Skilled Nursing Facility (SNF) 1,2 Our plan covers up to 100 days in a SNF. $40 per day for days 1 through 20 $150 per day for days 21 through 100 No prior hospital stay is required. A-12 to pay part of for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing The Original Medicare benefit period does not apply. For inpatient mental health care, see "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. $25 per day for days 1 through 20 $150 per day for days 21 through 100 No prior hospital stay is required.
PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemorapy drugs 1 : 20% of For Part B drugs such as chemorapy drugs 1 : 20% of Or Part B drugs 1 : 20% of Or Part B drugs 1 : 20% of When Part B drugs are given in an office/clinic, you pay 20% of Medicareallowed amount. When Part B drugs are obtained at a network pharmacy, you pay 20% of Blue Shield s contracted rate. When Part B drugs are given in an office/clinic, you pay 20% of Medicareallowed amount. When Part B drugs are obtained at a network pharmacy, you pay 20% of Blue Shield s contracted rate. Initial Coverage You pay following until your total yearly drug s reach $3,310. Total yearly drug s are total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. You pay following until your total yearly drug s reach $3,310. Total yearly drug s are total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Standard Retail Cost-Sharing Tier Onemonth Twomonth Tier Onemonth Twomonth Tier 1 (Preferred Generic) $7 Tier 2 (Generic) $12 Tier 3 (Preferred Brand) $47 $14 $24 $94 $21 $36 $141 Tier 1 (Preferred Generic) $7 Tier 2 (Generic) $12 Tier 3 (Preferred Brand) $47 $14 $24 $94 $21 $36 $141 A-13
Tier 4 (Non-Preferred $95 Brand) Tier 5 (Injectable Drugs) 25% of Tier 6 (Specialty Tier) 33% of Preferred Retail Cost-Sharing Preferred Retail Cost-Sharing Tier Onemonth $190 25% of Not Twomonth Tier 1 (Preferred Generic) $0 $0 $0 $285 25% of Not Tier 4 (Non-Preferred $95 Brand) Tier 5 (Injectable Drugs) 25% of Tier 6 (Specialty Tier) 33% of Tier Onemonth $190 25% of Not Twomonth Tier 1 (Preferred Generic) $0 $0 $0 $285 25% of Not Tier 2 (Generic) $5 Tier 3 (Preferred Brand) $40 Tier 4 (Non-Preferred $90 Brand) Tier 5 (Injectable Drugs) 25% of Tier 6 (Specialty Tier) 33% of $80 $180 25% of Not $80 $180 25% of Not Tier 2 (Generic) $5 Tier 3 (Preferred Brand) $40 Tier 4 (Non-Preferred $90 Brand) Tier 5 (Injectable Drugs) 25% of Tier 6 (Specialty Tier) 33% of $80 $180 25% of Not $80 $180 25% of Not A-14
Standard Mail Order Cost-Sharing Tier One- month Tier 1 (Preferred Generic) Not Tier 2 (Generic) Not Tier 3 (Preferred Brand) Not $80 Tier 4 (Non-Preferred Not $180 Brand) Tier 5 (Injectable Drugs) Not 25% of Tier 6 (Specialty Tier) 33% of Not If you reside in a long-term care facility, you pay same as at a standard retail -sharing pharmacy. You may get drugs from an out-of-network pharmacy at same as an in-network standard retail -sharing pharmacy. $0 Standard Mail Order Cost-Sharing Tier One- month Tier 1 (Preferred Generic) Not Tier 2 (Generic) Not Tier 3 (Preferred Brand) Not $80 Tier 4 (Non-Preferred Not $180 Brand) Tier 5 (Injectable Drugs) Not 25% of Tier 6 (Specialty Tier) 33% of Not If you reside in a long-term care facility, you pay same as at a standard retail -sharing pharmacy. You may get drugs from an out-of-network pharmacy at same as an in-network standard retail sharing pharmacy. $0 PRESCRIPTION DRUG BENEFITS Coverage Gap Most Medicare drug plans have a coverage gap (also called "donut hole"). This means that re's a temporary change in what you will pay for your drugs. The coverage gap begins after total yearly drug (including what our plan has paid and Most Medicare drug plans have a coverage gap (also called "donut hole"). This means that re's a temporary change in what you will pay for your drugs. The coverage gap begins after total yearly drug (including what our plan has paid and A-15
what you have paid) reaches $3,310. After you enter coverage gap, you pay 45% of plan's for covered brand name drugs and 58% of plan's for covered generic drugs until your s total $4,850, which is end of coverage gap. Not everyone will enter coverage gap. Under this plan, you may pay even less for brand and generic drugs on formulary. Your varies by tier. You will need to use your formulary to locate your drug's tier. See chart that follows to find out how much it will you. Standard Retail Cost-Sharing Standard Retail Cost-Sharing Tier Drugs Covered Onemonth Tier 1 (Preferred All $7 Generic) Tier 2 (Generic) All $12 Twomonth $14 $24 $21 $36 Tier Tier 1 (Preferred Generic) what you have paid) reaches $3,310. After you enter coverage gap, you pay 45% of plan's for covered brand name drugs and 58% of plan's for covered generic drugs until your s total $4,850, which is end of coverage gap. Not everyone will enter coverage gap. Under this plan, you may pay even less for brand and generic drugs on formulary. Your varies by tier. You will need to use your formulary to locate your drug's tier. See chart that follows to find out how much it will you. Drugs Covered Onemonth All $7 Tier 2 (Generic) All $12 Twomonth $14 $24 $21 $36 A-16
Preferred Retail Cost-Sharing Preferred Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Drugs Covered All $0 Onemonth Tier 2 (Generic) All $5 Twomonth $0 $0 Tier Tier 1 (Preferred Generic) Drugs Covered All $0 Onemonth Tier 2 (Generic) All $5 Standard Mail Order Cost-Sharing Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Drugs Covered Onemonth All Not Tier 2 (Generic) All Not $0 Tier Drugs Covered Onemonth Tier 1 (Preferred All Not Generic) Tier 2 (Generic) All Not A-17 Twomonth $0 $0 $0
PRESCRIPTION DRUG BENEFITS Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay greater of: After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay greater of: 5% of, or 5% of, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all or drugs. Optional Benefits (you must pay an extra premium each month for se benefits) $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all or drugs. Package 1: Dental Benefits include: Benefits include: Preventive Dental Preventive Dental Comprehensive Dental Comprehensive Dental How much is monthly premium? Additional $12.60 per month. You Additional $12.60 per month. You must keep paying your Medicare Part must keep paying your Medicare Part B premium and your $0 monthly plan B premium and your $0 monthly plan premium. premium. How much is deductible? This package does not have a deductible. This package does not have a deductible. A-18
An independent member of Blue Shield Association Optional Benefits (you must pay an extra premium each month for se benefits) Is re a limit on how much plan will pay? No. There is no limit to how much our plan will pay for benefits in this package. No. There is no limit to how much our plan will pay for benefits in this package. Exceptions include a $1,000 calendar year maximum for specialty services, and a 0 calendar year limit on amount reimbursed for out-of-area emergency dental care. See plan Evidence of Coverage for a complete list of s for covered services, as well as limitations, and exclusions. Exceptions include a $1,000 calendar year maximum for specialty services, and a 0 calendar year limit on amount reimbursed for out-of-area emergency dental care. See plan Evidence of Coverage for a complete list of s for covered services, as well as limitations, and exclusions. ADDITIONAL INFORMATION ABOUT BLUE SHIELD 65 PLUS (HMO) Blue Shield of California is a not-for-profit company that s been serving Californians for more than 75 years. Our mission is to ensure all Californians have access to high-quality health care at an affordable price. MR15772-SBDRIV (10/15) A-19