Blue Shield Select (PPO) H4937-001 is a 2023 Medicare Advantage Plan or Part-C by Blue Shield of California available to residents in California. This plan includes extra prescription drug (Part-D) coverage. Blue Shield of California Blue Shield Select (PPO) has a monthly premium of $57.00 and has an in-network maximum out-of-pocket limit of $6,200 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,200 out-of-pocket. This can be an extremely nice safety net.

Blue Shield of California works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Shield Select (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Shield of California and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Blue Shield of California except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in California.

2023 Blue Shield of California Medicare Advantage Plan Overview

What type of plan is Blue Shield Select (PPO)

Blue Shield Select (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network, but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

How much does Blue Shield Select (PPO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Blue Shield of California charges a $57.00 consolidated premium. The Part C premium is $12.00 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Blue Shield Select (PPO) has a monthly drug premium of $45.00 and a $0 drug deductible. This Blue Shield of California plan offers a $45.00 Part-D Basic Premium that is Not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Blue Shield of California above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $45.00. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Blue Shield of California Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers extra coverage. This Blue Shield of California plan does offer extra coverage through the gap.

Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Blue Shield Select (PPO) medicare insurance offers a $6.10 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $15.90 for 75% low-income subsidy $25.60 for 50% and $35.30 for 25%.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Shield Select (PPO) by Blue Shield of California MOOP is $6,200. Once you spend $6,200 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Blue Shield Select (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$5	$20
Tier 3	$40	$47
Tier 4	$95	$100
Tier 5	33%	33%

The complete Blue Shield Select (PPO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Blue Shield Select (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Blue Shield of California helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

---

Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglass lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglasses (frames and lenses)

Vision	Not covered

---

Other

Vision	Not covered

---

Routine eye exam

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

---

Upgrades

Vision	Not covered

---

Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $178 per day for days 21 through 100
Out-of-Network Skilled Nursing Facility	40% per stay

---

Occupational therapy visit

In-Network Rehabilitation services	$25 copay
Out-of-Network Rehabilitation services	40% coinsurance

---

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$25 copay
Out-of-Network Rehabilitation services	40% coinsurance

---

Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	20% coinsurance

---

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	20% coinsurance

---

Fluoride treatment

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	20% coinsurance

---

Oral exam

Out-of-Network Preventive dental	20% coinsurance
In-Network Preventive dental	$0 copay

---

Out-of-Network Preventive care	40% coinsurance
In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$250 copay per visit
Out-of-Network Outpatient hospital coverage	40% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	Yes

---

Inpatient hospital - psychiatric

Out-of-Network Mental health services	40% per stay
In-Network Mental health services	$1,660 per stay

---

Outpatient group therapy visit

Out-of-Network Mental health services	40% coinsurance
In-Network Mental health services	$35 copay

---

Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$35 copay
Out-of-Network Mental health services	40% coinsurance

---

Outpatient individual therapy visit

In-Network Mental health services	$35 copay
Out-of-Network Mental health services	40% coinsurance

---

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$35 copay
Out-of-Network Mental health services	40% coinsurance

---

Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	40% coinsurance

---

Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	40% coinsurance

---

Diabetes supplies

In-Network Medical equipment/supplies	$0 copay
Out-of-Network Medical equipment/supplies	20% coinsurance per item

---

Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

---

Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

---

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$11,000 In and Out-of-network $6,200 In-network
Out-of-Network Inpatient hospital coverage	30% per stay
In-Network Inpatient hospital coverage	$200 per day for days 1 through 7 $0 per day for days 8 through 90

---

Fitting/evaluation

Out-of-Network Hearing	40% coinsurance
In-Network Hearing	$0 copay

---

Hearing aids

In-Network Hearing	$0 copay
Out-of-Network Hearing	$0 copay

---

Hearing exam

Out-of-Network Hearing	40% coinsurance
In-Network Hearing	$5-20 copay

---

Health plan deductible	$750 annual deductible
In-Network Ground ambulance	$250 copay
Out-of-Network Ground ambulance	$250 copay

---

Foot exams and treatment

In-Network Foot care (podiatry services)	$25 copay
Out-of-Network Foot care (podiatry services)	40% coinsurance

---

Routine foot care

Foot care (podiatry services)	Not covered

---

Emergency

Emergency care/Urgent care	$95 copay per visit (always covered)

---

Urgent care

Emergency care/Urgent care	$5 copay per visit (always covered)

---

Primary

Out-of-Network Doctor visits	40% coinsurance per visit
In-Network Doctor visits	$5 copay per visit

---

Specialist

In-Network Doctor visits	$0-20 copay per visit
Out-of-Network Doctor visits	40% coinsurance per visit

---

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$75 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

---

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$0 copay

---

Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

---

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

---

Diagnostic services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	20% coinsurance

---

Endodontics

Comprehensive dental	Not covered

---

Extractions

Comprehensive dental	Not covered

---

Non-routine services

Comprehensive dental	Not covered

---

Periodontics

Comprehensive dental	Not covered

---

Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

---

Restorative services

Comprehensive dental	Not covered

---

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Blue Shield Select (PPO) Reviews

Is Blue Shield Select (PPO) a good plan? Blue Shield Select (PPO) received a 3.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Blue Shield Select Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H4937-001 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for Blue Shield of California

Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Blue Shield Select (PPO) requires you to live in that plan’s service area. The service area is listed below:

Go to top

Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.