|
|
BLUE SHIELD
Shield 65
800-488-8000
www.BlueShieldCA.com
|
INTERVALLEY
Service
to Seniors
800-505-7150
www.IVHP.com
|
KAISER
Senior Advantage
800-443-0815
www.CA.Kaiserpermanente.org
|
COUNTIES
COVERED
|
RIVERSIDE
SAN BERNARDINO
|
RIVERSIDE
SAN BERNARDINO
|
RIVERSIDE
SAN BERNARDINO
|
MONTHLY
PREMIUM
|
$55
(plus $54 for
Medicare Part B)
|
$50 Riverside
$30 San Bernardino
(plus $54 for
Medicare Part B)
|
$57
(plus $54 for
Medicare Part B)
|
OFFICE
VISIT
|
$10
|
$10
|
$10
|
HOSPITALIZATION
|
$250 a day for 1-3
days. $0 for days 4-90 for Medicare-covered stay. A max. of $750 out of pocket for each benefit period.
|
$0 for days 1-90 for
a Medicare- covered stay. $0
for additional days. Unlimited
days each benefit period.
|
$200 for each Medicare-covered
stay. Unlimited days
each benefit period. Maximum $800 out of pocket cost each year.
|
PRESCRIPTION DRUGS
Co-Payment and Cap
|
Formulary Generic
$10/30day sup. Mail order Formulary Generic drugs $20/90 day
supply. ANNUAL
LIMIT: $500 for
Formulary Generic.
|
Generic $10/30 day sup. Form. Pref. Brand $25/30 day sup. Non Form. Brand $42/30 day sup.(Riv) $38/30 day sup.(SB) Mail orders avail. LIMIT:
San Bern. Cnty Only brands subject to $450 limit. Riverside Cnty all drugs subject to $450 limit.
|
Formulary generic
$10/up to 100 day sup. Formulary
Brand names $25/up to a 100 day supply.
Mail order, same as above.
LIMIT: Combined formulary generic and
formulary brand prescriptions $2,000.
|
SKILLED
NURSING
Facility Co-Payment
(Medicare Criteria
applies)
|
$0 up to 100 days
per benefit period. No prior hospital stay required.
|
$0 up to 100 days
per benefit period. No
prior hospital stay required.
|
$0 up to 100 days
per benefit period. No
prior hospital stay required
|
AMBULANCE
|
$75 for Medicare-covered
ambulance services
|
$50 for Medicare-covered
ambulance services
|
$50 for Medicare-covered
ambulance services
|
CHIROPRACTIC CARE
|
$10 for Medicare approved services.
|
$10 for each Medicare-covered
visit. $15 for each routine visit up to 15 visits per year.
|
$10 for each Medicare-covered
visit. No referral necessary.
|
DENTAL
CARE
|
NOT COVERED
|
NOT COVERED
|
NOT COVERED
|
EMERGENCY ROOM
|
$50 each Medicare covered ER visit; waived if admitted within 24 hrs.
Worldwide coverage.
|
$50 each Medicare
covered ER visit; waived if admitted within 24 hrs. Worldwide
coverage.
|
$50
each Medicare covered ER visit; waived
if admitted within 24 hrs. Worldwide coverage.
|
HEARING
CARE
|
$0 for Medicare-covered
hearing exam (diagnostic hearing exams)
|
$10 for Medicare-covered hearing exam
(diagnostic hearing exams).
|
$10 for Medicare-covered hearing exam
(diagnostic hearing exams).
|
HOME
HEALTH CARE
|
$0 for Medicare-covered
home health visits.
|
$0 for Medicare-covered
home health visits.
|
$0 for Medicare-covered
home health visits.
|
MENTAL HEALTH
CARE (Outpatient)
|
$20 for Medicare-covered
mental health services
|
$10 for Medicare-covered
mental health services.
|
$10 for Medicare-covered
mental health services.
|
PODIATRY
CARE
|
$10 for each Medicare-covered
visit (medically necessary
foot care).
|
$10 for each
Medicare-covered visit (medically necessary foot care).
|
$10 for each Medicare-covered
visit (medically necessary foot care).
|
VISION
CARE
|
$10 for each Medicare-covered
eye exam(diag./treatment). $10 each routine exam. Covers up
to $90 for eye wear every 2 yrs.
|
$10 each Medicare-covered
eye exam(diag./treatment). $10 each routine exam. Covers up
to $45 for eye wear every 2 yrs.
|
$10 each Medicare-covered
eye exam(diag./treatment). $10 each routine exam. Covers up
to $60 for eye wear every 2 yrs.
|
URGENT
CARE
OUT
OF SERVICE AREA
|
$50 for each Medicare-covered
urgently needed care visit.
Waived if admitted to hospital within 24 hrs. Worldwide
coverage.
|
$10-$30 for each Medicare-covered
urgently needed care
visit. Waived if admitted to hospital
within 24 hrs. Worldwide
coverage.
|
$10-$50 for each Medicare-covered
urgently needed care visit.
Waived if admitted to hospital
within 24 hrs. Worldwide
coverage.
|
PREVENTIVE SERVICES
|
$10 for routine physical
exams. Limit 1 per year.
|
$10 for routine physical
exam. Limit 1 per year
|
$10 for routine physical
exam. No limit per year.
|
