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Below form is for California only

Blue Shield of CA logo  Medicare Advantage HMO & Part D Insurance 
(877)566-5454 Toll Free

Blue Shield 65 Plus Medicare Advantage HMO & Part D Plans

Member Satisfaction Rating  Above Average
PRINT & MAIL Application - Blue Shield 65 Plus & 65 Plus Choice (all plans)

Blue Shield 65 Plus CHOICE Plan (includes Part D prescription drugs)

Overview - Los Angeles & Orange Counties ¹ ²
Summary of Benefits - Los Angeles & Orange Counties
Evidence of Coverage - Los Angeles & Orange Counties

Blue Shield 65 Plus Plans (includes Part D prescription drugs)

Overview - Los Angeles & Orange Counties ¹
Summary of Benefits - Los Angeles & Orange Counties
Evidence of Coverage - Los Angeles & Orange Counties
Overview - Contra Costa County ¹
Summery of Benefits - Contra Costa County
Evidence of Coverage - Contra Costa County
Overview - Fresno County
Summery of Benefits - Fresno County
Evidence of Coverage - Fresno County
Overview - Riverside ¹ & San Bernardino Counties
Summery of Benefits - Riverside & San Bernardino Counties
Evidence of Coverage - Riverside & San Bernardino Counties
Overview - Sacramento County ¹
Summery of Benefits - Sacramento County
Evidence of Coverage - Sacramento County
Overview - San Diego County
Summery of Benefits - San Diego County
Evidence of Coverage - San Diego County
Overview - Santa Clara County ¹
Summery of Benefits - Santa Clara County
Evidence of Coverage - Santa Clara County
Overview - Ventura County ¹
Summery of Benefits - Ventura County
Evidence of Coverage - Ventura County

2015 Part D Prescription Drug Formularies

Blue Shield 65 Plus HMO Formulary
Blue Shield 65 Choice HMO Formulary
Blue Shield 65 Advantage HMO Pharmacy Directory
Blue Shield of CA Physicians Database

¹ Available in only certain ZIP codes. See the Evidence of Coverage or Summery of Benefits for details.
² The Blue Shield 65 plus Choice plans utilizes a different provider network.

Mail all applications to:


OR FAX TO 1-760-433-0304

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Fill in this form to have your Brochure with Pricing & Application for your Blue Shield of California 65 Plus HMO Health Insurance mailed to you.   Or just call us Toll-free at (877)566-5454.
Customer Information
Full Name
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Zip Code
Home Phone
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Our Ages   My Age or DOB       Spouse's Age  
People Covered
Type of Enrollment
Plan wanted

Have you any comments, questions or special instructions?


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Download a "Medicare & you" Brochure

Download a "Your Medicare Benefits" Brochure

Download a "Medicare Advantage vs Medigap" Brochure

Download a "Understanding Medicare Enrollment Periods" Brochure

Download a "Medicare Coverage Outside the United States"

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Turning 65? A one-time-only seven month period, starting three months before you turn 65, when you can buy any Medigap policy you want that is sold in your state. It starts in the first month that you are covered under Medicare Part B and you are age 65 or older. During this period, you can’t be denied coverage or charged more due to past or present health problems. If you enroll during this time, the insurance company cannot:

  • deny you medigap coverage or make you wait for coverage to start; or
  • charge you more for a policy because of past or present health problems.
If you purchase a Medigap (or Medicare Advantage) policy after this seven-month initial enrollment period, you could be denied the Medigap (or Medicare Advantage) policy of your choice, or any Medigap (or Medicare Advantage) policy, because of pre-existing health conditions.


In California, if you are younger than 65 years of age and entitled to Medicare because of a disability, you have an Open Enrollment period. This period is for six months after you first sign up for Medicare Part B. (However, this right does NOT apply to people who have permanent kidney failure known as End Stage Renal Disease or ESRD.) If you receive a notice from a government agency that your Medicare benefits began some time ago, then your Open Enrollment period begins on the date of that federal notice. It is a good idea to apply for a Medigap policy early so it will take effect on the same day as your Part B benefits.


You can only disenroll or switch plans once per year during the Annual Election Period (AEP) (October 15 - December 7 of each year for benefits that begin the following January). If you want to change your Advantage plan or Part D plan, you can submit an application for a new plan during this period. Your new coverage would begin on January 1.


If you should decide that the MA-PD you have chosen for 2011 is not the plan for you, you can disenroll from that plan during the new Disenrollment Period. The Open Enrollment Period (OEP), which has been January 1 to March 31 since 2006, has been eliminated. In its place, starting 2011, the Annual Disenrollment Period (ADP), which will be from January 1 to February 14, will allow you to disenroll from a Medicare Advantage plan and return to Original Medicare. The ADP does not allow people in an Medicare Advantage plan to switch to another Medicare Advantage plan or people in Original Medicare to join an Medicare Advantage plan. If you want to disenroll from an MA-PD plan and return to Original Medicare during the ADP starting 2011 will have a special enrollment period (SEP) to join a Part D plan.



You joined a Medicare Advantage (MA) plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare at age 65, and within the first year of joining, you decide you want to switch to Original Medicare. You have the Right to buy any Medigap policy that is sold in your state by any insurance company.
Note: You can/must apply for a Medigap policy as early as 60 calendar days before the date your coverage will end, but no later that 63 calendar days after your coverage ends. If you were previously in an MA plan or PACE organization, you are not eligible for this guaranteed-issue right.


You dropped a Medigap policy to join a Medicare Advantage (MA) plan for the first time; you have been in the plan less than a year, and you want to switch back. You have the Right to buy the Medigap policy you had before you joined the MA plan, if the same insurance company you had before still sells it. If your former Medigap policy isn't available, you can buy a Medigap plan A, B, C, F, K, or L that is sold in your state by any insurance company.
Note: You can/must apply for a Medigap policy as early as 60 calendar days before the date your coverage will end, but no later that 63 calendar days after your coverage ends. If you were previously in an MA plan, PACE organization, Medicare SELECT plan or any other health care organization contracting with Medicare, you are not eligible for this guaranteed-issue right.


CA Insurance Code §10192.11 (h) - If a person already has a Medigap (supplement) insurance, they have 30 days of "open enrollment" following their birthday each year when they may buy a new Medigap policy without medical underwriting or a new waiting period. The new policy must have the same or lesser benefits as the old policy. This rule is only for Medicare Supplement (Medigap) policies. Medicare Advantage plans (HMO & PPO) have different rules that apply to their open enrollment options.


Disabled members are allowed to downgrade or move to another Pre-65 Medicare Supplement plan with lesser benefits and a lower cost. Changes will be effective on the current policy paid-to-date.


Many Medigap plans do provide coverage for foreign travel. Medigap plans C, D, F, G, M & N cover 80 percent of the cost of emergency care abroad during the first two months of a trip with a $250 deductible and up to $50,000 in a lifetime.

If you have Original Medicare, you can travel anywhere in the U.S. and its territories (this includes all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands) and get the medical care you need from almost any doctor or hospital. Original Medicare does not cover medical care you get outside the country. If you will be traveling to a foreign country and want insurance, click here for HTH Travel Health Insurance.

The only exceptions in which Medicare may cover medical care you get outside of the U.S. are:

  • Medicare will pay for emergency services in Canada if you are traveling a direct route between Alaska and another state.

  • Medicare will pay for medical care you get on a cruise ship if:
    1. The ship is registered to the U.S.;
    2. The doctor is registered with the Coast Guard; and
    3. You get the care while the ship is in U.S. territorial waters. This means the ship is in a U.S. port or within six hours of arrival at or departure from a U.S. port.

  • Medicare may pay for non-emergency in-patient services in a foreign hospital (and connected physician and ambulance costs), if it is closer to your residence than the nearest U.S. hospital that is available and equipped to treat you medical condition. This may happen if, for example, you live near the border of Mexico or Canada.


Starting December 8, 2011, you can switch to a 5-star (Member Satisfaction Rating) Medicare Prescription Drug Plan at any time during the year. The overall plan star ratings are available at { page 85 of "Medicare & you" Brochure. }

Important Disclaimer:  Answers and comments provided above are general information, and are not intended to substitute for informed professional medical, psychiatric, psychological, tax, legal, investment, accounting, governmental, or other professional advice. We do not endorse, and expressly disclaims liability for any product, manufacturer, distributor, service, health plan, or service provider mentioned or any opinion expressed in the website.  Replies, comments, or information gathered on  website may not be accurate but are intended to be helpful.

Barricks Insurance Services
276 N El Camino Real #6, Oceanside, CA 92058
Phone:   (760) 433-0300    |   Fax:   (760) 433-0304
Toll-Free 1-877-Look4Life  (1-877-566-5454)

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