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Blue Shield Inspire (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield Inspire (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield Inspire (HMO) in 2025, please refer to our full plan details page.
Blue Shield Inspire (HMO) is a HMO plan offered by California Physicians' Service available for enrollment in 2025 to people living in Alameda and San Mateo Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Blue Shield Inspire (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Shield Inspire (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Blue Shield Inspire (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4300.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Blue Shield Inspire (HMO) plan has no deductible for prescription drugs. During the initial coverage phase, you will pay a copay depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies and a $12 copay at standard pharmacies. For non-preferred drugs, you will pay 33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs.
Additional Benefits
The Blue Shield Inspire (HMO) plan provides comprehensive coverage with a range of benefits. This plan includes coverage for inpatient hospital stays with a copay, various outpatient services with copays, and emergency services with copays. It also offers coverage for primary care, preventive services, hearing, vision, and dental services, each with specific copays or coverage limits. Additional benefits of this plan include ambulance services with copays or coinsurance, home health services with no copay, and skilled nursing facility services with copays. The plan also covers home infusion, dialysis, and medical equipment with varying cost-sharing. Moreover, it offers coverage for over-the-counter items and nicotine replacement therapy, but excludes several other services like acupuncture and private duty nursing.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $280 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, there is a $900 copay.
Outpatient Services See details
Outpatient services include all outpatient hospital services with a $250 copay, ambulatory surgical center services with a $100 copay, and outpatient substance abuse services with a $30 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Shield Inspire (HMO) plan with a $55 copay, but prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance. Ground ambulance services have a $275 copay, while air ambulance services have 20% coinsurance. Transportation Services to a plan-approved health-related location are covered for 12 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Blue Shield Inspire (HMO) plan, with copays of $125, $15, and $125, respectively, and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services have a $15 copay, with routine care covered. Occupational Therapy Services have a $15 copay. Physician Specialist Services have a $0-$15 copay. Individual and group sessions for Mental Health Specialty Services have a $30 copay. Medicare-covered Podiatry Services and Routine Foot Care have a $15 copay. Physical Therapy and Speech-Language Pathology Services have a $15 copay. Individual and group sessions for Psychiatric Services have a $30 copay.
Preventive Services See details
The Blue Shield Inspire (HMO) plan covers preventive services including annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Some preventive services, such as health education, in-home safety assessments, and weight management programs, are not covered.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams are limited to one in-person exam every year when performed by the network hearing aid vendor, while fitting/evaluation for hearing aids is limited to two visits per year; both have no deductible. Prescription hearing aids have a copay between $449 and $699, with two hearing aids covered per year; inner ear, outer ear, and over-the-ear hearing aids are not covered, and there is no deductible.
Vision Services See details
The Blue Shield Inspire (HMO) plan covers vision services, including eye exams with a $15 copay, contact lenses with a maximum benefit coverage of $195 every year, and eyeglass lenses and frames. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Shield Inspire (HMO) plan covers Medicare Dental Services with a copay between $0 and $15, and other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services. Orthodontic, restorative, and other services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B insulin drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Blue Shield Inspire (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics, and Diabetic Equipment. DME has a coinsurance between 0% and 20%, with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics have a 20% coinsurance, with no copay, while Medical Supplies are not covered. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
The Blue Shield Inspire (HMO) plan covers diagnostic and radiological services, but diagnostic procedures/tests, lab services, and outpatient X-ray services are not covered. Diagnostic Radiological Services have a copay of at most $75.00, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Blue Shield Inspire (HMO) plan with no copay and no coinsurance, but require prior authorization and a referral. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Blue Shield Inspire (HMO) plan, but none of the sub-services are covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
The Blue Shield Inspire (HMO) plan covers Skilled Nursing Facility (SNF) services, requiring prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $200.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $55.00 every three months, and Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, but does not cover Acupuncture, Meal Benefit, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services.
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