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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 2026, 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 4 out of 5 stars in 2026.
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 $56.00. 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 a $425.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 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 features a prescription drug deductible of $425.00. During the initial coverage phase, Tier 1 preferred generic drugs require a $5.00 copay at preferred pharmacies or a $12.00 copay at standard pharmacies. Other medications are subject to coinsurance, such as 24% for standard generics, 29% for preferred brands, and 28% for non-preferred drugs. Once your annual out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, beneficiaries who qualify for the Low-Income Subsidy can see their Part D premium reduced from $46.90 to $34.90.
Additional Benefits
The Blue Shield Inspire (HMO) plan offers comprehensive coverage for core medical services, featuring no copay for primary care visits and low copays ranging from no copay to $10 for specialist visits. For inpatient hospital stays, members pay a $280 copay per day for the first five days and no copay for days six through ninety. Emergency room visits require a $130 copay, while urgently needed services and annual physical exams are available with no copay. This plan also includes valuable supplemental benefits, such as up to 12 plan-approved one-way transportation trips per year and routine eye exams for a $10 copay with no copay for covered eyewear. While routine dental care is covered with no copay to a $10 copay, hearing aids require a copay between $449 and $999. Additionally, members receive a $40 over-the-counter allowance every three months with no copay to help cover everyday health-related items.
Inpatient Hospital See details
Blue Shield Inspire (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $280 copay per day for days 1 to 5 (no copay for days 6 to 90) for acute care, and a $900 copay per stay for psychiatric care. Prior authorization and doctor referrals are required, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Shield Inspire (HMO) covers outpatient services with no coinsurance, featuring a $250 copay for outpatient hospital services and a $100 copay for ambulatory surgical center and observation services. Outpatient substance abuse sessions carry a $30 copay, and outpatient blood services are covered with no copay and no deductible.
Partial Hospitalization See details
Partial hospitalization benefits are covered under the Blue Shield Inspire (HMO) plan with a $55.00 copay and no coinsurance. Receiving these services requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Blue Shield Inspire (HMO) partially covers ambulance and transportation services, excluding transportation to any health-related location that is not plan-approved. Ground ambulance services require a $280 copay and no coinsurance, air ambulance services carry a 20% coinsurance and no copay, and plan-approved transportation includes up to 12 one-way trips per year with no copay or coinsurance.
Emergency Services See details
Blue Shield Inspire (HMO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency and urgent services are also covered for a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Shield Inspire (HMO) covers primary care and professional services with no coinsurance, including specialist visits for no copay to a $10 copay. Patients will pay a $10 copay for chiropractic and podiatry care, a $15 copay for physical, occupational, and speech therapies, and a $30 copay for mental health and psychiatric services.
Preventive Services See details
Preventive services are partially covered by Blue Shield Inspire (HMO), offering Medicare-covered zero-dollar preventive benefits and annual physical exams with no copay or coinsurance. While kidney disease education, remote access technologies, and memory fitness are covered, many supplemental services are not covered, including health education, weight management, alternative therapies, therapeutic massage, in-home safety assessments, and caregiver support.
Hearing Services See details
Hearing services are partially covered by Blue Shield Inspire (HMO), which includes one annual routine hearing exam and three fitting evaluations with no deductible. Up to two prescription hearing aids (all types) are covered each year with a copay between $449 and $999 and no coinsurance, but OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Blue Shield Inspire (HMO) vision services are partially covered, with no coverage for upgrades and eyeglasses (lenses and frames). Routine eye exams require a $10 copay and no coinsurance, while covered eyewear like contact lenses, eyeglass lenses, and eyeglass frames have no copay and no coinsurance.
Dental Services See details
Dental services are partially covered by Blue Shield Inspire (HMO), which features Medicare-covered dental services with no copay to a $10 copay and no coinsurance. However, restorative, endodontic, periodontic, prosthodontic, oral surgery, implant, and orthodontic services are not covered.
Home Infusion bundled Services See details
Blue Shield Inspire (HMO) partially covers Home Infusion bundled Services with prior authorization, excluding Part D home infusion drugs as a mandatory supplemental benefit. Covered Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Blue Shield Inspire (HMO) covers dialysis services with 20% coinsurance and no copay. Prior authorization and a doctor referral are required to access these covered services.
Medical Equipment See details
Blue Shield Inspire (HMO) covers durable medical equipment with no copay and no coinsurance to 20% coinsurance, and prosthetic devices with no copay and 20% coinsurance. Prosthetics and medical supplies are partially covered because medical supplies are not covered, and while some diabetic equipment services are covered, diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Blue Shield Inspire (HMO) partially covers diagnostic and radiological services with a doctor's referral, though diagnostic procedures, lab services, and outpatient x-ray services are not covered. Covered diagnostic radiological services require an $85 copay and no coinsurance, while therapeutic radiological services have a 20% coinsurance and no copay.
Home Health Services See details
Home Health Services are covered under the Blue Shield Inspire (HMO) plan, requiring prior authorization and a doctor referral, though specific copay and coinsurance details are not specified.
Cardiac Rehabilitation Services See details
Blue Shield Inspire (HMO) technically covers Cardiac Rehabilitation Services, meaning some services are covered, but in practice, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. As these services are not covered under the plan, there are no copay or coinsurance costs for them.
Skilled Nursing Facility (SNF) See details
Blue Shield Inspire (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $200 copay for days 21 through 100. Prior authorization and a doctor referral are required, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Blue Shield Inspire (HMO), which features an Over-the-Counter (OTC) benefit of $40 every three months with no copay and no coinsurance. Acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered under this plan.
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