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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 Los Angeles and Orange 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 $0.00. 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 $250.00 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 $599.00 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 offers an enhanced alternative drug benefit with a yearly prescription drug deductible of $250. After meeting this deductible, you will pay no copay for Tier 1 preferred generic drugs at preferred pharmacies, or a $10 copay at standard pharmacies. For higher drug tiers, you will pay a coinsurance of 20% for standard generics, 25% for preferred brands, and 30% for non-preferred drugs. These cost-sharing rates apply during the initial coverage phase until your total drug costs reach $2,100. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, individuals who qualify for the low-income subsidy can benefit from a $0 Part D premium.
Additional Benefits
The Blue Shield Inspire (HMO) plan offers robust medical coverage with no deductibles on key services like vision and hearing. Members benefit from no copays and no coinsurance on urgently needed care, routine physical exams, and outpatient ambulatory surgical services. When emergency care or outpatient hospital services are needed, the plan features a predictable $150 copay with no coinsurance. For specialized care, dental services feature copays ranging from no copay up to $525, while prescription hearing aids require a copay between $449 and $999. The plan also includes valuable extras such as up to 24 one-way transportation trips per year with no copay and a $100 quarterly over-the-counter item allowance. Additionally, skilled nursing facility stays require no copay for the first 20 days and a $75 daily copay for days 21 through 100.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Blue Shield Inspire (HMO), requiring a doctor referral and prior authorization for both acute and psychiatric stays. Psychiatric admissions require a $900 copay per stay with no coinsurance, while upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Blue Shield Inspire (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with a $150 copay and outpatient substance abuse sessions with a $30 copay. Other covered benefits, such as ambulatory surgical center and outpatient blood services, are offered with no copay and no deductible.
Partial Hospitalization See details
Partial hospitalization benefits are covered under Blue Shield Inspire (HMO) with a $30 copay and no coinsurance. This benefit requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Blue Shield Inspire (HMO) covers ground ambulance services with a $200 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered, offering up to 24 one-way trips per year to plan-approved locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Blue Shield Inspire (HMO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with no copay or coinsurance. Worldwide emergency services are partially covered, featuring a $150 copay and no coinsurance for worldwide emergency and urgent care, but excluding worldwide emergency transportation.
Primary Care See details
Primary care benefits are covered under Blue Shield Inspire (HMO), including doctor visits, physical therapy, and up to 12 routine chiropractic sessions with no coinsurance. Mental health and psychiatric specialty services require a $30 copay, while opioid treatment services require a $10 copay, both with no coinsurance.
Preventive Services See details
Preventive services, including annual physical exams and kidney disease education, are covered under Blue Shield Inspire (HMO) with no copay and no coinsurance for Medicare-covered zero-dollar preventive services. Additional preventive benefits are partially covered, including memory fitness and personal emergency response systems, while sub-services like health education and weight management programs are not covered.
Hearing Services See details
Hearing services are partially covered by Blue Shield Inspire (HMO), which excludes OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids. Covered benefits include routine hearing exams and fitting evaluations with no deductible, alongside prescription hearing aids (all types) which require a copay of $449 to $999 and no coinsurance.
Vision Services See details
Vision Services are partially covered by Blue Shield Inspire (HMO) with no deductibles, featuring annual routine eye exams, eyeglass lenses, contact lenses up to $300 annually, and eyeglass frames up to $300 every two years. Upgrades and combined eyeglasses (lenses and frames) are not covered under this plan.
Dental Services See details
Blue Shield Inspire (HMO) offers partially covered dental services with copays ranging from no copay up to $525 and no coinsurance. While preventive, diagnostic, and restorative services are covered, maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Blue Shield Inspire (HMO) covers home infusion bundled services with prior authorization, including Medicare Part B insulin drugs for a $35 copay and no coinsurance to 20% coinsurance. Medicare Part B chemotherapy, radiation, and other Part B drugs are covered with no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Blue Shield Inspire (HMO) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
Medical Equipment is partially covered by Blue Shield Inspire (HMO) with no copays, featuring 20% coinsurance for prosthetic devices and ranging from no coinsurance to 20% coinsurance for durable medical equipment. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered under this plan.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Blue Shield Inspire (HMO), as diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-ray services are not covered. Covered therapeutic radiological services require a doctor referral and feature no copay and a 20% coinsurance.
Home Health Services See details
Home health services are covered by Blue Shield Inspire (HMO) when prior authorization and a doctor referral are obtained, though specific copay and coinsurance cost-sharing details are not provided in the plan benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Blue Shield Inspire (HMO) plan, including cardiac, intensive cardiac, pulmonary rehabilitation, and SET for PAD services.
Skilled Nursing Facility (SNF) See details
Blue Shield Inspire (HMO) partially covers Skilled Nursing Facility (SNF) services, as additional days beyond the Medicare-covered limit are not covered. For covered stays, there is no copay for days 1 through 20 and a $75 daily copay for days 21 through 100, with no coinsurance required.
Other Services See details
Other Services are partially covered by Blue Shield Inspire (HMO), which offers a meal benefit for chronic illnesses and a $100 quarterly over-the-counter item allowance with no specified copay or coinsurance. Acupuncture, naloxone, and highly integrated dual-eligible SNP services are not covered.
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