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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 Los Angeles and Orange 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 $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 no drug deductible. Your prescription medication coverage will start immediately.
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 has an "Enhanced Alternative" drug benefit type with no deductible. In the initial coverage phase, you will pay a copay for your prescriptions. For example, preferred generic drugs have a $3 copay at a preferred pharmacy. In the initial coverage phase, you'll pay these costs until your total drug costs reach $2000. After this, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The Blue Shield Inspire (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays. Inpatient hospital psychiatric stays have a $900 copay, while outpatient hospital services have a $150 copay. Emergency services have a $140 copay. The plan also covers a variety of services with no copay, including primary care, home health, and preventive services. There is also coverage for hearing, vision, and dental services, with specific copays for each. Additionally, the plan provides coverage for ambulance services with a copay, home infusion, dialysis, and medical equipment with some coinsurance requirements.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, as well as Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. A $900 copay is required for a Medicare-covered stay for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered under the Blue Shield Inspire (HMO) plan. Outpatient hospital services have a $150 copay, while individual and group sessions for outpatient substance abuse have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization is covered under the Blue Shield Inspire (HMO) plan, with a $30 copay. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for up to 24 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a $140 copay, with no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care, Chiropractic, Occupational Therapy, Physician Specialist, Mental Health Specialty, Podiatry, Other Health Care Professional, Psychiatric, Physical Therapy, Speech-Language Pathology, Additional Telehealth, and Opioid Treatment Program Services are covered under the Blue Shield Inspire (HMO) plan. Individual and Group Sessions for Mental Health Specialty and Psychiatric services have a $30 copay, while Occupational Therapy and Physical Therapy and Speech-Language Pathology Services have no copay or coinsurance. Routine Chiropractic Care is limited to 12 visits per year.
Preventive Services See details
The Blue Shield Inspire (HMO) plan covers preventive services including annual physical exams, glaucoma screenings, and diabetes self-management training. Additional services like health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered, with a limit of 1 routine hearing exam if performed by the PCP or specialist or 1 in-person exam every year when performed by the network hearing aid vendor, and 2 fitting/evaluation visits per year. Prescription hearing aids are covered with a copay between $449 and $699, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Blue Shield Inspire (HMO) plan covers vision services including routine eye exams with a doctor referral, eyewear, and contact lenses. Eyeglass lenses and frames are covered, but eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services are covered, including oral exams with a copay of $0-$16, dental x-rays with a copay of $0-$10, other diagnostic dental services with a copay of $0-$15, prophylaxis (cleaning) with no copay, fluoride treatment with a $5 copay, and other preventive dental services with a copay of $0-$80. Orthodontic Services are covered, and Restorative Services are covered with a copay of $19-$430, Adjunctive General Services are covered with a copay of $0-$80, Endodontics with a copay of $25-$373, Periodontics with a copay of $40-$60, Prosthodontics, removable with a copay of $28-$525, implant services, Prosthodontics, fixed with a copay of $40-$430, and Oral and Maxillofacial Surgery with a copay of $23-$80. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Blue Shield Inspire (HMO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by 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) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies - Non-Medicare benefit, and Diabetic Equipment. Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Blue Shield Inspire (HMO) plan. While there is no copay, Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered. 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. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Shield Inspire (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $75. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Blue Shield Inspire (HMO) plan's other services include coverage for over-the-counter items with a maximum benefit of $100 every three months, and meal benefits for chronic illnesses. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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