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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 Merced/San Joaquin/Stanislaus/Santa Clara 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 $38.00. 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 $5700.00 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 a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $10 copay at preferred pharmacies and $18 at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for your Medicare Part D covered drugs. If you qualify for the low-income subsidy, your monthly Part D premium is $13.60.
Additional Benefits
The Blue Shield Inspire (HMO) plan covers a range of services, including inpatient hospital stays with a copay, outpatient services with varying copays, and emergency services with a $125 copay. This plan also provides coverage for primary care, preventive services, and vision services, including routine eye exams. This plan offers additional benefits such as home health services with no copay, hearing exams with no copay, and dental services including oral exams and cleanings. However, it's important to note that some services like prescription hearing aids, eyeglass lenses, and orthodontic services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a $190 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $900 copay.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a $300 copay, ambulatory surgical center services with a $150 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. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Shield Inspire (HMO) plan. Ground Ambulance Services have a $275 copay, while Air Ambulance Services have a 20% coinsurance; however, transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Blue Shield Inspire (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, and there is no coinsurance. Worldwide Urgent Coverage also has a $125 copay, and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Shield Inspire (HMO) plan covers primary care physician services, chiropractic services (with a doctor referral), occupational therapy services with a $10 copay, physician specialist services (with a doctor referral), and mental health and psychiatric services with a $30 copay for individual and group sessions. Additionally, physical therapy and speech-language pathology services are covered with a $10 copay, and additional telehealth and opioid treatment program services are covered. Podiatry services are not covered.
Preventive Services See details
The Blue Shield Inspire (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. Some additional preventive services are not covered, including health education, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
Hearing Services for the Blue Shield Inspire (HMO) plan include routine hearing exams with no copay, but fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered. A doctor referral is required for hearing exams.
Vision Services See details
The Blue Shield Inspire (HMO) plan covers vision services including routine eye exams with one visit covered every year, and eyewear with a maximum plan benefit coverage amount. This plan does not cover eyeglass lenses and frames, and upgrades.
Dental Services See details
The Blue Shield Inspire (HMO) plan covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services, but some of these services are limited to one visit every six months. This plan does not cover orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
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 with prior authorization and a doctor referral. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, Prosthetics/Medical Supplies with coinsurance for Medicare-covered supplies, 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
The Blue Shield Inspire (HMO) plan covers diagnostic and radiological services. Diagnostic procedures/tests and lab services are not covered. Diagnostic Radiological Services have a copay of at most $45.00, while 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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Shield Inspire (HMO) plan. Prior authorization and a doctor's referral are required for this benefit.
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. You will have no copay for days 1-20, and a $200 copay per day for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other services include Over-the-Counter (OTC) Items, with a maximum benefit of $55 every three months, and Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, and many other services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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