A non-government entity
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 Merced/San Joaquin/Stanislaus/Santa Clara 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 $58.00. 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 $5300.00 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:
Sign up for Blue Shield Inspire (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Blue Shield Inspire (HMO) plan features an Enhanced Alternative drug benefit with an annual prescription drug deductible of $425. During the initial coverage phase, Tier 1 preferred generic drugs cost a $5 copay at preferred pharmacies and a $12 copay at standard pharmacies. For other tiers, you will pay a coinsurance of 24% for standard generics, 29% for preferred brands, and 28% for non-preferred drugs. After 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 full Low-Income Subsidy, or Extra Help, will pay nothing for their covered drugs.
Additional Benefits
The Blue Shield Inspire (HMO) plan offers comprehensive coverage for essential healthcare needs, featuring no copay for primary care visits, specialist consultations, and Medicare-covered preventive services. For urgent care needs, members pay no copay, while emergency room visits require a $130 copay. If hospitalized, inpatient acute care requires a $275 daily copay for the first five days and no copay for additional days, while outpatient hospital services carry a $300 copay. In addition to medical care, this plan provides valuable routine benefits, including annual eye exams, a $210 eyewear allowance, and coverage for basic dental cleanings. Members also benefit from a $35 quarterly allowance with no copay for over-the-counter health items. For specialized needs, services like dialysis and durable medical equipment generally require a 20% coinsurance.
Inpatient Hospital See details
Blue Shield Inspire (HMO) partially covers inpatient hospital services with no coinsurance required. Acute care requires a $275 copay per day for days 1 through 5 and no copay for days 6 and beyond, though upgrades and non-Medicare-covered stays are not covered. Psychiatric hospital stays carry a $900 copay per stay, but additional 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 for a $300 copay and ambulatory surgical center or observation services for a $150 copay. Outpatient substance abuse services require a $30 copay per session, and outpatient blood services are covered with no deductible.
Partial Hospitalization See details
Blue Shield Inspire (HMO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Blue Shield Inspire (HMO) partially covers ambulance and transportation services, requiring a $285 copay and no coinsurance for ground ambulance, and a 20% coinsurance and no copay for air ambulance. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Blue Shield Inspire (HMO) covers emergency services with a $130 copay and no coinsurance, while urgently needed services feature no copay and no coinsurance. Worldwide emergency services are partially covered with a $130 copay and no coinsurance for emergency and urgent care, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits are partially covered under Blue Shield Inspire (HMO), as podiatry services are not covered. Covered services feature no coinsurance, with copays ranging from no copay for primary care and specialist visits to $10 for therapy services, $20 for opioid treatment, and $30 for psychiatric and mental health sessions.
Preventive Services See details
Blue Shield Inspire (HMO) covers Medicare-covered zero-dollar preventive services with no copay or coinsurance, as well as annual physical exams and kidney disease education. Other preventive benefits are only partially covered, excluding services such as health education, personal emergency response systems, in-home safety assessments, and weight management programs.
Hearing Services See details
Hearing Services under Blue Shield Inspire (HMO) are partially covered with no deductible, though diagnostic exams require a doctor referral. Routine hearing exams, fitting and evaluation for hearing aids, prescription hearing aids, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Blue Shield Inspire (HMO) with no deductibles, including one routine eye exam every year and allowances for select eyewear. The plan covers eyeglass lenses, frames up to $210 every two years, and contact lenses up to $210 annually, though upgrades and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Shield Inspire (HMO) partially covers dental services, including covered oral exams, cleanings, fluoride, and X-rays, though specific copay and coinsurance details are not specified. Several key sub-services are not covered, including restorative, endodontic, periodontic, prosthodontic, implant, oral surgery, and orthodontic services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under Blue Shield Inspire (HMO) with prior authorization. Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Blue Shield Inspire (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Blue Shield Inspire (HMO) partially covers medical equipment with no copays for covered services, though medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered. Covered durable medical equipment features no coinsurance to 20% coinsurance, while prosthetic devices require 20% coinsurance.
Diagnostic and Radiological Services See details
Blue Shield Inspire (HMO) partially covers Diagnostic and Radiological Services, requiring a doctor referral for all covered treatments. Diagnostic radiological services have a $75 copay and no coinsurance, and therapeutic radiological services require a 20% coinsurance and a copay, while diagnostic procedures, lab services, and outpatient x-rays are not covered.
Home Health Services See details
Home health services are covered by Blue Shield Inspire (HMO), requiring a doctor referral and prior authorization. Specific copay and coinsurance information is not specified in the provided plan benefits.
Cardiac Rehabilitation Services See details
Blue Shield Inspire (HMO) indicates that some services are covered, but Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. Since these specific services are not covered, there is no copay or coinsurance required.
Skilled Nursing Facility (SNF) See details
Blue Shield Inspire (HMO) partially covers Skilled Nursing Facility (SNF) services, offering no copay and no coinsurance for days 1 through 20, and a $200 daily copay with no coinsurance for days 21 through 100. Prior authorization and a doctor referral are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Blue Shield Inspire (HMO) partially covers Other Services, offering a $35 allowance every three months with no copay or coinsurance for over-the-counter items. Acupuncture, meal benefits, and dual-eligible SNP services are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved