Fitness Benefit
Physical Fitness
Cost not publishedMandatory
IncludedBlue Shield Inspire (HMO)
Blue Shield of California
HMOSanta Clara CountyIncludes Part DPlan year 2026
$58/momonthly premium
$5,300most you pay in-network per year
4overall CMS star rating
3,815members enrolled, January 2026
Plan-level limits
Premium, deductibles, and the most you can pay out of pocket in a year.
In-network out-of-pocket maximum$5,300
Plan premium, per month$58
What a year on this plan would likely cost
What you pay for care
In-network costs for every service in this plan's CMS benefit filing. A copay is a fixed dollar amount; coinsurance is a percentage of the bill.
Hospital stays
Inpatient hospital stay
Days 1–5$275 per day
Days 6–90$0 per day
Skilled nursing facility stay
Days 1–20$0 per day
Days 21–100$200 per day
Emergency and urgent care
Emergency room visit
$130
Copay
Emergency care outside the U.S.
$130
Copay
Urgent care outside the U.S.
$130
Copay
Mental health and substance use
Individual therapy session
$30
Copay
Group therapy session
$30
Copay
Opioid treatment program
$20
Copay
Partial hospitalization program
$55
Copay
Referral required
Prior authorization required
Therapy and rehabilitation
Occupational therapy
$10
Copay
Physical and speech therapy
$10
Copay
Cardiac rehabilitation
$25
Copay
Intensive cardiac rehabilitation
$25
Copay
Pulmonary rehabilitation
$25
Copay
Supervised exercise therapy for peripheral artery disease
$25
Copay
Tests, labs and imaging
Diagnostic radiology (MRI, CT, PET)
$75
Copay
Therapeutic radiology
20%
Coinsurance — your share of the bill
Outpatient hospital and surgery
Outpatient hospital services
$300
Copay
Ambulatory surgical center
$150
Copay
Observation services
$150
Copay
Ambulance
Ground ambulance
$275
Copay
Air ambulance
20%
Coinsurance — your share of the bill
Medical equipment and supplies
Durable medical equipment
0–20%
Coinsurance, depends on the service
Prosthetic devices
20%
Coinsurance — your share of the bill
Dialysis
Dialysis
20%
Coinsurance — your share of the bill
Part B drugs
Part B drugs
0–20%
Coinsurance, depends on the service
Chemotherapy drugs
0–20%
Coinsurance, depends on the service
Part B insulin
0–20%
Coinsurance, depends on the service
Never more than $35 for a one-month supply
Vision
Eyeglass frames
Up to $210 every two years
Allowance
Contact lenses
Up to $210 per year
Allowance
Extra benefits
Over-the-counter items
Up to $35 every three months
Allowance
Extra benefits beyond Original Medicare
Supplemental benefits this plan filed with CMS, with the cap and period exactly as filed.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Nursing Hotline
Cost not publishedMandatory
IncludedNot offered by this plan
Health EducationIn-Home Safety AssessmentPersonal Emergency Response System (PERS)Medical Nutrition Therapy (MNT)Post discharge In-Home Medication ReconciliationRe-admission PreventionWigs for Hair Loss Related to ChemotherapyWeight Management ProgramsAlternative TherapiesTherapeutic MassageAdult Day Health ServicesNutritional/Dietary BenefitHome-Based Palliative CareIn-Home Support ServicesSupport for Caregivers of EnrolleesAdditional Sessions of Smoking and Tobacco Cessation CounselingEnhanced Disease ManagementTelemonitoring ServicesHome and Bathroom Safety Devices and ModificationsCounseling Services
Dental
No dental deductible.
Preventive
Oral examsBoth
CleaningsBoth
X-raysBoth
Fluoride treatmentBoth
Other diagnostic servicesBoth
Other preventive servicesBoth
Prescription drugs (Part D)
$425 annual drug deductible · 5 formulary tiers · mail order available. Costs shown for a 30-day supply.
Before the deductible
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | No copay | $5 copay | — | — | Waived |
| 2. Generic | $5 copay | $12 copay | — | — | Waived |
Initial coverage
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | No copay | $5 copay | — | — | Waived |
| 2. Generic | $5 copay | $12 copay | — | — | Waived |
| 3. Preferred Brand | 24% coinsurance | 24% coinsurance | — | $35 | Applies |
| 4. Non-Preferred Drug | 29% coinsurance | 29% coinsurance | — | $35 | Applies |
| 5. Specialty Tier specialty | 28% coinsurance | 28% coinsurance | — | — | Applies |
Catastrophic (after the out-of-pocket threshold)
| Tier | Preferred retail | Standard retail | Mail order | Insulin | Deductible |
|---|---|---|---|---|---|
| 1. Preferred Generic | No copay | No copay | No copay | — | Waived |
| 2. Generic | No copay | No copay | No copay | — | Waived |
| 3. Preferred Brand | No copay | No copay | No copay | $35 | Applies |
| 4. Non-Preferred Drug | No copay | No copay | No copay | $35 | Applies |
| 5. Specialty Tier specialty | No copay | No copay | No copay | — | Applies |
Out-of-pocket threshold for the catastrophic phase: $2,100.
Is my medicine on this plan’s list?
Pharmacies near you in this plan's network
From the plan's filed Part D pharmacy network, matched to geocoded pharmacy locations. Preferred pharmacies come first: they carry the lower copay column in the tier table above. The ZIP you enter stays in this browser.
CMS star ratings
Star ratings are set by CMS for the whole contract, so every plan under this contract shares them.
4 out of 5Overall rating
3.5 out of 5Health services (Part C)
4.5 out of 5Drug plan (Part D)
Staying healthy: screenings, tests and vaccines
4- Annual flu vaccine4
- Breast cancer screening4
- Colorectal cancer screening4
- Monitoring physical activity4
- Improving or maintaining mental health1
- Improving or maintaining physical health4
Managing chronic (long-term) conditions
4- Readmissions2
- Kidney health4
- Blood pressure3
- Reducing falls2
- Statin therapy4
- Bladder control5
- Diabetes eye exam4
- Transitions of care3
- Diabetes blood sugar4
- Osteoporosis management4
- Followup after emergency department visit3
- Medication reconciliation4
Member experience with the health plan
3- Customer service3
- Care coordination2
- Healthcare quality4
- Health plan rating4
- Getting needed care3
- Getting appointments2
Member complaints and changes in the plan's performance
4- Complaints5
- Members leaving4
- Quality improvement4
Health plan customer service
4- Call center4
- Timely decisions4
- Appeals decisions5
Drug plan customer service
5- Call center foreign language interpreter and TTY availability5
Drug plan complaints and changes
4- Complaints5
- Members leaving4
- Quality improvement4
Member experience with the drug plan
4- Drug plan rating4
- Prescription drugs3
Drug safety and accuracy of drug pricing
4- Price accuracy5
- Statin diabetes4
- Medication therapy management comprehensive medication review completion5
- Medication adherence for diabetes medications4
- Medication adherence for hypertension RAS antagonists s4
- Medication adherence for cholesterol statins4
Why members leave this contract
Service area and network
Sold in 4 California counties.
MercedSan JoaquinSanta ClaraStanislaus
Doctor directory
746 providers are named in Blue Shield of California’s directory for this plan, dated Jul 26, 2026.
A doctor named there is listed. A doctor missing from it is unknown, never out of network: carrier directories are partial and change monthly. Open the carrier directory
Contract with Medicare sinceMay 1, 1996
Medicare Advantage regionCalifornia
Ask about this plan
A question box grounded in this plan's filed benefits, drug list, and pharmacy network. It reads the same records shown on this page and says so when something is not filed.
Answers come from this plan’s filed benefits, drug list, and pharmacy network. They are not enrollment advice; the Evidence of Coverage is the final word.