2022 Blue Shield Inspire (PPO)

Blue Shield Inspire (PPO) H4937-001 is a 2022 Medicare Advantage Plan or Part-C by Blue Shield of California available to residents in California. This plan includes additional prescription drug (Part-D) coverage. The Blue Shield Inspire (PPO) has a monthly premium of $99.00 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be a extremely nice safety net.

Blue Shield Inspire (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Blue Shield of California works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Shield Inspire (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Shield of California and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Blue Shield of California except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Blue Shield of California Medicare Advantage Plan Costs

Blue Shield Inspire (PPO) Part-C Premium

Blue Shield of California charges a $39.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H4937-001 Part-D Deductible and Premium

Blue Shield Inspire (PPO) has a monthly drug premium of $60.00 and a $400.00 drug deductible. This Blue Shield of California plan offers a $60.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Blue Shield of California above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $60.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Blue Shield of California Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Shield of California plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Blue Shield Inspire (PPO) medicare insurance offers a $26.80 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $35.10 for 75% low income subsidy $43.40 for 50% and $51.70 for 25%.

H4937-001 Formulary or Drug Coverage

Blue Shield Inspire (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Shield Inspire (PPO) H4937-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$15	$20
Tier 3	$40	$47
Tier 4	$95	$100
Tier 5	25%	25%

*Initial Coverage Phase and 30 day supply

2021 Blue Shield Inspire (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$750 annual deductible

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$100 copay
Diagnostic tests and procedures	$40 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Lab services	40% coinsurance (Out-of-Network)
Lab services	$40 copay
Outpatient x-rays	$40 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	40% coinsurance per visit (Out-of-Network)
Primary	$10 copay per visit
Specialist	$0-35 copay per visit
Specialist	40% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$30 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$35 copay
Foot exams and treatment	40% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$225 copay
$225 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$0 copay
Hearing exam	40% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$175 per day for days 1 through 7 $0 per day for days 8 through 90
40% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	20% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	40% coinsurance (Out-of-Network)
Other Part B drugs	40% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$1,660 per stay
Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Outpatient group therapy visit	$20 copay
Outpatient group therapy visit	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$20 copay
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$20 copay
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$20 copay

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MOOP

$10,000 In and Out-of-network $6,700 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$250 copay per visit
40% coinsurance per visit (Out-of-Network)

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Package #1

Deductible	$50.00
Monthly Premium	$40.50

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Preventive Care

40% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	40% coinsurance (Out-of-Network)
Occupational therapy visit	$25 copay
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$25 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $178 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	$20 copay
Contact lenses	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass frames	$20 copay
Eyeglass lenses	$20 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$20 copay
Routine eye exam	$0 copay (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Blue Shield Inspire (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.