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Optimum Gold Rewards Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Gold Rewards Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Optimum Gold Rewards Plan (HMO) in 2026, please refer to our full plan details page.
Optimum Gold Rewards Plan (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select Counties in Florida. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Optimum Gold Rewards Plan (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 Optimum Gold Rewards Plan (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 Optimum Gold Rewards Plan (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. Additionally, this plan comes with a Part B Premium reduction of $185.00. You must continue to pay paying your reduced 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 $1900.00 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 Optimum Gold Rewards Plan (HMO) features a 0 dollar drug deductible, meaning your prescription coverage begins immediately without any upfront deductible costs. You will pay no copay for Tier 1 preferred generic drugs for up to a three-month supply at preferred pharmacies, standard pharmacies, and standard mail order. Tier 2 preferred brand drugs require a 30 dollar copay for a one-month supply, though you can save on three-month supplies with a 60 dollar copay through standard mail order. For Tier 3 non-preferred drugs, the cost is a 70 dollar copay for a one-month supply at preferred pharmacies and standard mail order, or a 75 dollar copay at standard pharmacies. Tier 4 specialty drugs require a 33 percent coinsurance for a one-month supply, regardless of whether you use preferred, standard, or standard mail order pharmacies. This straightforward cost structure helps you easily plan your monthly prescription medication expenses.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) features robust coverage with low out-of-pocket costs for essential medical services. Members enjoy no copay for primary care visits, while specialist visits and outpatient therapies require a low $10 copay. Inpatient hospital stays have a $95 daily copay for the first five days followed by no copay, and emergency room visits carry a $150 copay that is waived upon admission. This plan also offers comprehensive wellness benefits, including routine dental, vision, and hearing services with no copays or coinsurance. Members receive a $400 annual allowance for eyewear, up to $750 per ear annually for prescription hearing aids, and a $60 monthly allowance for over-the-counter items. While home health services are covered with no copay, please note that cardiac rehabilitation and acupuncture are not covered under this plan.
Inpatient Hospital See details
Optimum Gold Rewards Plan (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $95 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization and referrals are required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Optimum Gold Rewards Plan (HMO) covers outpatient hospital and observation services for a $95 copay and ambulatory surgical center services for a $25 copay, all with no coinsurance. Outpatient substance abuse sessions require a $10 to $95 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
The Optimum Gold Rewards Plan (HMO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to receive these services.
Ambulance and Transportation Services See details
Optimum Gold Rewards Plan (HMO) covers ground ambulance services with a $200 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered with no copay and no coinsurance for up to 20 one-way trips per year to plan-approved locations, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by the Optimum Gold Rewards Plan (HMO) with a $150 copay, which is waived if admitted to the hospital within 72 hours, and no coinsurance. Urgently needed services require a $10 copay with no coinsurance, and worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum limit with a $500 copay per service and no coinsurance.
Primary Care See details
Optimum Gold Rewards Plan (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical, occupational, speech, and mental health therapies require a $10 copay and no coinsurance. Chiropractic and podiatry services are not covered, but opioid treatment is available with a $0 to $95 copay and no coinsurance.
Preventive Services See details
Optimum Gold Rewards Plan (HMO) provides partial coverage for preventive services with no copays and no coinsurance for covered benefits, including kidney disease education, memory fitness, and glaucoma screenings. However, several services are not covered under this benefit, such as annual physical exams, health education, and weight management programs.
Hearing Services See details
Hearing services are partially covered by the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance for covered services, including one routine hearing exam and one fitting evaluation annually. Prescription hearing aids are covered up to $750 per ear every year, but OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Optimum Gold Rewards Plan (HMO), featuring no copay, no coinsurance, and no deductible for routine eye exams and eyewear. The plan covers one routine eye exam and one pair of eyeglasses or contact lenses per year up to a $400 combined maximum, though upgrades require a $30 copay, and other eye exams, individual lenses, and individual frames are not covered.
Dental Services See details
Dental Services are partially covered by the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance for covered services such as oral exams, cleanings, x-rays, fluoride, restorative care, periodontics, and oral surgery. However, this plan does not cover other diagnostic or preventive services, adjunctive general services, endodontics, implants, orthodontics, maxillofacial prosthetics, and fixed or removable prosthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Optimum Gold Rewards Plan (HMO) with no copay, requiring prior authorization. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered by the Optimum Gold Rewards Plan (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered under the Optimum Gold Rewards Plan (HMO) with no copay, though prior authorization is required. Members are responsible for a 20% coinsurance for durable medical equipment, prosthetics, and diabetic therapeutic shoes, while diabetic supplies carry a coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by the Optimum Gold Rewards Plan (HMO), requiring prior authorization and referrals. Lab services and outpatient X-rays have no copay but require coinsurance, while other diagnostic procedures and therapeutic services carry up to a 20% coinsurance and copays up to $95, and diagnostic radiological services require a minimum $25 copay with no coinsurance.
Home Health Services See details
Home health services are covered under the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance, though prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Optimum Gold Rewards Plan (HMO). This non-coverage applies to all related sub-services, including intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Optimum Gold Rewards Plan (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 to 20 and a $218 copay per day for days 21 to 100. Prior authorization and referrals are required, but a prior three-day inpatient hospital stay is not.
Other Services See details
Other services are partially covered by the Optimum Gold Rewards Plan (HMO), featuring no copay and no coinsurance for a chronic illness meal benefit and a $60 monthly over-the-counter (OTC) item allowance. Acupuncture and other additional services are not covered under this plan.
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