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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 2025, 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 5 out of 5 stars in 2025.
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 $174.70. 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) has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $5 copay at preferred and standard pharmacies, and $5 copay at standard mail. For standard generic drugs, you will pay $15 copay at preferred pharmacies and $20 copay at standard pharmacies, and $15 copay at standard mail. For preferred brand drugs, you will pay 33% coinsurance at all pharmacies.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) offers a range of benefits with varying costs. For inpatient hospital stays, there is a $95 copay for days 1-5 and no copay for days 6-90. Many services have no copay, including primary care, preventive services, hearing exams, vision exams, and dental services. The plan also covers outpatient services, ambulance services, emergency services, and home health services, with copays or coinsurance depending on the specific service. Medical equipment, diagnostic services, and dialysis services are covered with coinsurance. The plan offers additional benefits like OTC items with no copay, and a maximum benefit of $75 per month.
Inpatient Hospital See details
The Optimum Gold Rewards Plan (HMO) covers inpatient hospital stays, with a $95 copay for days 1-5 and no copay for days 6-90. Additional days for inpatient hospital-acute and inpatient hospital psychiatric, as well as non-Medicare-covered stays, are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital and Observation Services have a $95 copay, Ambulatory Surgical Center (ASC) Services have a $25 copay, and Outpatient Blood Services have no copay. Outpatient Substance Abuse Services have a copay between $10 and $95 depending on the session type.
Partial Hospitalization See details
Partial Hospitalization is covered under the Optimum Gold Rewards Plan (HMO), requiring prior authorization and a doctor referral, with a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Optimum Gold Rewards Plan (HMO). Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered with no copay for up to 20 one-way trips per year, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Optimum Gold Rewards Plan (HMO). Emergency Services have a $120 copay, while Urgently Needed Services have a $10 copay; Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $500 copay, up to a maximum of $100,000.
Primary Care See details
The Optimum Gold Rewards Plan (HMO) covers primary care physician services with no copay, chiropractic services with a $10 copay, occupational therapy with a $10 copay, physician specialist services with a $10 copay, and mental health specialty services with a $10 copay for individual and group sessions. This plan also covers physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits, and opioid treatment program services with a copay ranging from $0 to $95. Podiatry services are not covered.
Preventive Services See details
Preventive Services, including Medicare-covered zero dollar services, are covered by the Optimum Gold Rewards Plan (HMO). The plan does not cover annual physical exams, but it does cover other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, all with no copay.
Hearing Services See details
The Optimum Gold Rewards Plan (HMO) covers hearing exams with no copay, as well as routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a maximum benefit of $750 per year, per ear, with no copay for prescription hearing aids (all types). OTC hearing aids, and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include routine eye exams and eyewear, with no copay for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Eyeglass lenses and frames are not covered, and upgrades have a $30 copay.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, periodontics, and oral and maxillofacial surgery, all with no copay; however, some services such as adjunctive general services, endodontics, prosthodontics, maxillofacial prosthetics, implant services, prosthodontics, and orthodontics are not covered. The plan requires prior authorization for Medicare dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Optimum Gold Rewards Plan (HMO). The plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment benefits are covered under the Optimum Gold Rewards Plan (HMO), with Durable Medical Equipment (DME) requiring a 20% coinsurance and Prosthetics/Medical Supplies - Non-Medicare benefits requiring a coinsurance for Medicare-covered devices and supplies. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The Optimum Gold Rewards Plan (HMO) covers diagnostic and radiological services, including diagnostic procedures/tests with a copay between $0 and $95 and coinsurance of at most 20%, lab services with no copay, diagnostic radiological services with a copay of at most $95, therapeutic radiological services with coinsurance of at most 20%, and outpatient X-ray services with no copay. All services require prior authorization and a doctor's referral.
Home Health Services See details
Home Health Services are covered by the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization and a referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. A referral and prior authorization from your doctor are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Optimum Gold Rewards Plan (HMO). For days 1-20, there is no copay, and for days 21-100, the copay is $172.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items and Meal Benefits. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. OTC items have no copay, and a maximum benefit of $75 per month is offered.
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