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Optimum Platinum Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Platinum Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Optimum Platinum Plan (HMO) in 2025, please refer to our full plan details page.
Optimum Platinum 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 Platinum 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 Platinum 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 Platinum 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.
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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $1000.00 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 Platinum 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 example, preferred generic drugs have a $5 copay at preferred and standard pharmacies, while standard generic drugs have a $50 copay at preferred pharmacies. For preferred brand drugs, you'll pay 33% coinsurance at preferred and standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Optimum Platinum Plan (HMO) offers a wide range of benefits with a focus on low-cost care. Many services have no copay, including inpatient hospital stays, outpatient ambulatory surgical center services, primary care visits, and many preventive services. The plan also offers coverage for hearing, vision, and dental services, with no copays for routine eye exams, eyewear, oral exams, dental x-rays, and cleanings. In addition to these services, the plan covers ambulance and transportation, emergency services, and home health services. While some services like outpatient hospital services and diagnostic procedures may have copays, the plan aims to keep costs manageable. However, some services like Cardiac Rehabilitation, Podiatry, and certain dental and vision services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric services, are covered with no copay. Additional days, non-Medicare stays, and upgrades for inpatient hospital acute and psychiatric services are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $75 copay, Observation Services with a $75 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual and Group Sessions for Outpatient Substance Abuse with a copay between $0 and $75, and Outpatient Blood Services with no copay. Prior authorization and a doctor referral may be required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Optimum Platinum Plan (HMO) with a $25 copay, but requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground ambulance services have a $200 copay, while air ambulance services have 20% coinsurance. Transportation services to a plan-approved health-related location are covered with no copay, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Optimum Platinum Plan (HMO). Emergency Services have a $120 copay, and Urgently Needed Services have a $10 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $500 copay, and all three have no coinsurance.
Primary Care See details
The Optimum Platinum Plan (HMO) offers several primary care benefits, including no copay for Primary Care Physician Services, no copay for Chiropractic Services (prior authorization and referral required, routine care not covered), and no copay for Occupational Therapy Services (authorization and referral required). The plan also covers Physician Specialist Services, Mental Health Specialty Services (Individual and Group sessions), Other Health Care Professional, Psychiatric Services (Individual and Group sessions), Physical Therapy and Speech-Language Pathology Services (authorization and referral required), Additional Telehealth Benefits, and Opioid Treatment Program Services (with a copay up to $75 and prior authorization and referral required). Podiatry Services are not covered.
Preventive Services See details
The Optimum Platinum Plan (HMO) covers preventive services, including Medicare-covered zero-dollar preventive services, with prior authorization and a doctor referral required. Additional preventive services include Fitness Benefit, Remote Access Technologies, Kidney Disease Education Services, and Other Preventive Services, with no copay for Fitness Benefit, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Annual physical exams, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The Optimum Platinum Plan (HMO) covers hearing exams, routine hearing exams, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $750 per year, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Optimum Platinum Plan (HMO) covers vision services, including routine eye exams and eyewear. Routine eye exams and eyewear have no copay, and you are eligible for 1 routine eye exam per year, 2 pairs of contact lenses per year, and 2 pairs of eyeglasses (lenses and frames) per year. Eyeglass lenses and eyeglass frames are not covered. Upgrades have a $30 copay.
Dental Services See details
The Optimum Platinum Plan (HMO) covers dental services, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, periodontics, prosthodontics (removable), and oral and maxillofacial surgery with no copay. Adjunctive general services, endodontics, maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Optimum Platinum Plan (HMO), with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics and Medical Supplies with 20% coinsurance, and Diabetic Equipment. The plan does not cover Durable Medical Equipment for use outside the home. Diabetic Supplies have between 0% and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Optimum Platinum Plan (HMO). Diagnostic Procedures/Tests have a copay of at most $75.00 and a coinsurance of at least 20%, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at least $25.00 and at most $75.00, and Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Optimum Platinum Plan (HMO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
The Optimum Platinum Plan (HMO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor's referral are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Optimum Platinum Plan (HMO), requiring prior authorization and a doctor's referral. You will have no copay for days 1-20, and a $95 copay for days 21-100; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Optimum Platinum Plan (HMO) covers Over-the-Counter (OTC) Items with no copay, and a meal benefit with no copay, though a doctor's referral and prior authorization are required. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and other services are not covered.
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