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Optimum Gold Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Gold 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 Plan (HMO) in 2026, please refer to our full plan details page.
Optimum Gold 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 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 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 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 $4200.00 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 Plan (HMO) offers prescription drug coverage with a $0 drug deductible, allowing your benefits to begin immediately. For Tier 1 preferred generic drugs, you will pay no copay for a one-month, two-month, or three-month supply at standard and preferred pharmacies. Tier 2 preferred brand drugs require a $10 copay for a one-month supply, which increases to $20 for a two-month supply and $30 for a three-month supply at retail pharmacies. Tier 3 non-preferred drugs have a $50 copay for a one-month supply at preferred pharmacies, whereas standard pharmacies charge a $55 copay. Specialty tier drugs require a 33% coinsurance for a one-month supply at both preferred and standard pharmacies. Standard mail order options provide convenient access, including a reduced $20 copay for a three-month supply of Tier 2 drugs.
Additional Benefits
The Optimum Gold Plan (HMO) offers affordable healthcare coverage with no copays or coinsurance for primary care physician visits, home health services, and preventive care. For specialized care, members pay a $30 copay for specialist visits, while inpatient hospital stays require a $195 daily copay for days one through seven and no copay for additional days. Emergency room visits have a $150 copay, which is waived if admitted, and urgent care services are available with a $20 copay. This plan also includes valuable supplemental benefits, featuring no copays or coinsurance for routine dental, vision, and hearing exams. Covered prescription hearing aids are funded up to $500 per ear annually, and members receive a $60 monthly allowance for over-the-counter items with no copay. Additionally, the plan covers up to eight one-way routine transportation trips to plan-approved locations at no cost, while ground ambulance services carry a $200 copay.
Inpatient Hospital See details
Inpatient hospital services under the Optimum Gold Plan (HMO) are covered with no coinsurance, requiring a $195 daily copay for days 1 through 7 and no copay for days 8 through 90 for both acute and psychiatric stays. Prior authorization and referrals are required, and certain services such as upgrades, additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Optimum Gold Plan (HMO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $195 copay and ambulatory surgical center services for a $25 copay. Outpatient substance abuse services require a copay of $30 to $195 and no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Optimum Gold Plan (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Both prior authorization and a referral are required to access this benefit.
Ambulance and Transportation Services See details
Optimum Gold Plan (HMO) covers ambulance services with a $200 copay and no coinsurance for ground transport, and a 20% coinsurance with no copay for air transport, both requiring prior authorization. Transportation services are partially covered under this plan, offering up to 8 one-way trips per year to plan-approved health-related locations with no copay or coinsurance, while transportation to any other health-related locations is not covered.
Emergency Services See details
Optimum Gold Plan (HMO) covers emergency services with a $150 copay, which is waived if admitted to the hospital within 72 hours, and no coinsurance. Urgently needed services are covered with a $20 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 limit with a $500 copay per service and no coinsurance.
Primary Care See details
Primary Care benefits under the Optimum Gold Plan (HMO) feature no copay and no coinsurance for primary care physician services, while specialist visits, therapy services, and mental health care require a $30 copay with no coinsurance. Chiropractic and podiatry services are not covered, and most specialty services require prior authorization and a referral.
Preventive Services See details
Optimum Gold Plan (HMO) preventive services are partially covered with no copay and no coinsurance for covered options like kidney disease education, glaucoma screenings, and fitness benefits. Sub-services that are not covered under this plan include annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
The Optimum Gold Plan (HMO) offers Medicare-covered exams, routine hearing exams, and fitting evaluations with no copays, no coinsurance, and no deductible. Prescription hearing aids are partially covered with no copay or coinsurance up to $500 per ear annually, though inner ear, outer ear, over-the-ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Optimum Gold Plan (HMO) with no deductible and no coinsurance, though other eye exam services, eyeglass lenses, and eyeglass frames are not covered. Routine eye exams are available with no copay, while covered contact lenses and eyeglasses require a $10 copay up to a $100 annual combined maximum.
Dental Services See details
Optimum Gold Plan (HMO) offers partially covered dental services with no copay and no coinsurance for covered benefits such as oral exams, cleanings, fluoride, x-rays, restorative care, periodontics, and oral surgery. Services not covered under this plan include other diagnostic, other preventive, adjunctive general, endodontics, removable and fixed prosthodontics, maxillofacial prosthetics, implants, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Optimum Gold Plan (HMO) with no copay, although prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Optimum Gold Plan (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment is covered under the Optimum Gold Plan (HMO) with no copays, featuring a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic shoes, and no coinsurance to 20% coinsurance for diabetic supplies. Prior authorization is required for these benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Optimum Gold Plan (HMO) with prior authorization and referral requirements. Members pay no copay for lab services and outpatient X-rays, while diagnostic procedures carry a $0 to $195 copay with a 20% minimum coinsurance, and diagnostic radiological services require a minimum $25 copay.
Home Health Services See details
Optimum Gold Plan (HMO) covers home health services with no copay and no coinsurance. Members will need to obtain a referral and prior authorization to receive these covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Optimum Gold Plan (HMO), as none of the sub-services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, are covered in practice. While the plan technically features no coinsurance, these individual services are ultimately not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is partially covered by the Optimum Gold Plan (HMO), as additional days beyond the Medicare-covered limit are not covered. Covered stays require prior authorization and referrals, featuring no coinsurance, no copay for days 1 through 20, and a $218 copay for days 21 through 100.
Other Services See details
Optimum Gold Plan (HMO) provides partial coverage for other services, excluding acupuncture. Covered benefits include over-the-counter (OTC) items up to $60 per month and a chronic illness meal benefit, both featuring no copay and no coinsurance, though the meal benefit requires a referral and prior authorization.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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