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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 2025, 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 5 out of 5 stars in 2025.
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 $3400.00 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) has an enhanced alternative drug benefit. This plan has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay for generic drugs, and coinsurance for brand name drugs. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase where you will pay nothing for your Part D covered drugs.
Additional Benefits
The Optimum Gold Plan (HMO) offers a variety of benefits with a focus on outpatient and preventative care. Many services have no copay, including primary care, preventive services, hearing exams, and routine vision exams. The plan also includes coverage for inpatient hospital stays, outpatient services, ambulance services, emergency services, and home health services, but these services have varying copays and coinsurance costs. The plan has additional benefits, such as coverage for dental, hearing aids, and medical equipment, but with certain limitations and costs. For example, hearing aids are covered up to $500 per year, and dental services cover some procedures with no copay. Additionally, the plan covers skilled nursing facility stays, with copays that vary depending on the length of the stay.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under the Optimum Gold Plan (HMO), but require prior authorization and a doctor's referral. For days 1-7, the copay is $195 per admission, and there is no copay for days 8-90.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services and observation services, are covered. Outpatient hospital services and observation services have a $195 copay. Ambulatory Surgical Center (ASC) Services have a $25 copay, while Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization and a doctor referral. The copay for this benefit is $55.
Ambulance and Transportation Services See details
The Optimum Gold Plan (HMO) covers ambulance services with a $200 copay for ground ambulance and a 20% coinsurance for air ambulance. Transportation services to plan-approved health-related locations have no copay, and include 8 one-way trips per year via rideshare, bus/subway, van, medical transport, or other modes. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Optimum Gold Plan (HMO), with a $120 copay, and no coinsurance. Urgently Needed Services have a $20 copay and no coinsurance, and Worldwide Emergency Services have a $500 copay and no coinsurance.
Primary Care See details
The Optimum Gold Plan (HMO) covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $30 copay, and physician specialist services with a $30 copay. Mental health specialty services and psychiatric services are covered with a $30 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $30 copay, and opioid treatment program services have a copay between $0 and $195. Podiatry services are not covered.
Preventive Services See details
The Optimum Gold Plan (HMO) covers preventive services, including Medicare-covered services with no copay, and additional preventive services. Other preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit have no copay.
Hearing Services See details
The Optimum Gold Plan (HMO) covers hearing exams and fitting/evaluation for hearing aids with no copay, and covers prescription hearing aids up to $500 per year with no copay for all types except inner ear, outer ear, and over the ear hearing aids, which are not covered. Routine hearing exams are covered once per year with no copay. OTC hearing aids are not covered.
Vision Services See details
The Optimum Gold Plan (HMO) covers vision services, including routine eye exams with no copay, and eyewear with a combined maximum benefit of $100 per year. Contact lenses and eyeglasses (lenses and frames) have a $10 copay, while upgrades have a $30 copay; however, eyeglass lenses and frames are not covered.
Dental Services See details
The Optimum Gold Plan (HMO) offers dental services, including Medicare dental services and other dental services. Some services are covered with no copay, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, periodontics, and oral and maxillofacial surgery. Adjunctive general services, endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Optimum Gold Plan (HMO), 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 for these services.
Dialysis Services See details
Dialysis Services are covered under the Optimum Gold Plan (HMO), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Optimum Gold Plan (HMO), including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance; however, Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment is also covered, with Diabetic Supplies having a 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts having a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services, are covered. Diagnostic procedures have a copay of up to $195 and a coinsurance of at least 20%, while lab services have no copay. Diagnostic radiological services have a copay of at least $25, up to $195, 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 under the Optimum Gold Plan (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization and referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific sub-services are not covered. Prior authorization and a doctor referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Optimum Gold Plan (HMO), with a doctor referral and prior authorization required. For days 1-5, there is no copay, for days 6-20, the copay is $20, and for days 21-100, the copay is $150, and there is no coinsurance.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items and Meal Benefits. Over-the-Counter (OTC) Items have no copay, and Meal Benefits have no copay, but require prior authorization and a doctor referral. 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.
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