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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.
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 Rewards Plan (HMO) has an enhanced alternative drug benefit. This plan has no deductible. In the initial coverage phase, you will pay a copay or coinsurance for your prescriptions. For example, you will pay a $47.00 copay for preferred generic drugs at preferred and standard pharmacies. After your total drug costs reach $2000.00, you enter the catastrophic coverage phase and pay nothing for your Part D drugs.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) offers comprehensive coverage with varying costs depending on the service. Inpatient hospital stays have a $195 copay for the first 7 days, then no copay, while outpatient services have copays between $0 and $195. Emergency services have a $120 copay, and primary care visits are available with no copay, along with many other services that have no copay. This plan includes coverage for preventive services, hearing exams, and vision services with no copays for exams. It also covers dental, home health, and skilled nursing facility services. Additionally, the plan provides benefits like home infusion, dialysis, and durable medical equipment, with some services requiring copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered. For days 1-7, the copay is $195, and for days 8-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital and Observation Services have a $195 copay, Ambulatory Surgical Center Services have a $25 copay, and Outpatient Blood Services have no copay. Outpatient substance abuse services have a copay between $40 and $195 for individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Optimum Gold Rewards Plan (HMO), with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
The Optimum Gold Rewards Plan (HMO) covers ambulance and transportation services. 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 a maximum of 6 one-way trips per year, and transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, and Urgently Needed Services have a $20 copay. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $500 copay.
Primary Care See details
The Optimum Gold Rewards Plan (HMO) covers Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $40 copay, Physician Specialist Services with a $40 copay, and Individual and Group Sessions for Mental Health Specialty Services with a $40 copay. This plan also covers Physical Therapy and Speech-Language Pathology Services with a $40 copay. Podiatry Services are not covered.
Preventive Services See details
The Optimum Gold Rewards Plan (HMO) covers preventive services including Medicare-covered services with no copay, and additional preventive services where copays may apply. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay.
Hearing Services See details
The Optimum Gold Rewards Plan (HMO) covers hearing exams and routine hearing exams with no copay, as well as fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $500 per year, with no copay for all types of prescription hearing aids, except inner ear, outer ear, and over the ear prescription hearing aids, which are not covered. Over-the-counter hearing aids are not covered.
Vision Services See details
The Optimum Gold Rewards Plan (HMO) covers vision services, including eye exams with no copay, and eyewear with a $100 combined maximum plan benefit per year. Contact lenses and eyeglasses have a $10 copay, while 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, other services such as adjunctive general services, endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered. Oral exams, prophylaxis, and oral and maxillofacial surgery are limited to 2 visits per year, while dental x-rays are limited to 1 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Optimum Gold Rewards Plan (HMO), with a coinsurance between 20% and 20%.
Medical Equipment See details
The Optimum Gold Rewards Plan (HMO) covers Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetics/Medical Supplies, and Diabetic Equipment with a 20% coinsurance; however, Durable Medical Equipment for use outside the home is not covered. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay of up to $195 and a coinsurance of at most 20%, Lab Services with no copay, Diagnostic Radiological Services with a copay of at most $195, Therapeutic Radiological Services with a 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. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Optimum Gold Rewards Plan (HMO), but specific services like Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, and others are not covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Optimum Gold Rewards Plan (HMO), requiring prior authorization and a doctor's referral. The plan has a copay of $0 for days 1-5, $20 for days 6-20, and $150 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Under the Optimum Gold Rewards Plan (HMO), Other Services include Over-the-Counter (OTC) Items and a Meal Benefit. OTC items have no copay, and the plan offers a maximum of $47.00 per month. The Meal Benefit also has no copay and requires prior authorization and a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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