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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 2026, 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 4.5 out of 5 stars in 2026.
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 $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 Rewards Plan (HMO) features a $0 drug deductible, meaning your prescription drug coverage begins immediately. Under this plan, you will pay no copay for Tier 1 preferred generic drugs across preferred, standard, and standard mail-order pharmacies. For Tier 2 preferred brand drugs, you will pay a $10 copay for a one-month supply at both preferred and standard pharmacies. Tier 3 non-preferred drugs require a one-month copay of $50 at preferred pharmacies and standard mail order, or $55 at standard pharmacies. For Tier 4 specialty drugs, you will pay a 33% coinsurance for a one-month supply across preferred, standard, and standard mail-order pharmacies.
Additional Benefits
The Optimum Gold Rewards Plan (HMO) offers comprehensive healthcare coverage with no copay for primary care visits, while specialist visits require a $40 copay. Inpatient hospital stays feature a $195 daily copay for the first seven days and no copay thereafter, while emergency room visits carry a $150 copay that is waived if you are admitted. Outpatient surgery and hospital services are also accessible, featuring copays ranging from $25 to $195 with no coinsurance. This plan provides robust supplemental benefits, including dental, routine vision, and routine hearing exams with no copay or coinsurance, alongside a $500 annual hearing aid allowance per ear. Members also benefit from no copays on home health care, the first 20 days of skilled nursing facility stays, and up to six one-way routine transportation trips per year. Additional perks include a $45 monthly over-the-counter allowance and a chronic illness meal benefit, both available with no copay.
Inpatient Hospital See details
Optimum Gold Rewards Plan (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $195 daily copay for days 1 through 7 and no copay for days 8 through 90. This benefit is partially covered, as additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services under the Optimum Gold Rewards Plan (HMO) are covered with no coinsurance, featuring a $195 copay for outpatient hospital and observation services and a $25 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a copay of $40 to $195 with no coinsurance, while outpatient blood services are provided with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
The Optimum Gold Rewards Plan (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to access this benefit.
Ambulance and Transportation Services See details
Optimum Gold Rewards Plan (HMO) covers ambulance services and partially covers transportation services, excluding trips to non-plan-approved health-related locations. Ground ambulance services require a $200 copay and no coinsurance, air ambulance services carry a 20% coinsurance and no copay, and up to 6 one-way trips per year to plan-approved locations are provided with no copay and no coinsurance.
Emergency Services See details
Optimum Gold Rewards 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 require a $20 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum benefit with a $500 copay per service and no coinsurance.
Primary Care See details
Primary care services through the Optimum Gold Rewards Plan (HMO) feature no copay and no coinsurance for primary care physician visits, while specialist visits, physical therapy, occupational therapy, and mental health services require a $40 copay and no coinsurance. Chiropractic and podiatry services are not covered, but telehealth and opioid treatment programs are available with no coinsurance.
Preventive Services See details
Preventive services are partially covered under the Optimum Gold Rewards Plan (HMO) with no copays and no coinsurance for all covered services, although referrals and prior authorizations are frequently required. Covered benefits include Medicare-covered zero-dollar preventive services, kidney disease education, and select screenings, while annual physical exams, health education, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are covered under the Optimum Gold Rewards Plan (HMO) with no copays, no coinsurance, and no deductibles for annual routine exams and fitting evaluations. Prescription hearing aids are covered up to $500 per ear annually with no copay or coinsurance, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Optimum Gold Rewards Plan (HMO) partially covers vision services, offering routine eye exams with no copay and no coinsurance, while other eye exam services, eyeglass lenses, and eyeglass frames are not covered. Covered eyewear, including contact lenses and eyeglasses, requires a $10 copay and no coinsurance up to a $100 annual limit, while upgrades require a $30 copay.
Dental Services See details
Optimum Gold Rewards 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. Sub-services that are not covered under this plan include other diagnostic, other preventive, adjunctive general, endodontics, prosthodontics, maxillofacial prosthetics, implants, and orthodontics.
Home Infusion bundled Services See details
Optimum Gold Rewards Plan (HMO) covers home infusion bundled services with no copay, subject to prior authorization. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Optimum Gold Rewards Plan (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Optimum Gold Rewards Plan (HMO) covers durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts with no copay and a 20% coinsurance. Covered diabetic supplies also feature no copay and a coinsurance ranging from 0% to 20%, with prior authorization required across these medical equipment benefits.
Diagnostic and Radiological Services See details
Optimum Gold Rewards Plan (HMO) covers diagnostic and radiological services, both requiring prior authorization and referrals. Diagnostic procedures and tests feature a 20% coinsurance with copays ranging from no copay up to $195, while lab services and outpatient X-rays have no copay. Diagnostic radiological services require a minimum $25 copay, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Optimum Gold Rewards Plan (HMO) covers home health services with no copay and no coinsurance. Prior authorization and a referral are required to receive this care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Optimum Gold Rewards Plan (HMO) with no copay and no coinsurance, but require prior authorization and referrals. While some services are covered, specific sub-services including cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Optimum Gold Rewards Plan (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization and referrals are required for these services, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Optimum Gold Rewards Plan (HMO) offers partially covered other services, featuring a chronic illness meal benefit and a $45 monthly over-the-counter item allowance with no copay and no coinsurance. Acupuncture is not covered under this benefit, and the meal benefit requires a referral and prior authorization.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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