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Optimum Gold Plus Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Optimum Gold Plus 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 Plus Plan (HMO) in 2026, please refer to our full plan details page.
Optimum Gold Plus 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 Plus 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 Plus 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 Plus 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. Additionally, this plan comes with a Part B Premium reduction of $185.00. You must continue to pay paying your reduced 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 $1900.00 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 Plus Plan (HMO) features a $0 drug deductible, meaning your prescription drug coverage begins immediately without any upfront out-of-pocket costs. For Tier 1 preferred generic drugs, you will pay no copay for one-, two-, or three-month supplies at preferred and standard retail pharmacies, as well as through standard mail order. Tier 2 preferred brand drugs cost a $10 copay for a one-month supply at standard and preferred pharmacies, with standard mail order offering a three-month supply for a $20 copay. For Tier 3 non-preferred drugs, standard pharmacy copays are $55 for a one-month supply, while preferred pharmacies and standard mail order offer a lower $50 copay. Specialty drugs in Tier 4 require a 33% coinsurance for a one-month supply across preferred pharmacies, standard pharmacies, and standard mail order services. This structured plan provides clear, predictable copayments and coinsurance rates to help you easily manage your medication expenses.
Additional Benefits
The Optimum Gold Plus Plan (HMO) offers comprehensive medical coverage with low out-of-pocket costs, including no copay and no coinsurance for primary care visits and home health services. For specialist visits and therapy sessions, members pay a low $10 copay with no coinsurance. Inpatient hospital stays require a $75 daily copay for the first five days and no copay for days six through 90, while emergency room visits carry a $150 copay that is waived if admitted. This plan also features robust supplemental benefits, offering no copay and no coinsurance for routine dental care, annual hearing exams, and routine vision exams, which include up to $400 for covered eyewear. Additionally, members receive up to 20 one-way transportation trips per year to plan-approved locations and a $50 monthly allowance for over-the-counter items with no copay. These additional services help reduce overall healthcare expenses by eliminating copays and coinsurance for essential daily wellness needs.
Inpatient Hospital See details
Optimum Gold Plus Plan (HMO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $75 daily copay for days 1 through 5 and no copay for days 6 through 90 per stay. These benefits are partially covered because additional days, upgrades, and non-Medicare-covered stays are not covered, and both referrals and prior authorizations are required.
Outpatient Services See details
Optimum Gold Plus Plan (HMO) covers outpatient hospital and observation services with a $75 copay and no coinsurance, and ambulatory surgical center services with a $25 copay and no coinsurance. Outpatient substance abuse sessions require a $10 to $75 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Optimum Gold Plus Plan (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a referral are required for this covered benefit.
Ambulance and Transportation Services See details
Optimum Gold Plus Plan (HMO) covers ground ambulance services with a $200 copay and air ambulance services with a 20% coinsurance, both requiring prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 20 one-way trips per year to plan-approved locations, though transportation to any health-related location is not covered.
Emergency Services See details
Optimum Gold Plus Plan (HMO) covers emergency services with a $150 copay, which is waived if admitted to the hospital within 72 hours, and urgently needed services with a $10 copay, both with no coinsurance and no deductible. Worldwide emergency, urgent, and transportation services are also covered up to a $100,000 maximum with a $500 copay per service and no coinsurance.
Primary Care See details
Optimum Gold Plus Plan (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, mental health sessions, and physical, occupational, and speech therapies require a $10 copay and no coinsurance. Opioid treatment services have a $0 to $75 copay with no coinsurance, podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not.
Preventive Services See details
Optimum Gold Plus Plan (HMO) offers partially covered preventive services with no copay and no coinsurance for covered benefits, including Medicare-covered zero-dollar preventive services, kidney disease education, and a memory fitness benefit up to $500 per year. However, several services are not covered under this plan, including annual physical exams, health education, in-home safety assessments, and nutritional/dietary benefits.
Hearing Services See details
Optimum Gold Plus Plan (HMO) covers routine hearing exams and fitting evaluations once per year with no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to $750 per ear annually, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Optimum Gold Plus Plan (HMO) with no copay, no coinsurance, and no deductible for one routine eye exam and covered eyewear up to a $400 annual limit. Other eye exam services, eyeglass lenses, and eyeglass frames are not covered, though complete eyeglasses or contact lenses have no copay, and upgrades are available for a $30 copay.
Dental Services See details
Dental services are partially covered by the Optimum Gold Plus Plan (HMO) with no copay and no coinsurance for covered benefits, though prior authorization is required for Medicare-covered dental services. Sub-services that are 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
Optimum Gold Plus Plan (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
The Optimum Gold Plus Plan (HMO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Under the Optimum Gold Plus Plan (HMO), medical equipment is covered with no copay, though prior authorization is required. Covered durable medical equipment, prosthetics, medical supplies, and diabetic shoes are subject to a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Optimum Gold Plus Plan (HMO) covers diagnostic and radiological services with prior authorization and referrals, offering no copay for lab services and outpatient X-rays, though coinsurance applies to both. Diagnostic procedures and tests require a $0 to $75 copay and 20% coinsurance, while diagnostic radiology starts at a $25 copay and therapeutic radiology carries a 20% coinsurance and a copay.
Home Health Services See details
Home health services are covered under the Optimum Gold Plus Plan (HMO) with no copay and no coinsurance, though prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Optimum Gold Plus Plan (HMO) covers Cardiac Rehabilitation Services with a $10 copay and no coinsurance, subject to prior authorization and referral requirements. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by the Optimum Gold Plus 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, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Optimum Gold Plus Plan (HMO) partially covers other services, offering over-the-counter (OTC) items and a chronic illness meal benefit with no copay and no coinsurance, though acupuncture is not covered. The OTC benefit provides up to $50 monthly for eligible items, and the meal benefit requires prior authorization and a referral.
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