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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 2025, 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 5 out of 5 stars in 2025.
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 $174.70. 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) has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a $5 copay for preferred generic drugs at preferred and standard pharmacies, and a $5 copay at standard mail. You will pay 33% coinsurance for preferred brand drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, and you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you may have reduced premiums.
Additional Benefits
The Optimum Gold Plus Plan (HMO) offers a range of benefits with varying costs. Hospital stays have a copay of $75 for the first five days, with no copay for days 6-90. Outpatient services, including specialist visits, have copays ranging from $0 to $75. This plan includes coverage for ambulance services with a $200 copay for ground transport and 20% coinsurance for air transport, as well as emergency and urgent care services. Many services, like primary care, preventive services, hearing exams, and vision exams, have no copay. Additionally, the plan provides coverage for home health services with no copay, and offers benefits like over-the-counter items and meal benefits with no copay.
Inpatient Hospital See details
Inpatient Hospital coverage under the Optimum Gold Plus Plan (HMO) requires prior authorization and a doctor's referral, with a copay of $75 for days 1-5 and no copay for days 6-90 for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, and Non-Medicare-covered stays, as well as upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $75 copay, Observation Services with a $75 copay, Ambulatory Surgical Center (ASC) Services with a $25 copay, and Outpatient Substance Abuse Services with a copay between $10 and $75, depending on the service. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Optimum Gold Plus Plan (HMO) with a $55 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Optimum Gold Plus Plan (HMO), including all ambulance services and transportation services to a plan-approved health-related location. Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location have no copay, and are limited to 20 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, Urgently Needed Services have a $10 copay, and Worldwide Emergency Services have a $500 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, up to a maximum of $100,000.
Primary Care See details
The Optimum Gold Plus Plan (HMO) covers primary care physician services with no copay, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services with a $10 copay, mental health specialty services with a $10 copay for individual and group sessions, physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits, and opioid treatment program services with a copay between $0 and $75. Podiatry services are not covered.
Preventive Services See details
Preventive services are covered by the Optimum Gold Plus Plan (HMO), including Medicare-covered preventive services with no copay. Additional preventive services, including Fitness Benefit and Remote Access Technologies, are covered with a copay. Annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, and telemonitoring services are not covered.
Hearing Services See details
The Optimum Gold Plus Plan (HMO) covers hearing exams, routine hearing exams, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a maximum benefit of $750 per year. Prescription hearing aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Optimum Gold Plus Plan (HMO) covers vision services, including eye exams and eyewear, with no copay for eye exams, routine eye exams, contact lenses, and eyeglasses (lenses and frames). Eyeglass lenses and eyeglass frames are not covered, but upgrades have a $30 copay.
Dental Services See details
The Optimum Gold Plus Plan (HMO) covers dental services with no copay for Medicare Dental Services, Oral Exams (4 visits per year), Dental X-Rays (1 visit, other), Prophylaxis (Cleaning) (2 visits per year), Fluoride Treatment (2 visits per year), Periodontics (7 visits, other), and Oral and Maxillofacial Surgery (2 visits per year). 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 Plus Plan (HMO), including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Optimum Gold Plus Plan (HMO), with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment includes Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment, including Diabetic Supplies with 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The Optimum Gold Plus Plan (HMO) covers diagnostic and radiological services, including diagnostic procedures/tests with a maximum copay of $75 and at least 20% coinsurance, lab services with no copay, diagnostic radiological services with a copay up to $75, therapeutic radiological services with at least 20% coinsurance, and outpatient X-ray services with no copay. All services require prior authorization and a doctor referral.
Home Health Services See details
Home Health Services are covered by the Optimum Gold Plus 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, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization and a doctor referral are required for these services, but there is no copay or coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Optimum Gold Plus Plan (HMO), but require prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $172 per day; additional days beyond Medicare-covered SNF stays, and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Optimum Gold Plus Plan (HMO) offers an Other Services benefit that includes coverage for over-the-counter items and meal benefits with no copay, while acupuncture, Dual Eligible SNPs with Highly Integrated Services, and various other services are not covered. Over-the-counter items have a maximum benefit coverage amount of $75.00 every month.
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