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Blue Shield AdvantageOptimum Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield AdvantageOptimum Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield AdvantageOptimum Plan (HMO) in 2025, please refer to our full plan details page.
Blue Shield AdvantageOptimum Plan (HMO) is a HMO plan offered by California Physicians' Service available for enrollment in 2025 to people living in Los Angeles and Orange Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Blue Shield AdvantageOptimum 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 Blue Shield AdvantageOptimum 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 Blue Shield AdvantageOptimum 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 $2900.00 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 Blue Shield AdvantageOptimum Plan (HMO) has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for each prescription, depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $3 copay at preferred pharmacies, while standard generic drugs have a $40 copay at preferred pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. This plan offers an enhanced alternative, so make sure to check the plan's formulary for specific drug coverage details.
Additional Benefits
The Blue Shield AdvantageOptimum Plan (HMO) offers a range of benefits, including inpatient and outpatient hospital services with varying copays. This plan covers primary care, preventive, vision, and dental services, with specific copays for each. Emergency and ambulance services are covered, and the plan also includes hearing services, home health services, and skilled nursing facility stays.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute, with a $50 copay for days 1-5 and no copay for days 6-90, and Inpatient Hospital Psychiatric with a $900 copay per admission or stay. Additional days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, and outpatient substance abuse services, are covered. Outpatient Hospital Services have a $200 copay, Ambulatory Surgical Center Services have a $50 copay, and both individual and group sessions for outpatient substance abuse have a $30 copay. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Shield AdvantageOptimum Plan (HMO) with a $55 copay, and a doctor referral and prior authorization are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Shield AdvantageOptimum Plan (HMO). Ground ambulance services have a $300 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 14 one-way trips per year using rideshare services, bus/subway, medical transport, and other modes of transportation, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Coverage, are covered under the Blue Shield AdvantageOptimum Plan (HMO). Emergency Services and Worldwide Emergency Coverage have a $140 copay with no coinsurance, while Urgently Needed Services have a $10 copay with no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Shield AdvantageOptimum Plan (HMO) covers primary care physician services, chiropractic services (with a $5 copay), occupational therapy services (with a $15 copay), physician specialist services (with a $0-$5 copay), mental health specialty services (with a $30 copay for individual and group sessions), podiatry services (with a $5 copay), other health care professional services (with a $0-$5 copay), psychiatric services (with a $30 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $15 copay), additional telehealth benefits, and opioid treatment program services. Routine chiropractic care is not covered.
Preventive Services See details
The Blue Shield AdvantageOptimum Plan (HMO) covers preventive services, including annual physical exams, and other preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Some additional preventive services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing services include routine hearing exams, with no deductible, and are covered. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids (all types), Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision Services include eye exams with a $5 copay, and contact lenses with a maximum plan benefit coverage of $230 every year; eyeglass lenses are covered once per year, while eyeglass frames are covered once every two years with a maximum plan benefit coverage of $230. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Blue Shield AdvantageOptimum Plan (HMO) covers a variety of dental services. Medicare Dental Services have a copay between $0 and $5, while Dental X-Rays have a copay between $0 and $5. Other Diagnostic Dental Services have a copay between $0 and $8, and Fluoride Treatment has a $5 copay. Restorative Services have a copay between $0 and $300, and Adjunctive General Services have a copay between $0 and $105. Endodontics has a copay between $15 and $475, and Periodontics has a copay between $0 and $375. Prosthodontics, removable has a copay between $15 and $500, while Prosthodontics, fixed has a copay between $45 and $570. Oral and Maxillofacial Surgery has a copay between $0 and $150, and Orthodontics has a copay between $0 and $350. Maxillofacial Prosthetics and Implant Services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Blue Shield AdvantageOptimum Plan (HMO), but require prior authorization and a doctor's referral. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0-20% coinsurance and Prosthetic Devices with 20% coinsurance, while Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered with coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Radiological Services with a copay of at most $15, and Therapeutic Radiological Services with coinsurance of at most 20%. Outpatient X-Ray Services, Diagnostic Procedures/Tests, and Lab Services are not covered.
Home Health Services See details
Home Health Services are covered under the Blue Shield AdvantageOptimum Plan (HMO) with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Blue Shield AdvantageOptimum Plan (HMO). Prior authorization and a doctor referral are required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Blue Shield AdvantageOptimum Plan (HMO), requiring prior authorization and a doctor's referral. There is no copay for days 1-20, and a $175 copay for days 21-100; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items with a maximum benefit of $80 every three months, and the plan covers nicotine replacement therapy as a Part C OTC benefit. Acupuncture, meal benefits, 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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