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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 2026, 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 2026.
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 a $425.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3100.00 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) features an Enhanced Alternative drug benefit with a $425.00 annual prescription drug deductible. During the initial coverage phase, Tier 1 preferred generic drugs require a $3.00 copay at preferred pharmacies and a $10.00 copay at standard pharmacies. Standard generics, preferred brands, and non-preferred drugs require coinsurance ranging from 20% to 28% depending on the drug tier. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, individuals who qualify for the low-income subsidy will have no copay for their Part D costs.
Additional Benefits
The Blue Shield AdvantageOptimum Plan (HMO) features affordable cost-sharing for essential medical services, including no copay for preventive care, annual physicals, and inpatient hospital stays from days 6 through 90. For the first five days of inpatient care, members pay a $50 daily copay, while primary care visits require a copay ranging from $10 to $30. Outpatient services are also covered with no coinsurance, requiring a $200 copay for outpatient hospital services and a $50 copay for ambulatory surgical center visits. Emergency care is available with a $150 copay, whereas urgently needed services require no copay. Additional benefits include partially covered dental services with no coinsurance and copays up to $570, along with vision care that offers up to a $200 allowance for frames and contacts. Members also benefit from a $65 quarterly over-the-counter allowance and up to 14 one-way transportation trips to approved locations with no copay.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by the Blue Shield AdvantageOptimum Plan (HMO), requiring doctor referrals and prior authorization. Acute care costs a $50 daily copay for days 1 through 5, no copay for days 6 through 90, and no coinsurance, excluding upgrades and non-Medicare stays; psychiatric care requires a $900 copay per admission and no coinsurance, excluding additional days and non-Medicare stays.
Outpatient Services See details
Outpatient services are covered by the Blue Shield AdvantageOptimum Plan (HMO), featuring a $200 copay for outpatient hospital services, a $50 copay for ambulatory surgical center services, and a $30 copay for outpatient substance abuse sessions, all with no coinsurance. Outpatient blood services are also covered with no deductible, no copay, and no coinsurance.
Partial Hospitalization See details
Blue Shield AdvantageOptimum Plan (HMO) covers partial hospitalization services with a $55 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under the Blue Shield AdvantageOptimum Plan (HMO), as transportation to any health-related location is not covered. Ground ambulance services require a $300 copay and no coinsurance, air ambulance services require a 20% coinsurance and no copay, and up to 14 one-way trips to plan-approved locations are provided with no copay or coinsurance.
Emergency Services See details
Blue Shield AdvantageOptimum Plan (HMO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with no copay or coinsurance. Worldwide emergency and urgent care are covered with a $150 copay up to a $50,000 maximum limit, but worldwide emergency transportation is not covered.
Primary Care See details
Blue Shield AdvantageOptimum Plan (HMO) covers primary care benefits with copayments ranging from $10 to $30 and no coinsurance. Chiropractic services are only partially covered, as routine chiropractic care is not covered.
Preventive Services See details
Blue Shield AdvantageOptimum Plan (HMO) covers Medicare-covered zero-dollar preventive services and annual physical exams with no copay and no coinsurance. Additional preventive benefits are partially covered, offering memory fitness and remote access technologies, while sub-services like health education, weight management, and therapeutic massage are not covered.
Hearing Services See details
Hearing services are partially covered under the Blue Shield AdvantageOptimum Plan (HMO) with no deductible, though copay and coinsurance details are not specified. While some diagnostic hearing exams are covered with a doctor referral, routine exams, fitting evaluations, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Blue Shield AdvantageOptimum Plan (HMO) with no deductible, though specific copay and coinsurance details are not provided. Covered benefits require a doctor referral and include annual routine eye exams, eyeglass lenses, contact lenses up to $200 annually, and frames up to $200 every two years, while combined eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Blue Shield AdvantageOptimum Plan (HMO) offers partially covered dental services, as implant services and maxillofacial prosthetics are not covered. Covered dental services require no coinsurance, with copays ranging from no copay up to $570.00 depending on the service.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Blue Shield AdvantageOptimum Plan (HMO) with prior authorization, requiring a $35 copay and no coinsurance to 20% coinsurance for Medicare Part B insulin. Other covered Part B chemotherapy, radiation, and miscellaneous drugs have no copay and range from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Blue Shield AdvantageOptimum Plan (HMO) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
Blue Shield AdvantageOptimum Plan (HMO) partially covers medical equipment with no copays, offering durable medical equipment with no coinsurance to 20% coinsurance and prosthetic devices with 20% coinsurance. Prior authorization is required for covered items, while medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Blue Shield AdvantageOptimum Plan (HMO) partially covers diagnostic and radiological services, which require a doctor referral. Diagnostic services feature no copay (no coinsurance), but diagnostic procedures, tests, and lab services are not covered. Covered diagnostic radiological services require a $20 copay (no coinsurance), therapeutic radiological services have a 20% coinsurance (no copay), and outpatient X-ray services are not covered.
Home Health Services See details
Home health services are covered by the Blue Shield AdvantageOptimum Plan (HMO), requiring prior authorization and a doctor referral. Cost-sharing details, such as copayments and coinsurance, are not specified for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Blue Shield AdvantageOptimum Plan (HMO), as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by the Blue Shield AdvantageOptimum Plan (HMO), featuring no copay for days 1 through 20, a $175 daily copay for days 21 through 100, and no coinsurance. Prior authorization and a doctor referral are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Blue Shield AdvantageOptimum Plan (HMO) partially covers Other Services, offering a $65 allowance every three months with no copay or coinsurance for covered over-the-counter items, including nicotine replacement therapy. Acupuncture, meal benefits, Naloxone, and Dual Eligible SNPs with Highly Integrated Services are not covered under this plan.
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