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Blue Shield AdvantageOptimum Plan 1 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield AdvantageOptimum Plan 1 (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 1 (HMO) in 2026, please refer to our full plan details page.
Blue Shield AdvantageOptimum Plan 1 (HMO) is a HMO plan offered by California Physicians' Service available for enrollment in 2025 to people living in San Diego County. 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 1 (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 1 (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 1 (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 $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 Blue Shield AdvantageOptimum Plan 1 (HMO) features an enhanced alternative drug benefit with a yearly prescription drug deductible of $425. During the initial coverage phase, preferred generic drugs have a $5 copay at preferred pharmacies and a $10 copay at standard pharmacies. For other drug tiers, you will pay a coinsurance ranging from 20% to 28% depending on the tier and pharmacy. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Medicare Part D drugs. Additionally, those who qualify for the low-income subsidy will benefit from no cost for their Part D premium.
Additional Benefits
The Blue Shield AdvantageOptimum Plan 1 (HMO) provides comprehensive medical coverage with predictable out-of-pocket costs, featuring no coinsurance for inpatient hospital stays, outpatient services, and primary care. Inpatient acute hospital stays require a daily copay of $270 for the first seven days, while primary care visits and key preventive services are available with no copay. Emergency care is covered with a $150 copay, which is waived if you are admitted, and urgently needed services require no copay. This plan also includes valuable specialty benefits, such as dental care with no coinsurance and a $30 copay for routine annual eye exams, which features a $200 eyewear allowance. Additionally, members benefit from up to 14 one-way trips per year to approved health locations with no copay and a $70 quarterly allowance for over-the-counter items. Note that certain services, including cardiac rehabilitation and routine hearing aids, are not covered under this plan.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Blue Shield AdvantageOptimum Plan 1 (HMO) with no coinsurance, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. Acute stays require a $270 daily copay for days 1 to 7 and psychiatric stays require a $250 daily copay for days 1 to 8, with no copays for additional covered days.
Outpatient Services See details
Outpatient services are covered by Blue Shield AdvantageOptimum Plan 1 (HMO) with no coinsurance, featuring a $350 copay for outpatient hospital services and a $200 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay, while outpatient blood services are covered with no copay or deductible.
Partial Hospitalization See details
Partial hospitalization is covered under the Blue Shield AdvantageOptimum Plan 1 (HMO) with a $55 copay and no coinsurance. These services require prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Blue Shield AdvantageOptimum Plan 1 (HMO), featuring a $300 copay and no coinsurance for ground ambulance services, alongside a 20% coinsurance and no copay for air ambulance services. Transportation benefits are partially covered, providing up to 14 one-way trips per year to plan-approved health-related locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Blue Shield AdvantageOptimum Plan 1 (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if admitted to the hospital within one day, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $25,000 maximum, offering emergency and urgent care for a $150 copay and no coinsurance, while worldwide emergency transportation is not covered.
Primary Care See details
Blue Shield AdvantageOptimum Plan 1 (HMO) covers primary care services with no coinsurance, featuring copays ranging from no copay to $30 for specialists, $30 for mental health and podiatry, and $40 for occupational and physical therapy. Chiropractic benefits are partially covered with a $20 copay and no coinsurance, as routine chiropractic care is not covered.
Preventive Services See details
Preventive services are covered by Blue Shield AdvantageOptimum Plan 1 (HMO), including Medicare-covered zero-dollar preventive services with no copay and no coinsurance. While annual physical exams, kidney disease education, and select screenings are covered, additional preventive services are only partially covered, excluding options such as health education, weight management, and alternative therapies.
Hearing Services See details
Hearing services are partially covered under the Blue Shield AdvantageOptimum Plan 1 (HMO), requiring a doctor's referral and no deductible for covered exams. However, some services are not covered, including routine hearing exams, hearing aid fittings, over-the-counter hearing aids, and all types of prescription hearing aids.
Vision Services See details
Blue Shield AdvantageOptimum Plan 1 (HMO) offers partially covered vision services, including one routine eye exam per year for a $30 copay and no coinsurance. Eyewear is also partially covered with no copay or coinsurance, providing a $200 annual allowance for contact lenses and $200 every two years for eyeglass frames, though upgrades and combined eyeglasses (lenses and frames) are not covered.
Dental Services See details
Blue Shield AdvantageOptimum Plan 1 (HMO) partially covers dental services with copays ranging from no copay up to $570 and no coinsurance. While preventive, restorative, and orthodontic services are included, implant services and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Blue Shield AdvantageOptimum Plan 1 (HMO) covers home infusion bundled services with prior authorization, requiring a $35 copay and no coinsurance to 20% coinsurance for Medicare Part B insulin. Chemotherapy, radiation, and other Part B drugs under this benefit have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Blue Shield AdvantageOptimum Plan 1 (HMO) with a 20% coinsurance and no copay. Prior authorization and a doctor referral are required for these services.
Medical Equipment See details
Medical Equipment is partially covered by Blue Shield AdvantageOptimum Plan 1 (HMO) with no copays, featuring coinsurance ranging from no coinsurance to 20% for durable medical equipment and 20% for prosthetic devices. Medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under Blue Shield AdvantageOptimum Plan 1 (HMO), with diagnostic procedures, lab services, and outpatient x-rays not covered. Covered diagnostic radiological services require a $75 copay and no coinsurance, while therapeutic radiological services require a 20% coinsurance and a copay.
Home Health Services See details
Home Health Services are covered by Blue Shield AdvantageOptimum Plan 1 (HMO), requiring a doctor referral and prior authorization to access care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Blue Shield AdvantageOptimum Plan 1 (HMO). No coverage is provided for intensive cardiac rehabilitation, pulmonary rehabilitation, or supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Blue Shield AdvantageOptimum Plan 1 (HMO) with prior authorization and a doctor referral, though additional days beyond Medicare-covered stays are not covered. There is no coinsurance for this benefit, which features no copay for days 1 through 20 and a $200 daily copay for days 21 through 100.
Other Services See details
Other Services are partially covered by Blue Shield AdvantageOptimum Plan 1 (HMO), which provides a $70 allowance every three months for over-the-counter items that do not carry over to the next period. Acupuncture, meal benefits, and highly integrated dual-eligible SNP services are not covered under this plan.
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