A non-government entity
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 2025, 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 2025.
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 no drug deductible. Your prescription medication coverage will start immediately.
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:
Sign up for Blue Shield AdvantageOptimum Plan 1 (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Blue Shield AdvantageOptimum Plan 1 (HMO) has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions. For preferred generic drugs, the copay is $5 at a preferred pharmacy and $10 at a standard pharmacy. Standard generic drugs have a $40 copay at a preferred pharmacy and a $47 copay at a standard pharmacy. Preferred brand drugs have a $95 copay at a preferred pharmacy and a $100 copay at a standard pharmacy. Non-preferred drugs have 33% coinsurance. Once your total drug costs reach $2,000, you enter the next coverage phase. After your yearly out-of-pocket drug costs reach $2,000, you pay nothing for covered drugs.
Additional Benefits
The Blue Shield AdvantageOptimum Plan 1 (HMO) offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. Emergency services, primary care, and preventive services are covered, as are hearing and vision services, with specific copays and coverage limits for vision. Dental services offer broad coverage with a range of copays depending on the service. This plan also includes coverage for ambulance and transportation, home infusion, dialysis, and medical equipment, with cost-sharing through copays or coinsurance. Additionally, it provides coverage for skilled nursing facilities, and offers an over-the-counter benefit for OTC items. However, some services like cardiac rehabilitation, and certain diagnostic and radiological services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization and a doctor referral required. For Inpatient Hospital-Acute, you pay a $270 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you pay a $250 copay for days 1-8, and no copay for days 9-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered. Additional days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient hospital services require a $350 copay, while ambulatory surgical center services have a $200 copay. Individual and group outpatient substance abuse sessions have a copay between $30 and $30, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Shield AdvantageOptimum Plan 1 (HMO), requiring prior authorization and a doctor referral, with a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services. Ground ambulance services have a $300 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location have a limit of 14 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Blue Shield AdvantageOptimum Plan 1 (HMO), with a $125 copay for Emergency Services and Worldwide Emergency Coverage, and a $30 copay for Urgently Needed Services, and no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Blue Shield AdvantageOptimum Plan 1 (HMO) covers primary care services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a copay between $0 and $35, mental health specialty services with a $30 copay for individual and group sessions, podiatry services with a $35 copay for routine foot care, other health care professional services with a copay between $0 and $35, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services. Routine chiropractic care is not covered.
Preventive Services See details
The Blue Shield AdvantageOptimum Plan 1 (HMO) covers preventive services, including annual physical exams, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Additional services such as health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing services include routine hearing exams with no copay or coinsurance, but fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $35 copay, contact lenses with a maximum benefit of $240 every year, and eyeglass lenses with no copay, limited to one pair per year. Eyeglass frames are covered with a maximum benefit of $240 every two years. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a copay ranging from $0 to $35, and other dental services including oral exams, dental x-rays with a copay from $0 to $5, other diagnostic dental services with a copay from $0 to $8, prophylaxis (cleaning), fluoride treatment with a $5 copay, and other preventive dental services. Restorative services have a copay from $0 to $300, adjunctive general services have a copay from $0 to $105, endodontics have a copay from $15 to $475, periodontics have a copay from $0 to $375, prosthodontics (removable) have a copay from $15 to $500, prosthodontics (fixed) have a copay from $45 to $570, oral and maxillofacial surgery has a copay from $0 to $150, and orthodontics has a copay from $0 to $350. Maxillofacial prosthetics and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Blue Shield AdvantageOptimum Plan 1 (HMO) with a coinsurance between 20% and 20%, and require prior authorization and a doctor's referral.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetics/Medical Supplies - Non-Medicare benefit with coinsurance for Medicare-covered medical supplies. Some services are covered, but Durable Medical Equipment for use outside the home, Medical Supplies, Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Blue Shield AdvantageOptimum Plan 1 (HMO). Diagnostic procedures/tests, lab services, and outpatient X-ray services are not covered. Diagnostic Radiological Services have a copay of up to $60, and Therapeutic Radiological Services have a coinsurance of up to 20%.
Home Health Services See details
Home Health Services are covered by the Blue Shield AdvantageOptimum Plan 1 (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 not covered by the Blue Shield AdvantageOptimum Plan 1 (HMO). Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $200.
Other Services See details
The Blue Shield AdvantageOptimum Plan 1 (HMO) plan covers Over-the-Counter (OTC) items with a maximum benefit coverage amount of $90.00 every three months, and it offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. Acupuncture, meal benefit, Dual Eligible SNPs with Highly Integrated Services, and other specified services are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved