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2020 Medicare Advantage Plan Benefit Details for the Optimum Gold Rewards Plan (HMO)

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Medicare Advantage Plan Details
Medicare Plan Name:Optimum Gold Rewards Plan (HMO)
Location:Sumter, Florida
Plan ID:H5594 - 026 - 0     Click to see other plans
Member Services:1-866-245-5360 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Email a copy of the Optimum Gold Rewards Plan (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,020
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,365 drugsBrowse the Optimum Gold Rewards Plan (HMO) Formulary
This plan has 4 drug tiers. See cost-sharing for all pharmacies and tiers
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:
Number of Drugs per
Plan's Pharmacy Search:http://www.youroptimumhealthcare.com
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 020115   PCN: IS   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Sumter, Florida:52 members
Number of Members enrolled in this plan in (H5594 - 026):354 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
Customer Service Rating: 5 out of 5 Stars.
Member Experience Rating: 5 out of 5 Stars.
Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS): 100%
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,400 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $0 copay
• Specialist: $40 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-250 copay or 20% coinsurance (authorization and referral required)
• Lab services: $0-50 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $25-250 copay (authorization and referral required)
• Outpatient x-rays: $0-250 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $75 copay per visit (always covered)
• Urgent care: $20 copay per visit (always covered)
Inpatient hospital coverage
• $195 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization and referral required)
Outpatient hospital coverage
• $250 copay per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 5
$20 per day for days 6 through 20
$150 per day for days 21 through 100 (authorization and referral required)
Preventive care
• $0 copay (authorization and referral required)
Ground ambulance
• $175 copay
Rehabilitation services
• Occupational therapy visit: $40 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $40 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $195 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient group therapy visit: $40 copay (authorization and referral required)
• Outpatient individual therapy visit: $40 copay (authorization and referral required)
Opioid treatment program services
• In-network: 20% coinsurance or $0.00-$250.00 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: 0-20% coinsurance per item (authorization required)
• 20% coinsurance (authorization and referral required)
• Hearing exam: $0 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: $0 copay (limits apply)
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: Not covered
• Periodontics: $0 copay (limits apply, authorization required)
• Extractions: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $10 copay (limits apply)
• Eyeglasses (frames and lenses): $10 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: $30 copay (limits apply)
Wellness programs (e.g., fitness, nursing hotline)
• Covered
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: $40 copay (authorization and referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Not covered
• Telehealth: Not covered
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered

Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
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  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.