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Blue Shield AdvantageOptimum Plan (HMO)

H5928 - 004 - 0

(3.5 / 5)

Blue Shield AdvantageOptimum Plan (HMO) is a Medicare Advantage Plan by Blue Shield of California.

This page features plan details for 2025 Blue Shield AdvantageOptimum Plan (HMO) H5928 – 004 – 0 available in Los Angeles and Orange Counties.

Locations

Blue Shield AdvantageOptimum Plan (HMO) is offered in the following locations.

California

Los Angeles County, California

Orange County, California

Click to see more locations

Plan Overview

Blue Shield AdvantageOptimum Plan (HMO) offers the following coverage and cost-sharing.

Insurer:	Blue Shield of California
Health Plan Deductible:	$0
MOOP:	$2,900 In-network
Drugs Covered:	Yes

Ready to sign up for Blue Shield AdvantageOptimum Plan (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Blue Shield AdvantageOptimum Plan (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Blue Shield AdvantageOptimum Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm
1) Preferred Generic		$5.00 Copay
2) Generic	$3.00 Copay	$10.00 Copay
3) Preferred Brand	$40.00 Copay	$47.00 Copay
4) Non-Preferred Drug	$95.00 Copay	$100.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm
1) Preferred Generic		$5.00 Copay
2) Generic	$6.00 Copay	$20.00 Copay
3) Preferred Brand	$80.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$200.00 Copay
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$5.00 Copay
2) Generic	$7.50 Copay	$25.00 Copay	$7.50 Copay
3) Preferred Brand	$100.00 Copay	$117.50 Copay	$100.00 Copay
4) Non-Preferred Drug	$237.50 Copay	$250.00 Copay	$237.50 Copay
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Blue Shield AdvantageOptimum Plan (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – 0.00-105.00 Copay (Limits Apply)
Endodontics
- In-Network: No Coins – 15.00-475.00 Copay (Limits Apply, Authorization Required, Referral Required)
Oral and Maxillofacial Surgery
- In-Network: No Coins – 0.00-150.00 Copay (Limits Apply, Authorization Required, Referral Required)
Orthodontics
- In-Network: No Coins – 0.00-350.00 Copay (Limits Apply, Authorization Required, Referral Required)
Periodontics
- In-Network: No Coins – 0.00-375.00 Copay (Authorization Required, Referral Required)
Prosthodontics, fixed
- In-Network: No Coins – 45.00-570.00 Copay (Limits Apply, Authorization Required, Referral Required)
Prosthodontics, removable
- In-Network: No Coins – 15.00-500.00 Copay (Limits Apply, Authorization Required, Referral Required)
Restorative Services
- In-Network: No Coins – 0.00-300.00 Copay (Limits Apply, Authorization Required, Referral Required)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – 0.00-5.00 Copay
Fluoride Treatment
- In-Network: No Coins – 5.00 Copay
Oral Exams
- In-Network: No Coins – No Copay (Limits Apply)
Other Diagnostic Dental Services
- In-Network: No Coins – 0.00-8.00 Copay
Other Preventive Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI)
- $15 copay (Referral Required)
Diagnostic tests and procedures
- $0 copay (Referral Required)
Lab services
- $0 copay (Referral Required)
Outpatient x-rays
- $0 copay (Referral Required)

Doctor visits

Primary
- $0 copay
Specialist
- $0-5 copay per visit (Referral Required)

Emergency care/Urgent care

Urgent care
- $10 copay per visit (always covered)
Emergency
- $140 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $5 copay (Referral Required)
Routine foot care
- $5 copay (Referral Required)

Ground ambulance

- $300 copay

Health plan deductible

- $0

Hearing

Hearing aids – inner ear
- Not covered
Hearing aids – outer ear
- Not covered
Fitting/evaluation
- Not covered
Hearing aids – over the ear
- Not covered
Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $0 copay (Referral Required)

Inpatient hospital coverage

- $50 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $2,900 In-network

Medical equipment/supplies

Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- 0-20% coinsurance per item (Authorization Required)
Diabetes supplies
- $0 copay (Authorization Required)

Medicare Part B drugs

Other Part B drugs
- 0-20% coinsurance (Authorization Required)
Chemotherapy
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient individual therapy visit
- $30 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $30 copay (Authorization Required, Referral Required)
Inpatient hospital – psychiatric
- $900 per stay (Authorization Required, Referral Required)
Outpatient group therapy visit
- $30 copay (Authorization Required, Referral Required)
Outpatient group therapy visit with a psychiatrist
- $30 copay (Authorization Required, Referral Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $200 copay per visit (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $15 copay (Authorization Required, Referral Required)
Occupational therapy visit
- $15 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $175 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

- $0 copay (Limits Apply)

Vision

Eyeglass frames
- $0 copay (Limits Apply, Referral Required)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply, Referral Required)
Contact lenses
- $0 copay (Limits Apply, Referral Required)
Eyeglass lenses
- $0 copay (Limits Apply, Referral Required)
Eyeglasses (frames and lenses)
- Not covered
Upgrades
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered