Blue Shield AdvantageOptimum Plan 1 (HMO) H5928-010 is a 2023 Medicare Advantage Plan or Part-C by Blue Shield of California available to residents in California. This plan includes extra prescription drug (Part-D) coverage. Blue Shield of California Blue Shield AdvantageOptimum Plan 1 (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,500 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay
$3,500 out-of-pocket. This can be an extremely nice safety net.
Blue Shield of California works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Blue Shield AdvantageOptimum Plan 1 (HMO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance)
and Part B (Medical Insurance) coverage from Blue Shield of California and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all
the benefits of Original Medicare from Blue Shield of California except hospice care. Original Medicare still provides you with hospice care if you sign up for
Medicare Advantage in California.
What type of plan is Blue Shield AdvantageOptimum Plan 1 (HMO)
Blue Shield AdvantageOptimum Plan 1 (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.
How much does Blue Shield AdvantageOptimum Plan 1 (HMO) cost?
Monthly Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. Blue Shield of California charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
Part-D Deductible and Premium
An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Blue Shield AdvantageOptimum Plan 1 (HMO) has a monthly drug premium of $0 and a $0 drug deductible. This Blue Shield of California plan offers a $0 Part-D Basic Premium that is Not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by Blue Shield of California above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.
Blue Shield of California Gap Coverage
In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers extra coverage. This Blue Shield of California plan does offer extra coverage through the gap.
MOOP
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Shield AdvantageOptimum Plan 1 (HMO) by Blue Shield of California MOOP is $3,500. Once you spend $3,500 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.
Formulary and Drug Coverage
Blue Shield AdvantageOptimum Plan 1 (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers.
By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what Blue Shield AdvantageOptimum Plan 1 (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Blue Shield of California helps
get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.
$0 per day for days 1 through 20 $140 per day for days 21 through 100
Occupational therapy visit
Rehabilitation services
$0 copay
Physical therapy and speech and language therapy visit
Rehabilitation services
$0 copay
Cleaning
Preventive dental
$0 copay
Dental x-ray(s)
Preventive dental
$0-5 copay
Fluoride treatment
Preventive dental
$5 copay
Oral exam
Preventive dental
$0 copay
Preventive care
$0 copay
Outpatient hospital coverage
$200 copay per visit
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$200 per day for days 1 through 8 $0 per day for days 9 through 90
Outpatient group therapy visit
Mental health services
$20 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$20 copay
Outpatient individual therapy visit
Mental health services
$20 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$20 copay
Chemotherapy
Medicare Part B drugs
20% coinsurance
Other Part B drugs
Medicare Part B drugs
20% coinsurance
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
20% coinsurance per item
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$3,500 In-network
Inpatient hospital coverage
$125 per day for days 1 through 7 $0 per day for days 8 through 90
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$0 copay
Hearing exam
Hearing
$10 copay
Health plan deductible
$0
Ground ambulance
$250 copay
Foot exams and treatment
Foot care (podiatry services)
$0 copay
Routine foot care
Foot care (podiatry services)
$0 copay
Emergency
Emergency care/Urgent care
$125 copay per visit (always covered)
Urgent care
Emergency care/Urgent care
$0-25 copay per visit (always covered)
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0 copay
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$20 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$0 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic services
Comprehensive dental
$0-8 copay
Endodontics
Comprehensive dental
$15-475 copay
Extractions
Comprehensive dental
$20-150 copay
Non-routine services
Comprehensive dental
Not covered
Periodontics
Comprehensive dental
$0-375 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0-570 copay
Restorative services
Comprehensive dental
$16-300 copay
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
Blue Shield AdvantageOptimum Plan 1 (HMO) Reviews
Is Blue Shield AdvantageOptimum Plan 1 (HMO) a good plan? Blue Shield AdvantageOptimum Plan 1 (HMO) received a 3 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.
Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Blue Shield AdvantageOptimum Plan 1 Reviews among several different plans.
2022 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing
Staying Healthy, Screening, Testing, & Vaccines
Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity
Managing Chronic And Long Term Care for Older Adults
Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy
Member Experience with H5928-010 Health Plan
Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination
Member Complaints and Changes in Plans Performance
Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement
Health Plan Customer Service Rating for Blue Shield of California
Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language
Drug Plan Customer Service Ratings
Total Rating
Call Center, TTY, Foreign Language
Ratings For Member Complaints and Changes in the Drug Plans Performance
Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement
Member Experience with the Drug Plan
Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs
Drug Safety and Accuracy of Drug Pricing
Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Blue Shield AdvantageOptimum Plan 1 (HMO) requires you to live in that plan’s service area. The service area is listed below:
How much does Blue Shield AdvantageOptimum Plan 1 (HMO) cost?
Blue Shield of California charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.
How much is Blue Shield AdvantageOptimum Plan 1 (HMO) MOOP?
The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Blue Shield AdvantageOptimum Plan 1 (HMO) by Blue Shield of California MOOP is $3,500. Once you spend $3,500 you will pay nothing for Part A or Part B covered services.
What type of plan is Blue Shield AdvantageOptimum Plan 1 (HMO)?
Blue Shield AdvantageOptimum Plan 1 (HMO) is a Local HMO. With a health maintenance organization you will be required to receive most of your health care from an in-network provider. HMOs require that you select a primary care physician (PCP).
Is Blue Shield AdvantageOptimum Plan 1 (HMO) a good plan?
Blue Shield AdvantageOptimum Plan 1 (HMO) received a 3 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance.
Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit.
Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.
Site Search:
MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.
Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
