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Sharp Direct Advantage Gold Card (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sharp Direct Advantage Gold Card (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Sharp Direct Advantage Gold Card (HMO) in 2025, please refer to our full plan details page.
Sharp Direct Advantage Gold Card (HMO) is a HMO plan offered by Sharp Healthcare available for enrollment in 2025 to people living in Sharp Direct Advantage Gold San Diego County. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Sharp Direct Advantage Gold Card (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 Sharp Direct Advantage Gold Card (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 Sharp Direct Advantage Gold Card (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 $2900.00 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 Sharp Direct Advantage Gold Card (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy type. For example, you'll pay $8 for preferred generic drugs at a standard pharmacy, or $0 for preferred generic drugs with mail order. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Sharp Direct Advantage Gold Card (HMO) plan offers a variety of benefits with associated costs. Inpatient hospital stays have a copay, with different rates for acute and psychiatric care, while outpatient services have varying copays. Emergency and ambulance services have copays, and primary care visits have a $5 copay. Additional benefits include hearing and vision services with copays and coverage for hearing aids and eyewear. Dental services are partially covered. Diagnostic and radiological services are covered with copays and coinsurance, while home health and skilled nursing facilities have no or low copays.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $225 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, you will pay a $250 copay for days 1-7, and no copay for days 8-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades are not covered. Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the Sharp Direct Advantage Gold Card (HMO) plan. Outpatient Hospital Services have a copay of $20.00-$225.00, and Observation Services and Ambulatory Surgical Center (ASC) Services have a copay of $225.00. Individual and Group Sessions for Outpatient Substance Abuse have a copay of $20.00. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Sharp Direct Advantage Gold Card (HMO) plan. The plan requires prior authorization and a doctor referral, and has a $20 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Sharp Direct Advantage Gold Card (HMO), including Medicare-covered Ground and Air Ambulance Services, each with a $155 copay and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered by the Sharp Direct Advantage Gold Card (HMO), with a $90 copay for Emergency Services and a $30 copay for Urgently Needed Services. Worldwide Emergency Services are also covered, with a $90 copay for Worldwide Emergency Coverage and Worldwide Urgent Coverage, and a $250 copay for Worldwide Emergency Transportation. There is no coinsurance for any of these services.
Primary Care See details
The Sharp Direct Advantage Gold Card (HMO) plan covers primary care physician services with a $5 copay and covers chiropractic services, including routine care, with a $10 copay. Occupational therapy services have a $20 copay, while specialist, mental health, and psychiatric services all require a referral and have a $20 copay. Physical therapy and speech-language pathology services have a $20 copay, and additional telehealth benefits have a $5 copay. Opioid treatment program services have a minimum and maximum copay of $20. Podiatry services are not covered.
Preventive Services See details
The Sharp Direct Advantage Gold Card (HMO) plan covers preventive services including health education, fitness benefits, remote access technologies, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit. Annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $5 copay, routine hearing exams with a $5 copay for up to two visits per year, and fitting/evaluation for hearing aids with a $5 copay for up to two visits per year. Prescription Hearing Aids are covered up to $4,000 every three years, and OTC Hearing Aids are covered up to $4,000 every three years. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
Vision Services includes coverage for eye exams with a copay between $0 and $20, and eyewear benefits. The plan covers one routine eye exam per year, eyeglass lenses with no copay, and contact lenses, eyeglasses (lenses and frames), and eyeglass frames, each with a maximum benefit of $300 per year.
Dental Services See details
Dental Services are partially covered by the Sharp Direct Advantage Gold Card (HMO) plan, with a $35 copay for Medicare Dental Services, but Orthodontic services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Other covered services include Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, both with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Sharp Direct Advantage Gold Card (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetic Devices with a 20% coinsurance, and Medical Supplies with a 20% coinsurance; however, Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Lab Services are not. Diagnostic Procedures/Tests have no copay, but have a coinsurance of at least 15%. Diagnostic Radiological Services have a copay of up to $75, Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Sharp Direct Advantage Gold Card (HMO), with no copay or coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Sharp Direct Advantage Gold Card (HMO). There is no copay for days 1-20, a $125 copay for days 21-41, and no copay for days 42-100.
Other Services See details
Other Services include acupuncture, covered with a $10 copay, and over-the-counter (OTC) items, with a maximum benefit coverage amount of $150 every three months. Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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