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Sharp Direct Advantage Gold (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sharp Direct Advantage Gold (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 (HMO) in 2026, please refer to our full plan details page.
Sharp Direct Advantage Gold (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 3.5 out of 5 stars in 2026.
It's important to know that Sharp Direct Advantage Gold (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 (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 (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 a $350.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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 (HMO) plan offers an Enhanced Alternative drug benefit with a $350 prescription drug deductible. After meeting this deductible, you enter the initial coverage phase where Tier 1 preferred generics have an $8 copay at standard pharmacies and no copay through standard mail. Standard generics and preferred brands require a $40 and $90 copay respectively, while Tier 4 non-preferred drugs carry a 29% coinsurance and Tier 5 specialty drugs have no copay. These cost-sharing rates apply until total drug costs reach $2,100, at which point you transition to the next coverage phase. Once your yearly out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. If you qualify for the low-income subsidy, your premium may be reduced, resulting in $0 costs for Part D.
Additional Benefits
The Sharp Direct Advantage Gold (HMO) plan offers comprehensive medical coverage with no deductibles and predictable copays for essential services. Members pay a $5 copay for primary care visits and a $20 copay for specialists, with no coinsurance required. Inpatient hospital stays require a $250 daily copay for the first seven days and no copay thereafter, while outpatient hospital services feature copays ranging from $20 to $225. For everyday wellness, this plan features valuable vision, hearing, and extra benefits, including a $300 annual eyewear allowance and a $140 quarterly over-the-counter allowance with no copay. Routine eye exams start with no copay, OTC hearing aids have no copay, and prescription hearing aids are covered up to a $4,000 limit every three years. Emergency room visits require a $150 copay, while urgent care is available for a $30 copay with no coinsurance.
Inpatient Hospital See details
Sharp Direct Advantage Gold (HMO) covers inpatient hospital acute and psychiatric stays with a $250 daily copay for days 1 through 7, no copay for days 8 through 90, and no coinsurance. The benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, and services require prior authorization and a doctor referral.
Outpatient Services See details
Outpatient services are covered by Sharp Direct Advantage Gold (HMO) with no coinsurance and no deductibles. Members will pay copays ranging from $20 to $225 for outpatient hospital services, $225 for ambulatory surgical center visits, $250 per stay for observation services, and $20 for outpatient substance abuse sessions.
Partial Hospitalization See details
Sharp Direct Advantage Gold (HMO) covers partial hospitalization benefits with a $20 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these services.
Ambulance and Transportation Services See details
Sharp Direct Advantage Gold (HMO) partially covers ambulance and transportation services, offering ground and air ambulance services for a $250 copay and no coinsurance, subject to prior authorization. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Sharp Direct Advantage Gold (HMO) covers emergency services with a $150 copay and urgently needed services with a $30 copay, both with no coinsurance. Worldwide emergency and urgent services are covered with a $150 copay, and worldwide emergency transportation is covered with a $250 copay, all with no coinsurance.
Primary Care See details
Sharp Direct Advantage Gold (HMO) partially covers primary care benefits with no coinsurance, though podiatry services are not covered. Covered services feature a $5 copay for primary care and telehealth visits, a $20 copay for specialists and mental health services, and a $30 copay for physical, occupational, and speech therapies.
Preventive Services See details
Sharp Direct Advantage Gold (HMO) partially covers preventive services, offering covered benefits like health education, memory fitness, and kidney disease education with no copay and no coinsurance. However, the plan does not cover annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, and weight management. Also excluded are alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home/bathroom safety devices, and counseling.
Hearing Services See details
Sharp Direct Advantage Gold (HMO) covers hearing exams and fitting evaluations for a $5 copay and no coinsurance, alongside OTC hearing aids with no copay or coinsurance. Prescription hearing aids are partially covered with a $4,000 maximum benefit every three years and no copay or coinsurance, though inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Sharp Direct Advantage Gold (HMO) covers vision services with no deductibles and no coinsurance, although eyewear is only partially covered because upgrades are not covered. Routine eye exams are covered once per year with a $0 to $20 copay, eyeglass lenses have no copay, and there is a $300 annual allowance for contacts, frames, and eyeglasses.
Dental Services See details
Sharp Direct Advantage Gold (HMO) partially covers dental services, offering Medicare-covered dental care for a $35 copay and no coinsurance, subject to prior authorization and a doctor referral. However, specific sub-services including restorative, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Sharp Direct Advantage Gold (HMO) with prior authorization required. Medicare Part B insulin is covered for a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require no copay and range from no coinsurance up to 20% coinsurance.
Dialysis Services See details
Sharp Direct Advantage Gold (HMO) covers Dialysis Services with 20% coinsurance and no copay. Prior authorization and a doctor referral are required to receive these services.
Medical Equipment See details
Medical equipment is covered by Sharp Direct Advantage Gold (HMO) with no copay and a 20% coinsurance, though prior authorization is required. This benefit is partially covered, as durable medical equipment, prosthetic devices, and diabetic therapeutic shoes are covered, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Sharp Direct Advantage Gold (HMO) partially covers diagnostic and radiological services, requiring prior authorization and a doctor referral. Covered diagnostic procedures require a 15% coinsurance and no copay, though lab services are not covered. Radiological services feature no coinsurance, with copays ranging from no copay up to $75 for diagnostic, $60 for therapeutic, and $10 for outpatient X-rays.
Home Health Services See details
Home health services are covered by Sharp Direct Advantage Gold (HMO), though patients will need to obtain prior authorization and a doctor referral to receive these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Sharp Direct Advantage Gold (HMO) plan, as there is no coverage in practice for cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Sharp Direct Advantage Gold (HMO), with no coinsurance, no copay for days 1 to 20 and days 42 to 100, and a $125 daily copay for days 21 to 41. Prior authorization and a doctor referral are required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Sharp Direct Advantage Gold (HMO) covers acupuncture for a $10 copay and no coinsurance for up to 30 visits per year, and provides a $140 quarterly allowance for over-the-counter (OTC) items with no copay or coinsurance. While nicotine replacement therapy is covered under the OTC benefit, naloxone and meal benefits are not covered.
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