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Sharp Direct Advantage Platinum (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sharp Direct Advantage Platinum (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 Platinum (HMO) in 2026, please refer to our full plan details page.
Sharp Direct Advantage Platinum (HMO) is a HMO plan offered by Sharp Healthcare available for enrollment in 2025 to people living in Sharp Direct Advantage Platinum 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 Platinum (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 Platinum (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 Platinum (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $62.00. 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 Platinum (HMO) features an enhanced alternative drug benefit with a $350 prescription drug deductible and a standard Part D premium of $62, which may be reduced to $50 with Extra Help. After meeting your deductible, Tier 1 preferred generic drugs have an $8 copay at standard pharmacies and no copay through standard mail. Tier 2 standard generics cost a $40 copay, Tier 3 preferred brands cost a $90 copay, Tier 4 non-preferred drugs require 29% coinsurance, and Tier 5 specialty drugs have no copay. These copays and coinsurance rates apply during the initial coverage phase until total drug costs reach $2,100. Once your yearly out-of-pocket drug costs hit $2,100, you enter the catastrophic coverage phase and will pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Sharp Direct Advantage Platinum (HMO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no coinsurance for inpatient hospital stays, outpatient services, and primary care. Patients pay a $5 copay for primary care and telehealth visits, while acute inpatient hospital stays require a $200 daily copay for the first eight days and no copay thereafter. Emergency care is covered with a $150 copay, and urgent care visits require a $30 copay, with both services featuring no coinsurance. For auxiliary healthcare needs, this plan provides robust dental, vision, and hearing benefits with no coinsurance, including a $300 annual eyewear allowance and a $4,800 hearing aid allowance every three years with no copay. Members also benefit from no copay on Medicare-covered preventive services and a generous $180 quarterly over-the-counter allowance. While durable medical equipment requires a 15% coinsurance and no copay, routine diagnostic lab services are covered with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are partially covered by Sharp Direct Advantage Platinum (HMO) with no coinsurance, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. Acute care requires a $200 daily copay for days 1 to 8 and no copay for days 9 and beyond, while psychiatric care requires a $200 daily copay for days 1 to 7 and no copay for days 8 to 90.
Outpatient Services See details
Sharp Direct Advantage Platinum (HMO) covers outpatient services with no coinsurance, including outpatient hospital services with copays ranging from $20 to $175 and ambulatory surgical center services for a $175 copay. Patients also pay a $20 copay for outpatient substance abuse sessions, a $200 copay per stay for observation services, and no deductible for outpatient blood services.
Partial Hospitalization See details
Sharp Direct Advantage Platinum (HMO) covers partial hospitalization services with a $20 copay and no coinsurance. This benefit requires both a doctor referral and prior authorization.
Ambulance and Transportation Services See details
Sharp Direct Advantage Platinum (HMO) partially covers Ambulance and Transportation Services, as transportation services to plan-approved or any health-related locations are not covered. Ground and air ambulance services are covered with a $250 copay and no coinsurance, subject to prior authorization.
Emergency Services See details
Sharp Direct Advantage Platinum (HMO) covers emergency services with a $150 copay and urgently needed services with a $30 copay, both with no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered with copays ranging from $150 to $250 and no coinsurance.
Primary Care See details
Primary Care benefits are partially covered by Sharp Direct Advantage Platinum (HMO) with no coinsurance, though podiatry services are not covered. Covered services require no coinsurance, with copays ranging from $5 for primary care and telehealth visits up to $30 for physical, occupational, and speech therapies.
Preventive Services See details
Preventive services are partially covered by the Sharp Direct Advantage Platinum (HMO) plan, which offers Medicare-covered preventive benefits, health education, and kidney disease education with no copay and no coinsurance. Excluded from coverage are annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Sharp Direct Advantage Platinum (HMO) covers hearing services, offering hearing exams and fitting evaluations for a $5 copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to a $4,800 allowance every three years, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Vision services are partially covered by Sharp Direct Advantage Platinum (HMO), which features annual routine eye exams with no copay to a $20 copay and no coinsurance. The plan also provides a $300 annual allowance for contact lenses or eyeglasses with no copay and no coinsurance, though eyewear upgrades are not covered.
Dental Services See details
Dental services are partially covered by Sharp Direct Advantage Platinum (HMO), featuring no coinsurance and copays ranging from no copay up to $495, including a $30 copay for Medicare dental services. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Sharp Direct Advantage Platinum (HMO) covers Home Infusion bundled Services, requiring prior authorization and step therapy. Medicare Part B insulin drugs feature a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under the Sharp Direct Advantage Platinum (HMO) plan with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive coverage for these services.
Medical Equipment See details
Sharp Direct Advantage Platinum (HMO) partially covers medical equipment benefits with 15% coinsurance and no copay, requiring prior authorization for services. Covered items include durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Sharp Direct Advantage Platinum (HMO), as outpatient X-ray services are not covered. Covered lab services require no copay, diagnostic tests require a copay and 15% coinsurance, and radiological services require no copay and up to 15% coinsurance (with no coinsurance for some diagnostic radiological services).
Home Health Services See details
Home Health Services are covered by the Sharp Direct Advantage Platinum (HMO) plan, but members must obtain prior authorization and a doctor referral to receive care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Sharp Direct Advantage Platinum (HMO) plan, meaning there is no coverage, copay, or coinsurance 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 Platinum (HMO), requiring a doctor referral and prior authorization but no prior three-day inpatient hospital stay. There is no coinsurance for these services, featuring no copay for days 1 to 20 and days 42 to 100, and a $125 daily copay for days 21 to 41, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Sharp Direct Advantage Platinum (HMO) partially covers Other Services, offering up to 30 acupuncture treatments per year with a $10 copay and no coinsurance, and a $180 quarterly over-the-counter allowance with no copay or coinsurance. Meal benefits and Dual Eligible SNPs with Highly Integrated Services are not covered.
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