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Sharp Direct Advantage VIP Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sharp Direct Advantage VIP Plan (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 VIP Plan (HMO) in 2025, please refer to our full plan details page.
Sharp Direct Advantage VIP Plan (HMO) is a HMO plan offered by Sharp Healthcare available for enrollment in 2025 to people living in Sharp Direct Advantage VIP 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 VIP Plan (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 VIP Plan (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 VIP Plan (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 VIP Plan (HMO) has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays based on the drug tier and pharmacy type. For instance, you'll pay $8.00 for preferred generic drugs at a standard pharmacy, and $0 for preferred generic drugs through mail order. Once your total drug costs reach $2000.00, 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 VIP Plan (HMO) offers a variety of benefits, including inpatient hospital care with a copay, outpatient services, ambulance and emergency services, and coverage for primary care physician visits and mental health services. This plan also covers hearing and vision services, with routine eye exams and hearing exams available, as well as dental services, including oral exams and other dental procedures. This plan also includes benefits for home infusion services, dialysis, and durable medical equipment with coinsurance. Additionally, the plan covers home health services, skilled nursing facilities, and other services such as acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute, with a $225 copay for days 1-7 and no copay for days 8-90, and Inpatient Hospital Psychiatric, with a $250 copay for days 1-7 and no copay for days 8-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $100, Observation Services with a $225 copay, and Ambulatory Surgical Center Services with a $100 copay, but Outpatient Substance Abuse Services are not covered. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered with prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Sharp Direct Advantage VIP Plan (HMO). Ground and Air Ambulance Services have a $150 copay, and there is no coinsurance; however, Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered under the Sharp Direct Advantage VIP Plan (HMO), with a $90 copay for emergency services and $30 copay for urgently needed services. Worldwide emergency services are also covered, with a $90 copay for worldwide emergency and urgent coverage, and a $250 copay for worldwide emergency transportation.
Primary Care See details
The Sharp Direct Advantage VIP Plan (HMO) covers primary care physician services, chiropractic services with a $10 copay for routine care, occupational therapy services with a $30 copay, physician specialist services, mental health specialty services with a $20 copay for individual and group sessions, other health care professionals with a copay between $0 and $10, psychiatric services with a $20 copay for individual and group sessions, physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits, and opioid treatment program services. Podiatry services are not covered.
Preventive Services See details
The Sharp Direct Advantage VIP Plan (HMO) covers preventive services, including Medicare-covered services with no copay, but requires prior authorization and a doctor's referral; however, 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. The plan also covers health education, fitness benefits, remote access technologies (including web/phone-based technologies and nursing hotline), kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visit, all requiring prior authorization.
Hearing Services See details
The Sharp Direct Advantage VIP Plan (HMO) covers hearing exams, routine hearing exams (2 visits per year), and fitting/evaluation for hearing aids (2 visits per year), with no copay. Prescription hearing aids are covered up to $3800 every three years, and OTC hearing aids are covered up to $3800 every three years. However, prescription hearing aids for the inner ear, outer ear, and over-the-ear are not covered.
Vision Services See details
The Sharp Direct Advantage VIP Plan (HMO) covers vision services, including routine eye exams with a limit of one per year. Eyewear benefits include contact lenses, eyeglasses (lenses and frames), and eyeglass lenses, with a maximum plan benefit coverage amount of $400 for contact lenses, eyeglasses (lenses and frames), and a $0 copay for eyeglass lenses and frames.
Dental Services See details
The Sharp Direct Advantage VIP Plan (HMO) covers a range of dental services, including oral exams with a $0-$5 copay, dental x-rays with a limited benefit, other diagnostic dental services with a $0-$5 copay, prophylaxis (cleaning) with a $15 copay, and other preventive dental services with a $0-$150 copay; however, fluoride treatment is not covered. Orthodontic services are also covered, including restorative services with a $20-$425 copay, adjunctive general services with a $0-$50 copay, endodontics with a $0-$475 copay, periodontics with a $0-$450 copay, removable prosthodontics with a $20-$495 copay, fixed prosthodontics with a $30-$425 copay, and oral and maxillofacial surgery with a $0-$65 copay, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered by the Sharp Direct Advantage VIP Plan (HMO). Medicare Part B Insulin Drugs have a $35 copay, while the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Sharp Direct Advantage VIP Plan (HMO), but require prior authorization and a doctor's referral. You will pay 20% coinsurance.
Medical Equipment See details
The Sharp Direct Advantage VIP Plan (HMO) covers Durable Medical Equipment (DME), Prosthetic Devices, and Medical Supplies with a 20% coinsurance and no copay, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and outpatient X-ray services, but lab services are not covered. Diagnostic procedures have no copay, but have at least 15% coinsurance, while outpatient X-ray services have a $10 copay. Therapeutic radiological services have a copay of $60, and diagnostic radiological services have a copay of up to $75.
Home Health Services See details
Home Health Services are covered by the Sharp Direct Advantage VIP Plan (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 not covered under the Sharp Direct Advantage VIP Plan (HMO). Prior authorization and a doctor's referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Sharp Direct Advantage VIP Plan (HMO), but require prior authorization and a doctor referral. There is no copay for days 1-20, a $125 copay for days 21-41, and no copay for days 42-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes acupuncture, covered with a $10 copay for up to 30 treatments per year, and over-the-counter (OTC) items, with a maximum benefit of $150 every three months. The plan does not cover meal benefits, 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, or Self-Directed Personal Assistance Services.
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