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Sharp Direct Advantage VIP Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sharp Direct Advantage VIP Plus (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 Plus (HMO) in 2026, please refer to our full plan details page.
Sharp Direct Advantage VIP Plus (HMO) is a HMO plan offered by Sharp Healthcare available for enrollment in 2026 to people living in Sharp Direct Advantage VIP Plus 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 VIP Plus (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 Plus (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 Plus (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 VIP Plus (HMO) plan features an Enhanced Alternative drug benefit with a $350 prescription drug deductible. During the initial coverage phase, standard pharmacy copays for a 30-day supply are $8 for preferred generics, $40 for standard generics, and $90 for preferred brands. Non-preferred drugs require a 29% coinsurance, while specialty drugs have no copay, and standard mail order offers no copay for preferred generics. After 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. Additionally, qualifying for the low-income subsidy reduces your Part D premium to $0. This structured coverage helps beneficiaries manage prescription costs effectively throughout the year.
Additional Benefits
The Sharp Direct Advantage VIP Plus (HMO) plan offers comprehensive coverage with predictable cost-sharing, featuring no coinsurance for inpatient hospital stays and a daily copay of $225 for the first seven days. Outpatient services and emergency care are highly accessible, with outpatient surgery requiring a $100 copay and emergency room visits carrying a $150 copay. Additionally, primary care visits and Medicare-covered preventive services are available with no copay or low copays up to $30. Members also benefit from robust ancillary coverage, including routine vision exams and a $400 annual eyewear allowance with no copay or deductible. Dental care features low copays, such as $15 for cleanings, while hearing benefits include up to a $4,000 hearing aid allowance every three years. The plan further supports daily health needs with a $160 over-the-counter allowance every three months and acupuncture sessions for a $10 copay.
Inpatient Hospital See details
Sharp Direct Advantage VIP Plus (HMO) partially covers inpatient hospital services, featuring a $225 daily copay for days 1 through 7, no copay for days 8 through 90, and no coinsurance. While unlimited additional days for acute care are covered at no copay, this plan does not cover upgrades, non-Medicare-covered stays, or additional psychiatric stay days.
Outpatient Services See details
Outpatient services covered by Sharp Direct Advantage VIP Plus (HMO) include outpatient hospital services with no copay to a $100 copay, ambulatory surgical center services for a $100 copay, and observation services for a $225 copay per stay, all with no coinsurance. Outpatient blood services are covered with no deductible, while outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial hospitalization benefits are covered under the Sharp Direct Advantage VIP Plus (HMO) plan, requiring a doctor referral and prior authorization. Specific copay and coinsurance costs are not detailed in the plan summary, but the service is covered when these clinical requirements are met.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by Sharp Direct Advantage VIP Plus (HMO), which features a $150 copay and no coinsurance for covered ground and air ambulance services, subject to prior authorization. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Sharp Direct Advantage VIP Plus (HMO) covers emergency services with a $150 copay and urgently needed services with a $30 copay, with no coinsurance for either service. Worldwide emergency and urgent care 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 VIP Plus (HMO) partially covers primary care benefits, as podiatry services are not covered. Covered services require no coinsurance, with copays ranging from no copay up to $30 per visit for chiropractic care, therapies, psychiatric services, and mental health sessions.
Preventive Services See details
Sharp Direct Advantage VIP Plus (HMO) partially covers preventive services, offering Medicare-covered zero-dollar preventive services with no copay, alongside health education, memory fitness, and remote access technologies. However, several services are not covered under this plan, including annual physical exams, in-home safety assessments, medical nutrition therapy, and weight management programs.
Hearing Services See details
Hearing services are covered by Sharp Direct Advantage VIP Plus (HMO) with no deductible and no specified copays or coinsurance, including up to two routine exams and hearing aid fittings annually. Prescription hearing aids are partially covered up to a $4,000 maximum every three years, though inner ear, outer ear, and over-the-ear devices are not covered.
Vision Services See details
Vision services are partially covered by Sharp Direct Advantage VIP Plus (HMO), which includes one routine eye exam per year and up to $400 annually for contact lenses, eyeglass lenses, and frames with no copay, coinsurance, or deductible. Eyewear upgrades are not covered, and eye exams require prior authorization and a doctor referral.
Dental Services See details
Dental services are partially covered by Sharp Direct Advantage VIP Plus (HMO) with no coinsurance and copays ranging from no copay up to $495.00, while fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Covered benefits include cleanings for a $15.00 copay, oral exams with no copay to a $5.00 copay, and Medicare-covered dental services for a $35.00 copay.
Home Infusion bundled Services See details
Sharp Direct Advantage VIP Plus (HMO) covers home infusion bundled services with prior authorization, featuring a $35 copay and no coinsurance for Medicare Part B insulin drugs. Medicare Part B chemotherapy, radiation, and other Part B drugs require no copay and carry a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Sharp Direct Advantage VIP Plus (HMO) covers Dialysis Services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Sharp Direct Advantage VIP Plus (HMO) partially covers medical equipment, with diabetic supplies not covered under the plan. Covered services, including durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, require a 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Sharp Direct Advantage VIP Plus (HMO), with lab services excluded from coverage. Covered diagnostic procedures require a 15% coinsurance and no copay, while covered radiological services carry no coinsurance and copays ranging from no copay up to $75.
Home Health Services See details
Home health services are covered by the Sharp Direct Advantage VIP Plus (HMO) plan, although members are required to obtain prior authorization and a doctor referral first.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered by the Sharp Direct Advantage VIP Plus (HMO) plan with no copay or coinsurance, but in practice some services are covered while Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Sharp Direct Advantage VIP Plus (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and days 42 through 100, and a $125 daily copay for days 21 through 41. Prior authorization and a doctor referral are required, and additional days beyond Medicare-covered SNF stays are not covered.
Other Services See details
Other Services are partially covered by Sharp Direct Advantage VIP Plus (HMO), which excludes meal benefits, Dual Eligible SNPs, and Naloxone under over-the-counter (OTC) items. Covered acupuncture requires a $10 copay and no coinsurance for up to 30 treatments per year, while OTC items are available with no copay or coinsurance up to a $160 allowance every three months.
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