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HealthSun HealthAdvantage Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HealthSun HealthAdvantage Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HealthSun HealthAdvantage Plan (HMO) in 2026, please refer to our full plan details page.
HealthSun HealthAdvantage Plan (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Miami-Dade. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that HealthSun HealthAdvantage 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 HealthSun HealthAdvantage 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 HealthSun HealthAdvantage 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. Additionally, this plan comes with a Part B Premium reduction of $50.00. You must continue to pay paying your reduced 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 $1500.00 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 HealthSun HealthAdvantage Plan (HMO) features a zero-dollar drug deductible, meaning your prescription coverage begins immediately. You will pay no copay for Tier 1 preferred generic, Tier 2 generic, and Tier 6 supplemental drugs at preferred, standard, and standard mail-order pharmacies. Additionally, Tier 3 preferred brand drugs carry no copay for a one-month supply at preferred pharmacies and standard mail order, with only a ten-dollar copay at standard pharmacies. For Tier 4 non-preferred drugs, the one-month copay is thirty dollars at preferred pharmacies and standard mail order, or thirty-five dollars at standard pharmacies. Tier 5 specialty drugs require a thirty-three percent coinsurance at all participating pharmacy types. This structure ensures low out-of-pocket costs for generic and preferred brand medications under this Medicare Advantage plan.
Additional Benefits
The HealthSun HealthAdvantage Plan (HMO) offers comprehensive healthcare coverage with no copays and no coinsurance for a wide range of core medical services. This includes inpatient hospital stays, outpatient services, primary and specialist visits, and preventive care. Members also enjoy no-cost supplemental benefits, such as dental coverage up to a $5,000 annual limit, a $400 annual eyewear allowance, and up to $2,000 annually for prescription hearing aids. While many services feature no out-of-pocket costs, certain medical needs require copayments or coinsurance. Emergency room visits and ground ambulance rides carry a $75 copay, while dialysis and air ambulance services require a 20% coinsurance. Additionally, Medicare Part B drugs may incur up to a 20% coinsurance, and skilled nursing facility stays require a $60 daily copay after the first 20 days.
Inpatient Hospital See details
HealthSun HealthAdvantage Plan (HMO) covers inpatient acute and psychiatric hospital stays with no copay and no coinsurance, although prior authorization and referrals are required. This benefit is partially covered, as upgrades, additional days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HealthSun HealthAdvantage Plan (HMO) covers outpatient services, including outpatient hospital, ambulatory surgical center, substance abuse, and blood services, with no copay and no coinsurance. Prior authorization and referrals are required for most of these covered services.
Partial Hospitalization See details
Partial hospitalization is covered under the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance. Members are required to obtain prior authorization and a referral to access these services.
Ambulance and Transportation Services See details
HealthSun HealthAdvantage Plan (HMO) covers ground ambulance services with a $75 copay (coinsurance applies) and air ambulance services with a 20% coinsurance (copay applies). Transportation services are partially covered, offering unlimited rides to plan-approved locations with no copay and no coinsurance, while trips to any health-related location are not covered.
Emergency Services See details
HealthSun HealthAdvantage Plan (HMO) covers emergency services with a $75 copay and no coinsurance, with the copay waived if admitted to the hospital within 24 hours. Urgently needed services are covered with no copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum with a $75 copay and no coinsurance.
Primary Care See details
HealthSun HealthAdvantage Plan (HMO) covers primary care, specialist visits, mental health, and physical therapy services with no copay and no coinsurance. While most of these medical services feature zero out-of-pocket costs, chiropractic services are not covered in practice.
Preventive Services See details
HealthSun HealthAdvantage Plan (HMO) partially covers preventive services with no copay and no coinsurance, though some services require referrals and prior authorization. Services not covered under this benefit include annual physical exams, weight management programs, medical nutrition therapy, in-home safety assessments, and adult day health services.
Hearing Services See details
Hearing Services are covered by the HealthSun HealthAdvantage Plan (HMO) with no copay, no coinsurance, and no deductible for Medicare-covered exams, routine exams, and fitting evaluations. Up to two prescription hearing aids are covered annually with no copay or coinsurance up to a $2,000 maximum, but OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by the HealthSun HealthAdvantage Plan (HMO), featuring no copay and no coinsurance for one routine eye exam per year and eyewear, including contacts and eyeglasses, up to a $400 annual limit. Other eye exam services and eyewear upgrades are not covered under this plan.
Dental Services See details
HealthSun HealthAdvantage Plan (HMO) offers partially covered dental services with no copay and no coinsurance up to a $5,000 annual maximum, though prior authorization is required for several procedures. Sub-services that are not covered include other diagnostic dental, other preventive dental, maxillofacial prosthetics, fixed prosthodontics, and orthodontics.
Home Infusion bundled Services See details
HealthSun HealthAdvantage Plan (HMO) covers home infusion bundled services with no copay, although prior authorization and step therapy are required. Medicare Part B chemotherapy, radiation, and other drugs require a 0% to 20% coinsurance, while Medicare Part B insulin is covered with no coinsurance and a copay of $0 to $35.
Dialysis Services See details
Dialysis Services are covered by the HealthSun HealthAdvantage Plan (HMO) with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these covered services.
Medical Equipment See details
HealthSun HealthAdvantage Plan (HMO) covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copay and no coinsurance. Prior authorization is required for these covered services, and some benefits may be limited to specified manufacturers or preferred vendors.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance for lab services, diagnostic procedures, X-rays, and therapeutic radiological services. Both prior authorization and referrals are required for these benefits.
Home Health Services See details
Home health services are covered under the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance. To receive these services, both a referral and prior authorization are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the HealthSun HealthAdvantage Plan (HMO) require no copay and no coinsurance, but only some services are covered in practice as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HealthSun HealthAdvantage Plan (HMO) with no coinsurance, requiring no prior three-day hospital stay but subject to prior authorization and referral requirements. There is no copay for days 1 through 20, followed by a $60 daily copay for days 21 through 100, though additional days beyond the standard Medicare limit are not covered.
Other Services See details
Other services are partially covered by HealthSun HealthAdvantage Plan (HMO), featuring no copay and no coinsurance for chronic illness meal benefits and up to $90 per month in over-the-counter (OTC) items, while acupuncture is not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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