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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 2025, 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 5 out of 5 stars in 2025.
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.
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 $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) has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay varying copays or coinsurance amounts depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay, while standard generic drugs have a $20 copay at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. This plan's premium may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The HealthSun HealthAdvantage Plan (HMO) offers comprehensive coverage with no copays for many services, including inpatient hospital stays, outpatient services, primary care, preventive services, hearing exams, vision services, dental services, home health, and medical equipment. The plan also covers ambulance services, with a $75 copay for ground transport and 20% coinsurance for air ambulance. Emergency services have a $50 copay, and the plan provides additional benefits like OTC items with a monthly allowance and skilled nursing facility stays with a copay after 20 days.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both with no copay for Medicare-covered stays, but Non-Medicare-covered Stays and Upgrades for Inpatient Hospital-Acute, as well as Additional Days and Non-Medicare-covered Stays for Inpatient Hospital Psychiatric are not covered. The plan also covers 3 additional days per benefit period for Inpatient Hospital-Acute.
Outpatient Services See details
Outpatient services include outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, ambulatory surgical center services, and outpatient blood services have no copay. Outpatient substance abuse services including individual and group sessions have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with no copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the HealthSun HealthAdvantage Plan (HMO). Ground ambulance services have a $75 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location have no copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $50 copay. Urgently Needed Services are covered with no copay, while Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $50 copay.
Primary Care See details
The HealthSun HealthAdvantage Plan (HMO) covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, individual and group mental health and psychiatric sessions, physical therapy and speech-language pathology services, and additional telehealth benefits have no copay, while occupational therapy services, podiatry services, and other services have a $0 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive services are covered, but annual physical exams are not covered. Medicare-covered preventive services, kidney disease education services, and other preventive services including glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit have no copay. Additional preventive services are covered, including health education, personal emergency response systems (PERS), alternative therapies, therapeutic massage, nutritional/dietary benefits, remote access technologies, fitness benefits, and home and bathroom safety devices and modifications; some of these services may have a copay.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered with no copay. Prescription hearing aids (all types) are covered with a maximum benefit of $2000 per year, and prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The HealthSun HealthAdvantage Plan (HMO) covers vision services including routine eye exams, with no copay. Eyewear benefits are also covered, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames, all with no copay, but upgrades are not covered.
Dental Services See details
Dental services include coverage for oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), implant services, and oral and maxillofacial surgery, all with no copay, but with visit limits. Maxillofacial prosthetics, prosthodontics (fixed), and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the HealthSun HealthAdvantage Plan (HMO). For Medicare Part B Insulin Drugs, there is a copay of $0.00 - $35.00. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the HealthSun HealthAdvantage Plan (HMO), but prior authorization and a doctor referral are required. There is no copay for this service.
Medical Equipment See details
Medical Equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered by this plan. Durable Medical Equipment (DME) has no copay and no coinsurance, but requires authorization and has preferred vendors. Prosthetic Devices and Medical Supplies have no copay and no coinsurance. Diabetic Equipment has no copay and no coinsurance, but also requires prior authorization.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests and Outpatient X-Ray Services have no copay, while Lab Services and Diagnostic and Therapeutic Radiological Services have a copay of $0.
Home Health Services See details
Home Health Services are covered by the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the HealthSun HealthAdvantage Plan (HMO). Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered under the HealthSun HealthAdvantage Plan (HMO), with a doctor's referral and prior authorization required. For days 1-20, there is no copay, and for days 21-100, there is a $20 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The HealthSun HealthAdvantage Plan (HMO) covers over-the-counter (OTC) items with no copay, and a maximum benefit coverage amount of $80.00 per month. Acupuncture, 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, and Self-Directed Personal Assistance Services are not covered.
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Every year, Medicare evaluates plans based on a 5-star rating system.
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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