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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 Palm Beach. 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 $3450.00 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:
Sign up for HealthSun HealthAdvantage Plan (HMO)
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Drug Coverage
The HealthSun HealthAdvantage Plan (HMO) features a $0 prescription drug deductible, allowing your coverage to begin immediately. You will pay no copay for Tier 1 preferred generic and Tier 2 generic medications for up to a three-month supply at preferred, standard, or standard mail-order pharmacies. Tier 6 supplemental drugs also feature no copay for a one-month supply. For higher-tier medications, Tier 3 preferred brand drugs require a $10 copay for a one-month supply. Tier 4 non-preferred drugs carry a $50 copay at preferred pharmacies and standard mail order, or a $55 copay at standard pharmacies. Tier 5 specialty drugs require a 33% coinsurance for a one-month supply.
Additional Benefits
The HealthSun HealthAdvantage Plan (HMO) offers robust coverage with no copays for primary care, specialist visits, preventive care, and urgent care. Inpatient hospital stays require a low $20 daily copay for the first six days and no copay thereafter, while outpatient hospital services feature a budget-friendly $15 copay. Emergency room visits carry a $150 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes generous supplemental benefits, featuring no copays for routine vision and hearing exams, plus up to $300 annually for eyewear and a $2,000 annual hearing aid allowance. Dental care is covered with no copay up to a $5,000 annual limit, and members receive unlimited free transportation to approved locations alongside a $60 monthly over-the-counter allowance. For medical equipment and dialysis, members can expect a standard 20% coinsurance with no copays.
Inpatient Hospital See details
HealthSun HealthAdvantage Plan (HMO) covers inpatient hospital services with no coinsurance, though prior authorization and referrals are required. Acute care stays require a $20 daily copay for days 1 through 6 and no copay for days 7 through 90, while psychiatric stays have no copay; however, additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
HealthSun HealthAdvantage Plan (HMO) covers outpatient hospital and observation services with a $15 copay and no coinsurance, and ambulatory surgical center services with a $10 copay and no coinsurance. Outpatient substance abuse sessions and outpatient blood services are also covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance. Prior authorization and a referral are required to receive these services.
Ambulance and Transportation Services See details
HealthSun HealthAdvantage Plan (HMO) covers ground ambulance services with a $250 copay and air ambulance services with a 20% coinsurance, both requiring prior authorization. Unlimited one-way transportation services to plan-approved locations are covered with no copay and no coinsurance, but transportation to any other health-related location is not covered.
Emergency Services See details
HealthSun HealthAdvantage Plan (HMO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services are available with no copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 maximum benefit with a $150 copay and no coinsurance.
Primary Care See details
HealthSun HealthAdvantage Plan (HMO) offers primary care, specialist, telehealth, mental health, psychiatric, podiatry, and opioid treatment services with no copay and no coinsurance. Physical, occupational, and speech-language therapy services are covered with no coinsurance and a copay of $0 to $5, while chiropractic services are not covered.
Preventive Services See details
HealthSun HealthAdvantage Plan (HMO) preventive services are partially covered with no copays and no coinsurance, although some covered services require prior authorization and referrals. Sub-services that are not covered include the annual physical exam, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs for chemotherapy-related hair loss, weight management programs, adult day health, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, home and bathroom safety modifications, and counseling.
Hearing Services See details
HealthSun HealthAdvantage Plan (HMO) offers partially covered hearing services with no copay and no coinsurance for Medicare-covered exams, routine exams, and fitting evaluations. Up to two prescription hearing aids are covered every year with a $2,000 maximum benefit and no copay or coinsurance, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
HealthSun HealthAdvantage Plan (HMO) offers partially covered vision services with no copay and no coinsurance, including one routine eye exam per year and up to $300 annually for contact lenses and eyeglasses. Other eye exam services and eyewear upgrades are not covered.
Dental Services See details
Dental services are partially covered under the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance up to a $5,000 annual maximum, though prior authorization is required for certain treatments. While exams, cleanings, fillings, and implants are covered, this plan does not cover other diagnostic dental services, other preventive dental services, maxillofacial prosthetics, fixed prosthodontics, or orthodontics.
Home Infusion bundled Services See details
HealthSun HealthAdvantage Plan (HMO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other drugs require no copay and a 0% to 20% coinsurance, while Part B insulin features a copay of $0.00 to $35.00 and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the HealthSun HealthAdvantage Plan (HMO) with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these services.
Medical Equipment See details
HealthSun HealthAdvantage Plan (HMO) covers durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes with a 20% coinsurance and no copay. Diabetic supplies and non-Medicare medical supplies are covered with no copay and no coinsurance, with prior authorization required for most items.
Diagnostic and Radiological Services See details
HealthSun HealthAdvantage Plan (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization and referrals are required. Members pay no copay for lab services and outpatient X-rays, while diagnostic procedures and tests carry a $0 to $15 copay, and other radiological services have copays starting at $0.
Home Health Services See details
Home Health Services are covered by the HealthSun HealthAdvantage Plan (HMO) with no copay and no coinsurance. This benefit requires both a referral and prior authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by HealthSun HealthAdvantage Plan (HMO) with no coinsurance, and while some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered and require a $5 copay.
Skilled Nursing Facility (SNF) See details
HealthSun HealthAdvantage Plan (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $60 daily copay for days 21 through 100. Prior authorization and referrals are required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
HealthSun HealthAdvantage Plan (HMO) other services are partially covered, providing meal benefits for chronic illnesses and up to $60 per month for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture is not covered under this benefit.
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