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HealthSun HealthAdvantage Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for HealthSun HealthAdvantage Plus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on HealthSun HealthAdvantage Plus (HMO) in 2025, please refer to our full plan details page.
HealthSun HealthAdvantage Plus (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 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 HealthSun HealthAdvantage 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 HealthSun HealthAdvantage 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. Additionally, this plan comes with a Part B Premium reduction of $174.70. 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 Plus (HMO)
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Drug Coverage
The HealthSun HealthAdvantage Plus (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay varying copays or coinsurance depending on the drug tier and pharmacy type. For example, preferred generic drugs have no copay, while standard generic drugs have a $10 copay. For preferred brand drugs, you will pay a $30 copay at a preferred pharmacy and a $35 copay at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The HealthSun HealthAdvantage Plus (HMO) plan offers comprehensive coverage with no copay for many services, including inpatient hospital stays, outpatient observation services, ambulance transportation to plan-approved locations, emergency services, primary care, preventive services, hearing exams, eye exams, eyewear, dental services, dialysis services, medical equipment, home health services, and skilled nursing facilities (days 1-20). The plan also covers outpatient services, with a $75 copay, and ground ambulance services with a $150 copay. Additional benefits include coverage for hearing aids (up to $2000/year), vision services (up to $200), and a monthly OTC benefit (up to $55). Some services may require prior authorization or doctor referrals.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with no copay for Medicare-covered stays. Additional days for Inpatient Hospital-Acute are also covered. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $75 copay, observation services with no copay, ambulatory surgical center services with no copay, outpatient substance abuse services with no copay for individual and group sessions, and outpatient blood services with no copay. Prior authorization and doctor referrals are required for some services.
Partial Hospitalization See details
Partial Hospitalization is covered with no copay, but requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by HealthSun HealthAdvantage Plus (HMO). Ground ambulance services have a $150 copay, while air ambulance services have a 20% coinsurance. Transportation to plan-approved health-related locations has no copay, and other transportation services are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by HealthSun HealthAdvantage Plus (HMO). Emergency Services and Worldwide Emergency Coverage, Urgent Coverage, and Transportation have a $120 copay, while Urgently Needed Services have no copay; all services have no coinsurance.
Primary Care See details
The HealthSun HealthAdvantage Plus (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, physician specialist services, and additional telehealth benefits have no copay. Occupational therapy services have a $15 copay, and physical therapy and speech-language pathology services have a copay between $0 and $15.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, and additional preventive services, including health education, alternative therapies, therapeutic massage, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit with no copay. 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, adult day health services, 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.
Hearing Services See details
The HealthSun HealthAdvantage Plus (HMO) plan covers hearing exams with no copay, and also covers routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a maximum plan benefit of $2000 per year, but inner ear, outer ear, and over-the-ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams and eyewear have no copay, and eyewear has a combined maximum benefit of $200.
Dental Services See details
Dental services are covered under the HealthSun HealthAdvantage Plus (HMO) plan. You will have no copay for Medicare dental services, oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered. The plan has a $2,000 maximum benefit per year.
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 this plan. For Medicare Part B Insulin Drugs, there is a copay of $0-$35; for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0-20%.
Dialysis Services See details
Dialysis Services are covered, with a doctor referral and prior authorization required. There is no copay for this benefit.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has no copay or coinsurance, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts have no copay, and no coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $75, Lab Services with no copay, Diagnostic Radiological Services with a copay up to $75, Therapeutic Radiological Services with a copay up to $60, and Outpatient X-Ray Services with no copay. Prior authorization and a doctor referral are required.
Home Health Services See details
Home Health Services are covered by the HealthSun HealthAdvantage Plus (HMO) plan with no copay and no coinsurance. However, 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 Plus (HMO) plan. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by HealthSun HealthAdvantage Plus (HMO), but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $60 copay for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, which have no copay, and a meal benefit, which also has no copay; 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. The plan also offers a monthly OTC benefit with a maximum of $55.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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