| | VIP Plan
(HMO) | Gold Card (HMO) | Platinum Card (HMO) |
| Plan overview
|
| Monthly plan premium | $0 | $0 | $51 |
| Deductible | $0 |
| Annual out-of-pocket maximum | $2,900 yearly limit for services you receive from in-network providers |
| Doctor visits
|
| Primary care physician visit | $0 | $5 | $5 |
| Specialist visit | $0 | $20 | $20 |
| Preventive care | $0 |
| Lab services / X-rays | $0 / $10 | $0 / $10 | $0 / $0 |
| Diagnostic radiology services (e.g., MRIs) | $75 copay
$0 for diagnostic mammogram | $75 copay
$0 for diagnostic mammogram | 15% coinsurance
$0 for diagnostic mammogram |
| Physical therapy | $30 | $20 | $30 |
| Outpatient rehabilitation | $30 | $20 | $30 |
| Hospital visits and emergencies
|
| Inpatient hospital coverage | $225/day for days 1–7
$0/day for days 8+ | $150/day for days 1–8 $0/day for days 9+ |
| Outpatient hospital coverage | $0–100 | $20–225 | $20–$175 |
| Emergency care | $90 |
| Urgently needed services | $30 ($90 for worldwide urgent care and emergency coverage) |
| Supplemental benefits
|
| Hearing aids | $3,800 allowance every 36 months | $4,000 allowance every 36 months | $4,800 allowance every 36 months |
| Silver&Fit®
Fitness Benefit | $0 | $0 | $0 |
| Chiropractic care | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) | $10, limit 30 visits per year (combined) |
| Acupuncture |
Over-the-counter (OTC) items Loaded to your Sharp Health Plan Advantage card | Up to $150 per quarter | Up to $150 per quarter | Up to $170 per quarter |
| Dental |
| Delta Dental DHMO | $0 monthly premium | $13 monthly premium | $0 monthly premium |
| Delta Dental PPO | $40 monthly premium | $40 monthly premium | $40 monthly premium |
| Vision |
| Frames or Contacts
| $400 (every 12 months) | $300 (every 12 months) | $300 (every 12 months) |
| Routine eye exam | $0 (every 12 months) | $0 (every 12 months) | $0 (every 12 months) |
| Medicare Part D drugs: initial coverage
|
| Retail: 1-month supply |
| Tier 1 (Preferred Generic) | $2 |
| Tier 2 (Generic) | $8 for VIP Plan and Gold Card; $5 for Platinum only
|
| Tier 3 (Preferred Brand) | $40 |
| Tier 4 (Non-preferred Brand) | $90 |
| Tier 5 (Specialty) | 33% of the cost |
| Tier 6 (Select Care)
| $0 |
| Mail order: 100-day supply
|
| Tier 1 (Preferred Generic) | $0 |
| Tier 2 (Generic) | $0
|
| Tier 3 (Preferred Brand) | $80 |
| Tier 4 (Non-preferred Brand) | $180
|
| Tier 5 (Specialty) | Not offered |
| Tier 6 (Select Care)
| $0 |