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Alignment Health Sutter Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Sutter Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health Sutter Advantage (HMO) in 2025, please refer to our full plan details page.
Alignment Health Sutter Advantage (HMO) is a HMO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in Sacramento, Placer & Yolo Counties. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Alignment Health Sutter Advantage (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 Alignment Health Sutter Advantage (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 Alignment Health Sutter Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $19.00. 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 $4900.00 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 Alignment Health Sutter Advantage (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay for your prescriptions. For example, you will pay a $5 copay for preferred generic drugs at a standard pharmacy or through the mail, and a $100 copay for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. If you qualify for the low-income subsidy, you will pay $0 for Part D drugs.
Additional Benefits
The Alignment Health Sutter Advantage (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services, including substance abuse treatment, have copays. Emergency services have a copay, and primary care visits cost $5. This plan also covers preventive services, including hearing and vision services, with routine exams and eyewear benefits. Dental services, home infusion, and dialysis services are covered with copays or coinsurance. Other benefits include ambulance, home health, and skilled nursing facility services with specific cost structures.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $150 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you'll pay a $120 copay for days 1-10, and no copay for days 11-90. Additional days are covered for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a limit of 40 days for the latter. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered under the Alignment Health Sutter Advantage (HMO) plan. Outpatient hospital services have a $195 copay, while individual and group sessions for outpatient substance abuse have a copay of $40.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health Sutter Advantage (HMO) plan, but requires prior authorization and a doctor's referral. The copay for this service is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Sutter Advantage (HMO) plan. Medicare-covered ground and air ambulance services have a $250 copay, with no coinsurance, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services are covered by the Alignment Health Sutter Advantage (HMO) plan, with a $90 copay and no coinsurance, and Urgently Needed Services are covered with no copay and no coinsurance. Worldwide Emergency Services are covered with a maximum plan benefit coverage of $7,500, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health Sutter Advantage (HMO) plan covers primary care services, with a $5 copay for primary care physician services. The plan also covers occupational therapy services, physical therapy, and speech-language pathology services with no copay or coinsurance, but requires prior authorization and a referral. Physician specialist services have a $25 copay, while mental health specialty services and podiatry services are not covered. Additionally, the plan offers additional telehealth benefits and covers Opioid Treatment Program Services with a 20% coinsurance.
Preventive Services See details
Preventive Services are covered under the Alignment Health Sutter Advantage (HMO) plan, including Medicare-covered services with prior authorization, an annual physical exam, and additional preventive services. Additional services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, 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, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. The plan also covers Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (with prior authorization), Digital Rectal Exams, EKG following Welcome Visit, and a Fitness Benefit that offers Memory Fitness.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year; however, prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health Sutter Advantage (HMO) plan covers vision services, including routine eye exams once per year. Eyewear is covered up to a combined maximum of $100 every two years, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, with a limit on the number of pairs or frames provided. Upgrades are not covered.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments, but require prior authorization and a doctor referral. Restorative services have a copay of $20-$400, endodontics have a copay of $25-$350, periodontics have a copay of $15-$550, prosthodontics, removable have a copay of $20-$570, prosthodontics, fixed have a copay of $40-$400, and oral and maxillofacial surgery have a copay of $25-$250. Adjunctive General Services, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and between 0-20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered, with a coinsurance of 20%. Prior authorization and a doctor referral are required for coverage.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, Prosthetics/Medical Supplies with 20% coinsurance and no copay, and Diabetic Equipment with coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Alignment Health Sutter Advantage (HMO) plan, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Alignment Health Sutter Advantage (HMO) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor's referral. There is no copay for days 1-20 and days 52-100, but there is a $160 copay for days 21-51; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $15.00 per month. Acupuncture, Meal Benefit, 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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