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Alignment Health Sutter Advantage +More (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Sutter Advantage +More (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 +More (HMO) in 2026, please refer to our full plan details page.
Alignment Health Sutter Advantage +More (HMO) is a HMO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in Santa Clara County. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Alignment Health Sutter Advantage +More (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 +More (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 +More (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.00. 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 +More (HMO) plan offers an Enhanced Alternative drug benefit with no prescription drug deductible. The plan features a Part D premium of $49.00, which lowers to $37.00 for members who qualify for full Extra Help. During the initial coverage phase, you will pay set copays or coinsurance rates until your total drug costs reach $2,100.00. At standard retail or standard mail pharmacies, Tier 1 preferred generics and Tier 5 specialty drugs carry a $5.00 copay, while Tier 2 standard generics require a $40.00 copay. Tier 3 preferred brands and Tier 4 non-preferred drugs are subject to 32% and 33% coinsurance, respectively. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs.
Additional Benefits
The Alignment Health Sutter Advantage +More (HMO) plan offers comprehensive medical coverage with predictable copayments and no coinsurance for many key services. Members benefit from a $5 copay for primary care visits, a $25 copay for specialist visits, and no copay for urgent care or Medicare-covered preventive services. Emergency room visits carry a $120 copay, and inpatient hospital stays require a $275 daily copay for the first five days, with no coinsurance for either service. Additional benefits include annual routine hearing and vision exams, along with a $100 eyewear allowance every two years and no deductibles. Dental care features no copay for preventive services and fixed copays for comprehensive care, while members also receive a $15 monthly reimbursement for over-the-counter items. Although transportation and hearing aids are not covered, the plan provides robust cost savings with no coinsurance required for most outpatient and skilled nursing services.
Inpatient Hospital See details
Alignment Health Sutter Advantage +More (HMO) offers partially covered inpatient hospital benefits with no coinsurance, excluding acute care upgrades and non-Medicare-covered stays. Acute care requires a $275 daily copay for days 1 to 5 (no copay for days 6 to 90), while psychiatric care has a $120 daily copay for days 1 to 10 (no copay for days 11 to 90).
Outpatient Services See details
Outpatient services are covered by Alignment Health Sutter Advantage +More (HMO), featuring a $325 copay for outpatient hospital services and a $100 copay for ambulatory surgical center services, with no coinsurance for either. Outpatient substance abuse sessions require a $40 copay and no coinsurance, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Alignment Health Sutter Advantage +More (HMO) covers partial hospitalization benefits with a $55 copay and no coinsurance. These covered services require a doctor referral and prior authorization.
Ambulance and Transportation Services See details
Alignment Health Sutter Advantage +More (HMO) covers ground and air ambulance services with a $250 copay and no coinsurance, and this copay is waived if you are admitted to the hospital. Transportation services to plan-approved or any health-related locations are not covered under this plan.
Emergency Services See details
Alignment Health Sutter Advantage +More (HMO) covers emergency services with a $120 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $7,500 maximum, though worldwide emergency transportation is not covered.
Primary Care See details
Alignment Health Sutter Advantage +More (HMO) covers primary care visits with a $5 copay and no coinsurance, specialist visits with a $25 copay and no coinsurance, and psychiatric sessions with a $40 copay and no coinsurance. Podiatry is not covered, chiropractic care is partially covered because routine chiropractic care is not covered, and while some mental health specialty services are covered, individual and group sessions are not.
Preventive Services See details
Preventive services are partially covered by Alignment Health Sutter Advantage +More (HMO), featuring no copay and no coinsurance for Medicare-covered zero-dollar preventive services. However, the plan does not cover health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, bathroom safety, and counseling.
Hearing Services See details
Hearing services are covered by Alignment Health Sutter Advantage +More (HMO), which includes one routine hearing exam and one fitting or evaluation for hearing aids every year with no deductible. Prescription hearing aids and over-the-counter (OTC) hearing aids are not covered under this plan.
Vision Services See details
Vision services are partially covered by Alignment Health Sutter Advantage +More (HMO), which provides one routine eye exam annually and a $100 combined eyewear allowance every two years with no deductible and no specified copay or coinsurance. While routine exams, contacts, and lenses are covered, upgrades are not covered.
Dental Services See details
Alignment Health Sutter Advantage +More (HMO) dental services are partially covered, with adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics excluded from coverage. Preventive services are offered with no copay and no coinsurance, while covered comprehensive services require copays ranging from $15.00 to $570.00 and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Alignment Health Sutter Advantage +More (HMO) with prior authorization and step therapy. Covered Medicare Part B insulin drugs require a $35 copay and range from no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and range from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Alignment Health Sutter Advantage +More (HMO) with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to access these services.
Medical Equipment See details
Medical equipment is partially covered by the Alignment Health Sutter Advantage +More (HMO) plan, as diabetic supplies are not covered. Covered durable medical equipment has no copay and no coinsurance to 20% coinsurance, while prosthetics, medical supplies, and diabetic therapeutic shoes or inserts require no copay and 20% coinsurance.
Diagnostic and Radiological Services See details
Alignment Health Sutter Advantage +More (HMO) partially covers Diagnostic and Radiological Services, though diagnostic procedures, tests, and lab services are not covered. Covered radiological services require prior authorization and a doctor referral, carrying a $150 copay and no coinsurance for diagnostic radiology, a 20% coinsurance and no copay for therapeutic radiology, and a $15 copay and no coinsurance for outpatient X-rays.
Home Health Services See details
Home Health Services are covered by Alignment Health Sutter Advantage +More (HMO), requiring both a doctor referral and prior authorization for members to access care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health Sutter Advantage +More (HMO) plan, with no coverage provided for cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Alignment Health Sutter Advantage +More (HMO) partially covers Skilled Nursing Facility (SNF) services, as additional days beyond Medicare-covered SNF are not covered. Covered days require prior authorization and a doctor referral, and feature no coinsurance with a copay of $10 for days 1-20, $160 for days 21-57, and no copay for days 58-100.
Other Services See details
Other Services are partially covered by Alignment Health Sutter Advantage +More (HMO), which provides Digital Health Technology Support and a $15 monthly reimbursement for over-the-counter (OTC) items. Acupuncture, meal benefits, and highly integrated dual-eligible SNP services are not covered.
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