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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 Santa Clara County. 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 $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 (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy. For example, standard generic drugs have a $40 copay, while preferred brand drugs have a $100 copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. This plan also offers a Part D premium reduction for those who qualify for the low-income subsidy, with no copay.
Additional Benefits
The Alignment Health Sutter Advantage (HMO) plan offers comprehensive coverage with varying costs. Inpatient hospital stays have copays, while outpatient services have copays for hospital and substance abuse. Emergency services have a copay, while urgently needed services have no copay. The plan covers primary care with a $5 copay and specialist visits with a $20 copay. Additional benefits include coverage for vision, dental, and hearing services, with specific copays and limitations. The plan also provides coverage for home infusion, dialysis, medical equipment, and skilled nursing facilities, each with its own cost-sharing structure.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $225 for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $120 for days 1-10 and no copay for days 11-90 for Inpatient Hospital Psychiatric. Additional days are covered for Inpatient Hospital-Acute, and Non-Medicare-covered stays and upgrades are not covered. Additional days are covered for Inpatient Hospital Psychiatric, and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services and outpatient substance abuse services, with a $325 copay for outpatient hospital services and a $40 copay for individual and group outpatient substance abuse sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Alignment Health Sutter Advantage (HMO) plan, with a $55 copay. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Sutter Advantage (HMO) plan. Ground and Air Ambulance Services have a $250 copay, with no coinsurance, and the copay is waived if admitted to the hospital, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered. Emergency Services have a $90 copay and no coinsurance, while Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $7500. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health Sutter Advantage (HMO) plan covers Primary Care Physician Services with a $5 copay, Physician Specialist Services with a $20 copay, and Psychiatric Services with a $40 copay for individual and group sessions. Chiropractic Services, Individual and Group Sessions for Mental Health Specialty Services, Podiatry Services, and Routine Chiropractic Care are not covered. Occupational Therapy and Physical Therapy/Speech-Language Pathology Services have no copay or coinsurance. Opioid Treatment Program Services are covered with a 20% coinsurance.
Preventive Services See details
Preventive services, including annual physical exams, are covered by Alignment Health Sutter Advantage (HMO). Additional preventive services such as 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 (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered.
Hearing Services See details
Hearing exams and fitting/evaluation for hearing aids are covered, with one routine hearing exam and one fitting/evaluation per year. 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, and eyewear, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames, with a combined maximum benefit of $100.00 every two years; upgrades are not covered.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment. 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 has 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, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis services are covered, with a 20% coinsurance and require prior authorization and a doctor's referral. The plan has a minimum and maximum coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered, with varying costs depending on the specific service. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with no copay for all diagnostic services, but diagnostic procedures/tests and lab services are not covered. Outpatient X-Ray services have a $15 copay, while diagnostic radiological services have a copay of at most $150, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but prior authorization and a referral are required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically 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 this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Alignment Health Sutter Advantage (HMO) plan, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, for days 21-57, the copay is $160, and for days 58-100, there is no copay. 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, with a maximum plan benefit of $15.00 every month, and Digital Health Technology Support; however, 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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