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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 Cruz 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 $59.00. 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 different copays or coinsurance amounts depending on the drug tier and pharmacy type. For example, you will pay a $5 copay for preferred generic drugs at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D 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, including coverage for inpatient hospital stays with varying copays, outpatient services, and partial hospitalization. The plan covers emergency services with a $90 copay and primary care with a $5 copay, along with specialist and psychiatric services. Vision services include routine eye exams and eyewear, while dental services cover various procedures with associated copays. Additional benefits include home health services with no copay, and skilled nursing facility stays with copays depending on the length of stay. The plan also offers hearing exams, medical equipment coverage, and home infusion services, with some services requiring prior authorization. Other covered services include ambulance, dialysis, and diagnostic/radiological services.
Inpatient Hospital See details
Inpatient Hospital benefits include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization and a doctor referral. For Inpatient Hospital-Acute, you will pay a $225 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $120 copay for days 1-10, and no copay for days 11-90.
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 substance abuse sessions. Outpatient blood services are also covered, with a waived three-pint deductible.
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 benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Sutter Advantage (HMO) plan. Both ground and air ambulance services have a $250 copay, with no coinsurance, and 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 by the Alignment Health Sutter Advantage (HMO) plan. Emergency Services have a $90 copay and no coinsurance, while Urgently Needed Services have no copay and no coinsurance. Worldwide Emergency Services has a maximum plan benefit of $7,500, and 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 have a $20 copay, and Psychiatric Services have a $40 copay for both individual and group sessions. The plan also covers Occupational Therapy Services and Physical Therapy and Speech-Language Pathology Services with no copay and no coinsurance, but authorization and referrals are required. Chiropractic Services, Individual and Group Sessions for Mental Health Specialty Services, and Podiatry Services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services, annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, EKG following a Welcome Visit, and other preventive services. 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.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription 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. The plan covers eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, with a combined maximum benefit of $100 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 treatments. Restorative services have a copay between $20 and $400, while endodontics has a copay between $25 and $350, and periodontics has a copay between $15 and $550. Prosthodontics (removable) has a copay between $20 and $570, and prosthodontics (fixed) has a copay between $40 and $400. Oral and maxillofacial surgery has a copay between $25 and $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, but 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 by the Alignment Health Sutter Advantage (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 0-20% coinsurance and no copay, Prosthetics/Medical Supplies with 20% coinsurance and no copay, and Diabetic Therapeutic Shoes/Inserts with 20% 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 Alignment Health Sutter Advantage (HMO). Diagnostic Procedures/Tests and Lab Services are not covered, while Diagnostic Radiological Services have a copay of $150, Therapeutic Radiological Services have a coinsurance of 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 or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor referral. You will have no copay for days 1-20, a $160 copay for days 21-62, and no copay for days 63-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items with a maximum benefit of $15.00 per month, as well as Nicotine Replacement Therapy (NRT) and Naloxone. 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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