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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 Sonoma, San Mateo, San Francisco Counties. 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 $48.00. 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 standard Part D premium is $48.00, which reduces to $36.00 for members qualifying for full Low-Income Subsidy (LIS) support. After 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. During the initial coverage phase, standard pharmacy and standard mail-order costs vary by drug tier. You will pay a $5.00 copay for Tier 1 preferred generics and Tier 5 specialty drugs, and a $40.00 copay for Tier 2 standard generics. Tier 3 preferred brands require 32% coinsurance, while Tier 4 non-preferred drugs carry a 33% coinsurance.
Additional Benefits
The Alignment Health Sutter Advantage +More (HMO) plan offers affordable medical coverage with a $5 copay for primary care visits and a $25 copay for specialists with no coinsurance. For hospital services, inpatient stays require a $275 daily copay for days 1 through 5, while outpatient hospital services carry a $250 copay. Emergency room visits have a $120 copay, whereas urgent care and preventive services are covered with no copay and no coinsurance. This HMO plan also includes essential dental, vision, and hearing benefits, providing routine exams and preventive dental care with no copay or coinsurance. Members receive a $100 eyewear allowance every two years, alongside a $15 monthly reimbursement for over-the-counter items. Additionally, durable medical equipment is covered with no copay and up to 20% coinsurance, though diabetic supplies and hearing aids are not covered.
Inpatient Hospital See details
Inpatient hospital care is covered by Alignment Health Sutter Advantage +More (HMO) with no coinsurance, requiring a $275 daily copay for days 1 through 5 of acute stays and a $120 daily copay for days 1 through 10 of psychiatric stays, with no copay for subsequent days. Non-Medicare-covered stays and hospital upgrades are not covered.
Outpatient Services See details
Alignment Health Sutter Advantage +More (HMO) covers outpatient services with no coinsurance across all covered categories. Under this plan, you will pay a $250 copay for outpatient hospital services, a $100 copay for ambulatory surgical center services, and a $40 copay for outpatient substance abuse individual or group sessions.
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 prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered under the Alignment Health Sutter Advantage +More (HMO) plan, as transportation services to plan-approved or any health-related locations are not covered. Ground and air ambulance services require prior authorization and are covered with a $250 copay and no coinsurance, which is waived if you are admitted to the hospital.
Emergency Services See details
Emergency services are covered by Alignment Health Sutter Advantage +More (HMO) with a $120 copay and no coinsurance, while urgently needed services are available with no copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $7,500 maximum limit, though worldwide emergency transportation is not covered.
Primary Care See details
Alignment Health Sutter Advantage +More (HMO) partially covers primary care, featuring a $5 copay for primary care visits, a $25 copay for specialists, and a $40 copay for psychiatric services, all with no coinsurance. Opioid treatment is covered with a 20% coinsurance and no copay, while podiatry, routine chiropractic, and mental health specialty services are not covered.
Preventive Services See details
Alignment Health Sutter Advantage +More (HMO) covers Medicare-covered zero-dollar preventive services, annual physical exams, and kidney disease education with no copay and no coinsurance. Additional preventive benefits are only partially covered; memory fitness is covered, but health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, 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 devices, and counseling are not covered.
Hearing Services See details
Alignment Health Sutter Advantage +More (HMO) covers one routine hearing exam and one fitting evaluation annually with no deductible, though copay and coinsurance details are not specified. For prescription hearing aids, some services are covered, but in practice, all sub-services—including inner ear, outer ear, and over-the-ear models—as well as over-the-counter hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Alignment Health Sutter Advantage +More (HMO), featuring one routine eye exam every year and a $100 combined maximum for eyewear every two years with no deductibles. While specific copay and coinsurance information is not specified in the plan details, eyewear upgrades are not covered.
Dental Services See details
Alignment Health Sutter Advantage +More (HMO) partially covers dental services, offering preventive care like cleanings and exams with no copay or coinsurance. Covered comprehensive services require copays ranging from $15 to $570 with no coinsurance, while implants, orthodontics, maxillofacial prosthetics, and adjunctive general services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Alignment Health Sutter Advantage +More (HMO) and require prior authorization. Covered Medicare Part B chemotherapy and other drugs have no copay and between no coinsurance and 20% coinsurance, while Part B insulin drugs require a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Alignment Health Sutter Advantage +More (HMO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Alignment Health Sutter Advantage +More (HMO) partially covers medical equipment, as diabetic supplies are not covered. Durable medical equipment requires no copay and ranges from no coinsurance to 20% coinsurance, while prosthetics, medical supplies, and diabetic shoes require no copay and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Alignment Health Sutter Advantage +More (HMO), as diagnostic procedures, tests, and lab services are not covered. Other diagnostic services are covered with no copay and no coinsurance, while covered radiological services require prior authorization and a referral, costing a $150 copay with no coinsurance for diagnostic radiological services, a $15 copay with no coinsurance for outpatient X-rays, and a 20% coinsurance with no copay for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by Alignment Health Sutter Advantage +More (HMO), requiring prior authorization and a doctor referral. Specific copay and coinsurance costs for these covered services are not specified in the plan details.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are technically covered under the Alignment Health Sutter Advantage +More (HMO) plan, but in practice, some services are covered while cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Alignment Health Sutter Advantage +More (HMO), as additional days beyond Medicare-covered stays are not covered. For covered stays, there is no coinsurance, with a $10 copay for days 1-20, a $160 copay for days 21-51, and no copay for days 52-100.
Other Services See details
Alignment Health Sutter Advantage +More (HMO) partially covers Other Services, providing a $15 monthly reimbursement for over-the-counter (OTC) items and digital health technology support with no copay or coinsurance. Acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services are not covered.
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