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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 Sonoma, San Mateo, San Francisco 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 $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 $3900.00 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 you use. For example, generic drugs have a $5 copay at standard and mail order pharmacies, while non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Alignment Health Sutter Advantage (HMO) plan offers a variety of benefits with varying cost structures. Inpatient hospital stays have copays, while outpatient services have copays for specific services like hospital visits and substance abuse treatment. Emergency services have a copay, and primary care visits have a $5 copay, with specialist visits costing $25. Preventive services, hearing exams, and vision exams are covered, with specific limitations on eyewear coverage. Dental services cover various procedures with copays. The plan also covers home infusion, dialysis, and medical equipment with copays or coinsurance. Other benefits include home health services, skilled nursing facility stays, and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, 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 for Inpatient Hospital-Acute are covered with no limit, while additional days for Inpatient Hospital Psychiatric are limited to 40 days. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Non-Medicare-covered stay for Inpatient Hospital Psychiatric is not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered with a $250 copay for outpatient hospital services and a $40 copay for individual and group 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, but requires prior authorization and a doctor's referral. You will have a $55 copay for this benefit.
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. Emergency Services have a $90 copay and no coinsurance. Worldwide Emergency Services has a maximum plan benefit coverage of $7,500. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services have a $5 copay, while Physician Specialist Services have a $25 copay. Occupational Therapy and Physical Therapy/Speech-Language Pathology Services have no copay or coinsurance, but require prior authorization and a referral. Individual and group sessions for Psychiatric Services have a $40 copay. Opioid Treatment Program Services have a 20% coinsurance.
Preventive Services See details
The Alignment Health Sutter Advantage (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. Some preventive services, such as health education, in-home safety assessments, and others, are not covered.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered with no deductible, but are limited to one visit 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, with one exam covered every year. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames, are covered, with a combined maximum benefit of $100 every two years, with one pair of contact lenses, one pair of eyeglasses (lenses and frames), one pair of eyeglass lenses, and one pair of eyeglass frames covered every two years. Upgrades are not covered.
Dental Services See details
Dental services include coverage for oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatment. Restorative services have a copay of $20-$400, endodontics has a copay of $25-$350, periodontics has a copay of $15-$550, prosthodontics (removable) has a copay of $20-$570, prosthodontics (fixed) has 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, with prior authorization required. The plan covers Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance.
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 these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment with 0-20% coinsurance and no copay, and Prosthetics/Medical Supplies with a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered, while Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests and Lab Services are not covered. For Diagnostic Radiological Services, there is a copay of at most $150.00. 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 additional hours of care and personal care services are not covered. Both a referral and authorization are required for this benefit.
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 under the Alignment Health Sutter Advantage (HMO) plan, requiring prior authorization and a doctor's referral. There is no copay for days 1-20, a $160 copay for days 21-51, and no copay for days 52-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $15.00 every month, including nicotine replacement therapy and naloxone coverage. Acupuncture, Meal Benefit, 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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