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Alignment Health Heroes+ (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Heroes+ (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health Heroes+ (HMO) in 2025, please refer to our full plan details page.
Alignment Health Heroes+ (HMO) is a HMO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in NorCal and SoCal. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Alignment Health Heroes+ (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 Heroes+ (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 Heroes+ (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5900.00 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 Heroes+ (HMO) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you will pay a $10 copay for preferred generic drugs at a standard or mail-order pharmacy. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Alignment Health Heroes+ (HMO) plan offers a range of benefits with varying cost-sharing. You'll find coverage for inpatient and outpatient services, including mental health, with some services requiring prior authorization and doctor referrals. Emergency services have a 20% coinsurance, but worldwide emergency coverage has a $75 copay. This plan also includes preventive services like annual exams and offers additional benefits such as hearing, vision, and dental services. Hearing and vision services are limited to exams and specific eyewear, while dental includes exams, X-rays, and cleanings, as well as up to $500 for orthodontics. The plan also covers home health, dialysis, and home infusion services, with different copays and coinsurance amounts depending on the specific service.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered under the Alignment Health Heroes+ (HMO) plan, but additional days and non-Medicare-covered stays are not covered. Prior authorization and a doctor referral are required for these services.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, ambulatory surgical center services, and outpatient substance abuse services, are covered. Outpatient blood services are covered with 20% coinsurance, and individual and group sessions for outpatient substance abuse have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health Heroes+ (HMO) plan. Prior authorization and a doctor referral are required for this benefit.
Ambulance and Transportation Services See details
The Alignment Health Heroes+ (HMO) plan covers ambulance services with a 20% coinsurance for both ground and air ambulance services, and there is no copay. Transportation services to a plan-approved health-related location are covered for up to 50 one-way trips per year, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered. Emergency Services and Urgently Needed Services have a 20% coinsurance, while Worldwide Emergency Coverage has a $75 copay. Worldwide Urgent Coverage also has a $75 copay, and Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health Heroes+ (HMO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are partially covered, but routine chiropractic care is not covered. The plan requires prior authorization and a doctor referral for chiropractic, occupational therapy, physician specialist, mental health specialty, other health care professional, psychiatric services, physical therapy, speech-language pathology, and opioid treatment program services. Individual and group sessions for mental health specialty services and psychiatric services have a 20% coinsurance. Physical therapy and speech-language pathology services have a 20% coinsurance.
Preventive Services See details
The Alignment Health Heroes+ (HMO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, and other preventive services that require prior authorization. Additional benefits include Personal Emergency Response System (PERS), Therapeutic Massage (12 sessions per year), In-Home Support Services, Support for Caregivers of Enrollees (with a $300 annual maximum for caregiver training), and Fitness Benefit. Some services are not covered, including Health Education, In-Home Safety Assessment, 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, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services. Other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas (with prior authorization), Digital Rectal Exams, and EKG following Welcome Visit are also covered.
Hearing Services See details
Hearing services under the Alignment Health Heroes+ (HMO) plan include routine hearing exams and fitting/evaluation for hearing aids, each covered for one visit per year, but prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health Heroes+ (HMO) plan covers vision services, including routine eye exams once per year, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, each once every two years, with a combined maximum benefit of $500 for eyewear. Upgrades are not covered.
Dental Services See details
Dental Services are covered, with a 20% coinsurance for Medicare Dental Services. Other Dental Services include oral exams (1 visit every six months), dental x-rays (1 visit every three years), prophylaxis (cleaning) (1 visit every six months), and fluoride treatment (1 visit every six months). Orthodontic services are covered up to a maximum of $500 every three months, while restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered. 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 Heroes+ (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance, and requires authorization. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 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 the Alignment Health Heroes+ (HMO) plan. All diagnostic services have no copay, but the plan does not cover diagnostic procedures/tests or lab services. Radiological services have no copay; however, therapeutic radiological services have a 20% coinsurance, and outpatient X-ray services are not covered.
Home Health Services See details
Home Health Services are covered by the Alignment Health Heroes+ (HMO) plan, with no copay or coinsurance, but 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 specific services including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor referral. The plan charges the Medicare-defined cost share for tier 1, and additional days beyond Medicare-covered, as well as non-Medicare-covered stays, are not covered.
Other Services See details
Other Services includes a meal benefit and digital health technology support, while acupuncture, over-the-counter items, 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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