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Alignment Health Balance (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Balance (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health Balance (PPO) in 2026, please refer to our full plan details page.
Alignment Health Balance (PPO) is a PPO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in San Joaquin and Stanislaus. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Alignment Health Balance (PPO) 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 Balance (PPO).
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 Balance (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $41.00. 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 combined Maximum Out-Of-Pocket cost of $5150.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5150.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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:
Sign up for Alignment Health Balance (PPO)
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Drug Coverage
The Alignment Health Balance (PPO) plan features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, members pay a $3 copay for preferred generics and specialty drugs at standard pharmacies or through standard mail. Standard generics carry a $40 copay, while preferred brands and non-preferred drugs require 32% and 33% coinsurance, respectively. This coverage phase lasts until yearly out-of-pocket drug costs reach $2,100, at which point you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. Additionally, individuals who qualify for the full low-income subsidy will pay a Part D premium of $41.
Additional Benefits
The Alignment Health Balance (PPO) plan offers comprehensive coverage for core medical needs with structured cost-sharing and no coinsurance for many services. Inpatient hospital stays require a $75 daily copay for the first three days and no copay for days four through 90, while emergency room visits carry a $75 copay and urgent care has no copay. Outpatient hospital services require a $200 copay, and skilled nursing facility stays feature no copay for the first 20 days followed by a $50 daily copay. For routine wellness, the plan features no copay for preventive services and annual physical exams. Vision and hearing benefits include routine annual exams with no deductibles, alongside a $200 annual eyewear allowance, while preventive dental services require no copay and a 50% coinsurance. Additional perks include up to 26 one-way transportation trips per year and a $20 monthly allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Alignment Health Balance (PPO), as upgrades and non-Medicare-covered stays are not covered. Acute stays require a $75 daily copay for days 1 to 3 and no copay for days 4 to 90, while psychiatric stays require a $120 daily copay for days 1 to 10 and no copay for days 11 to 90, with no coinsurance required for either service.
Outpatient Services See details
Alignment Health Balance (PPO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital services, a $100 copay for ambulatory surgical center services, and a $20 copay for outpatient substance abuse sessions. Prior authorization and doctor referrals are required for most of these covered benefits, which also include outpatient blood services with no deductible.
Partial Hospitalization See details
Alignment Health Balance (PPO) covers partial hospitalization benefits with a $55 copay and no coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Alignment Health Balance (PPO), requiring a $100 copay and no coinsurance for ground and air ambulance services, with the copay waived if you are admitted to the hospital. Transportation services are partially covered, offering up to 26 one-way trips per year to plan-approved locations, while transportation to any health-related location is not covered.
Emergency Services See details
Alignment Health Balance (PPO) covers emergency services with a $75 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency services are partially covered up to a $25,000 maximum, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are covered by Alignment Health Balance (PPO), including therapy and specialist visits, though podiatry is not covered, chiropractic services are partially covered with routine care excluded, and while some mental health specialty services are covered, individual and group sessions are not. Psychiatric services carry a $40 copay and no coinsurance, whereas opioid treatment requires a 20% coinsurance and no copay.
Preventive Services See details
Alignment Health Balance (PPO) covers preventive services, including annual physical exams and kidney disease education, with no copays or coinsurance. The benefit is partially covered, as multiple additional services—such as health education, personal emergency response systems, and weight management programs—are not covered, though a memory fitness benefit is included.
Hearing Services See details
Hearing services are partially covered by Alignment Health Balance (PPO) with no deductible, offering one routine hearing exam and one fitting evaluation annually. While prescription hearing aids are listed as covered, no actual types—including inner ear, outer ear, over the ear, and over-the-counter hearing aids—are covered in practice.
Vision Services See details
Alignment Health Balance (PPO) partially covers vision services, which feature no deductible but exclude upgrades. Covered benefits include one routine eye exam per year and a $200 annual maximum limit for in-network eyewear, including contacts and eyeglasses.
Dental Services See details
Alignment Health Balance (PPO) dental services are partially covered, offering unlimited oral exams, cleanings, x-rays, and fluoride treatments with no copay and a 50% coinsurance. Restorative, endodontic, periodontic, orthodontic, prosthodontic, oral surgery, and implant services are not covered.
Home Infusion bundled Services See details
Alignment Health Balance (PPO) covers Home Infusion bundled Services, including Medicare Part B insulin, chemotherapy, and other Part B drugs, with prior authorization and step therapy required. Covered Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy and other Part B drugs have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Alignment Health Balance (PPO) plan, requiring prior authorization and a doctor referral, though specific copay and coinsurance costs are not detailed in the plan benefits.
Medical Equipment See details
Alignment Health Balance (PPO) partially covers medical equipment with no copay and coinsurance ranging from no coinsurance to 20%. While durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes are covered, diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Alignment Health Balance (PPO), which covers therapeutic radiological services with a 20% coinsurance and no copay. However, diagnostic radiological services, outpatient X-ray services, diagnostic procedures and tests, and lab services are not covered.
Home Health Services See details
Home Health Services are covered under the Alignment Health Balance (PPO) plan, though prior authorization and a doctor referral are required. Specific copay and coinsurance cost details are not provided for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health Balance (PPO) plan, as none of the sub-services, including standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Alignment Health Balance (PPO), which does not cover additional days beyond the Medicare-covered limit. Covered stays feature no coinsurance, with no copay for days 1 through 20 and a $50 daily copay for days 21 through 100.
Other Services See details
Alignment Health Balance (PPO) partially covers other services, including digital health technology support and over-the-counter items with a $20 monthly limit, both featuring no copay or coinsurance. Personalized health risk screenings are covered with a $75 copay and no coinsurance up to $200 every two years, while acupuncture, meal benefits, and dual eligible SNP services are not covered.
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