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Saint Alphonsus Health Plan Glory No RX (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Saint Alphonsus Health Plan Glory No RX (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Saint Alphonsus Health Plan Glory No RX (HMO) in 2025, please refer to our full plan details page.
Saint Alphonsus Health Plan Glory No RX (HMO) is a HMO plan offered by Trinity Health Corporation available for enrollment in 2025 to people living in Select Counties in Idaho. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Saint Alphonsus Health Plan Glory No RX (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Saint Alphonsus Health Plan Glory No RX (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 Saint Alphonsus Health Plan Glory No RX (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. Additionally, this plan comes with a Part B Premium reduction of $100.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4500.00 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
Prescription drugs are not covered by Saint Alphonsus Health Plan Glory No RX (HMO).
Additional Benefits
The Saint Alphonsus Health Plan Glory No RX (HMO) offers coverage for a wide range of services with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services offer a mix of copays and no copays depending on the service. Emergency, primary care, and preventive services have copays, but some services have no copay. The plan also covers hearing, vision, and dental services with copays or coinsurance. Additionally, it provides benefits for home infusion, dialysis, and medical equipment, with copays and coinsurance. Other benefits include home health services with no copay, and other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, the copay is $275 for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, the copay is also $275 for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $275, observation services with no copay, ambulatory surgical center (ASC) services with a $275 copay, outpatient substance abuse services with a $20 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Saint Alphonsus Health Plan Glory No RX (HMO), with a copay of $30.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Saint Alphonsus Health Plan Glory No RX (HMO) plan, including ground ambulance services with a $225 copay and air ambulance services with a $275 copay, though transportation services to health-related locations are not covered. All ambulance services require prior authorization, and there is no coinsurance.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Saint Alphonsus Health Plan Glory No RX (HMO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $30 copay, Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $110 copay, and Worldwide Emergency Transportation has a copay between $225 and $275.
Primary Care See details
Primary Care Physician Services have no copay, while Chiropractic Services have a $20 copay, but routine care is not covered. Occupational Therapy Services and Physical Therapy and Speech-Language Pathology Services have a $20 copay, and Physician Specialist Services have a $25 copay. Mental Health Specialty Services and Psychiatric Services have a $20 copay for individual and group sessions. Other Health Care Professional services have a copay between $0 and $25. Additional Telehealth Benefits have a copay between $0 and $25, and Opioid Treatment Program Services have a $20 copay.
Preventive Services See details
The Saint Alphonsus Health Plan Glory No RX (HMO) plan covers preventive services, including an annual physical exam with no copay. Other preventive services, such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered with no copay.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription Hearing Aids (all types) are covered with a copay between $399 and $699, while other prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Saint Alphonsus Health Plan Glory No RX (HMO) plan covers vision services, including routine eye exams with a copay between $0 and $25, and eyewear with a $0 copay. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are included, but upgrades are not covered.
Dental Services See details
Dental services include a $25 copay for Medicare dental services and no copay for other dental services. Restorative services and oral and maxillofacial surgery have a 50% coinsurance, endodontics and periodontics have a 70% coinsurance, and other services like maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with a 0%-20% coinsurance, and Other Medicare Part B Drugs with a 0%-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Saint Alphonsus Health Plan Glory No RX (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance and requires authorization, while Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay for Medicare-covered diagnostic procedures, tests, and lab services, and a copay for Medicare-covered diagnostic and therapeutic radiological services. Diagnostic Procedures/Tests have a $10 copay, while Lab Services have no copay. Diagnostic Radiological Services have a $150 copay, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Saint Alphonsus Health Plan Glory No RX (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Saint Alphonsus Health Plan Glory No RX (HMO), including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. The plan does not specify any cost sharing information for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Saint Alphonsus Health Plan Glory No RX (HMO) plan. There is no copay for days 1-20 and 56-100, but there is a $214 copay for days 21-55. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture with a $20 copay, over-the-counter (OTC) items with no copay, and a meal benefit with no copay. The plan provides up to $80 for OTC items every three months. Additionally, 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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