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Alignment Health AVA (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health AVA (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health AVA (PPO) in 2026, please refer to our full plan details page.
Alignment Health AVA (PPO) is a PPO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in Mountains and Piedmont Regions. The overall rating for this plan is not yet available for 2026.
It's important to know that Alignment Health AVA (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 AVA (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 AVA (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $10.00. 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 $6200.00 (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 $6200.00 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:
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Drug Coverage
The Alignment Health AVA (PPO) plan features a $0 drug deductible, meaning your prescription drug coverage begins immediately. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay for one-, two-, or three-month fills at standard pharmacies and standard mail order. Additionally, Tier 6 select care drugs are highly affordable, with a $5 copay for a one-month supply, a $10 copay for a two-month supply, and no copay for a three-month supply. For brand-name and specialty medications, the plan uses a mix of copays and coinsurance. Tier 3 preferred brand drugs require a $40 copay for a one-month supply, while Tier 4 non-preferred drugs carry a 40% coinsurance. Specialty medications in Tier 5 are covered with a 33% coinsurance for a one-month supply through standard pharmacies and standard mail order.
Additional Benefits
Alignment Health AVA (PPO) offers robust medical coverage with predictable costs, including inpatient hospital stays that feature no coinsurance and a daily copay of $200 for the first six days. Primary care doctor visits require a low $5 copay, while specialist visits have a $20 copay, and both services feature no coinsurance. Outpatient hospital services require a $165 copay with no coinsurance, and emergency room visits carry an $85 copay. This plan also provides valuable supplemental care, offering annual routine vision and hearing exams with no copay, alongside a $150 eyewear allowance every two years. Dental care is covered with no copay and no coinsurance up to a $1,000 annual maximum, and home health services are available with no copay or coinsurance. For medical equipment and dialysis, beneficiaries will pay no copay and up to a 20% coinsurance.
Inpatient Hospital See details
Alignment Health AVA (PPO) offers partially covered inpatient hospital services with no coinsurance, though upgrades and non-Medicare-covered stays are not covered. Acute stays require a $200 daily copay for days 1 through 6 with no copay for days 7 through 90, while psychiatric stays require a $120 daily copay for days 1 through 10 and no copay for days 11 through 90.
Outpatient Services See details
Alignment Health AVA (PPO) covers outpatient services with no coinsurance, featuring a $165 copay for outpatient hospital services and a $100 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Alignment Health AVA (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to access this covered benefit.
Ambulance and Transportation Services See details
Alignment Health AVA (PPO) covers ground and air ambulance services with a $250 copay per service, which is waived if you are admitted to the hospital, and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered.
Emergency Services See details
Alignment Health AVA (PPO) covers emergency services with an $85 copay and no coinsurance, alongside urgently needed services for a $20 copay and no coinsurance. Worldwide emergency and urgent services are partially covered with no copay or coinsurance up to a $10,000 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Alignment Health AVA (PPO) covers primary care visits for a $5 copay and specialist visits for a $20 copay, both with no coinsurance, while physical, occupational, speech, and telehealth services have no copay and no coinsurance. Psychiatric services require a $40 copay with no coinsurance, and opioid treatment has a 20% coinsurance with no copay, though podiatry, chiropractic services, and mental health specialty services are not covered.
Preventive Services See details
Preventive services are covered by Alignment Health AVA (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and glaucoma screenings. Additional preventive services are partially covered with no copay and no coinsurance for memory fitness, but do not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission 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, home modifications, and counseling.
Hearing Services See details
Alignment Health AVA (PPO) covers one routine hearing exam and one hearing aid fitting evaluation annually with no copay and no coinsurance. Hearing aids, including all prescription and over-the-counter (OTC) types, are not covered.
Vision Services See details
Alignment Health AVA (PPO) features partially covered vision services with no copay, no coinsurance, and no deductible. Beneficiaries receive one routine eye exam annually and a $150 allowance for in-network eyewear every two years, though upgrades and other eye exam services are not covered.
Dental Services See details
Dental services are partially covered by Alignment Health AVA (PPO) with no copay and no coinsurance up to a maximum annual benefit of $1,000 for both in-network and out-of-network care. While preventive and basic restorative services are covered, other diagnostic and preventive services, adjunctive general services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Alignment Health AVA (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Covered Medicare Part B drugs, including insulin, chemotherapy, and radiation, have a copay of up to $35 and coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered by Alignment Health AVA (PPO) with no copay and a 20% coinsurance. Prior authorization and a referral are required to receive these services.
Medical Equipment See details
Alignment Health AVA (PPO) covers medical equipment with no copays, though prior authorization is required for these benefits. Durable medical equipment incurs no coinsurance to 20% coinsurance, prosthetics and medical supplies carry a 20% coinsurance, and diabetic equipment is partially covered with a 20% coinsurance for therapeutic shoes and inserts, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under Alignment Health AVA (PPO), though diagnostic services are only partially covered as diagnostic procedures, tests, and lab services are not covered. Covered diagnostic services require no copay and no coinsurance, while radiological services incur a $150 minimum copay with no coinsurance for diagnostic radiology, a 20% minimum coinsurance with no copay for therapeutic radiology, and a $15 copay with coinsurance for outpatient X-rays.
Home Health Services See details
Home Health Services are covered by Alignment Health AVA (PPO) with no copay and no coinsurance. Prior authorization and a referral are required to receive this benefit.
Cardiac Rehabilitation Services See details
Alignment Health AVA (PPO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, though prior authorization and referrals are required. However, standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Alignment Health AVA (PPO) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization and referrals, and allowing admission without a prior three-day hospital stay. There is no copay for days 1 to 20 and days 52 to 100, a $100 daily copay for days 21 to 51, and additional days beyond the 100-day Medicare benefit period are not covered.
Other Services See details
Alignment Health AVA (PPO) partially covers other services, offering digital health technology support with no copay and no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered under this plan.
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