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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 2025, 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 2025.
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 has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy type. For example, standard generic drugs have a $40 copay, while preferred brand drugs have a $100 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you 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 AVA (PPO) plan offers a variety of benefits to its members. This plan covers inpatient hospital stays, outpatient services, and emergency services, each with varying copays. Preventive services, hearing exams, and vision services are also covered, with no copay for routine eye exams. Additional benefits include dental services with a $1,000 annual maximum, home infusion, dialysis, and medical equipment coverage, each with its own copay or coinsurance structure. Other services like home health, cardiac rehabilitation, and skilled nursing facility stays are also covered, with some requiring prior authorization. However, this plan does not cover services like acupuncture, orthodontics, and certain other services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $200 copay for days 1-6, and no copay for days 7-90; non-Medicare-covered stays and upgrades are not covered. For Inpatient Hospital Psychiatric, you will pay a $120 copay for days 1-10, and no copay for days 11-90; and additional days are covered up to 40 days.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient Hospital Services have a $165 copay, Ambulatory Surgical Center (ASC) Services have a $100 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a minimum and maximum copay of $40.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health AVA (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Alignment Health AVA (PPO) plan. Ground and Air Ambulance Services each have a $250 copay, with no coinsurance, and the copay is waived if admitted to the hospital. 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 has a $85 copay with no coinsurance, and Urgently Needed Services has a $20 copay with no coinsurance; the copay is waived if admitted to the hospital within 24 hours. Worldwide Emergency Services has a maximum benefit coverage of $10,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care for Alignment Health AVA (PPO) includes coverage for Primary Care Physician Services with a $5 copay, Physician Specialist Services with a $20 copay, and Psychiatric Services with a $40 copay for individual and group sessions. Chiropractic Services, Mental Health Specialty Services for individual and group sessions, and Podiatry Services are not covered, and Opioid Treatment Program Services have a 20% coinsurance. Physical Therapy and Speech-Language Pathology Services and Occupational Therapy Services have no copay or coinsurance.
Preventive Services See details
The Alignment Health AVA (PPO) plan covers preventive services including Medicare-covered preventive services, annual physical exams, kidney disease education services, glaucoma screenings, diabetes self-management training, digital rectal exams, and EKG following a Welcome Visit. Additional preventive services are covered, but some services like health education, in-home safety assessments, and weight management programs are not covered.
Hearing Services See details
Hearing services include routine hearing exams and fitting/evaluation for hearing aids, each covered once per year; however, prescription hearing aids and OTC hearing aids are not covered.
Vision Services See details
The Alignment Health AVA (PPO) plan covers vision services including routine eye exams with no copay, and eyewear with a combined maximum benefit of $150 every two years. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, with the specific amounts and frequencies detailed in the plan.
Dental Services See details
The Alignment Health AVA (PPO) plan covers dental services, with a maximum benefit of $1,000 per year for both in-network and out-of-network services. Oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments are covered, but have visit limits. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are also 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, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%; for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Alignment Health AVA (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Alignment Health AVA (PPO) plan, including Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetics/Medical Supplies with a 20% coinsurance for Medicare-covered supplies. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, but 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 under the Alignment Health AVA (PPO) plan. Diagnostic procedures and tests, as well as lab services, are not covered. Diagnostic Radiological Services have 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 AVA (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but some services are not covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, days 21-51 have a $100 copay, and days 52-100 have no copay. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Alignment Health AVA (PPO) plan's "Other Services" benefit does not cover acupuncture, over-the-counter items, meal benefits, 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, or Self-Directed Personal Assistance Services.
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