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Alignment Health Advantage PPO (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Alignment Health Advantage PPO (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Alignment Health Advantage PPO (PPO) in 2025, please refer to our full plan details page.
Alignment Health Advantage PPO (PPO) is a PPO plan offered by Alignment Healthcare USA, LLC available for enrollment in 2025 to people living in LA, OC, SD, Fresno, Madera, Ventura. The overall rating for this plan is not yet available for 2025.
It's important to know that Alignment Health Advantage PPO (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 Advantage PPO (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 Advantage PPO (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $45.00. 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 $8950.00 (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 $8950.00 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 Advantage PPO (PPO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you'll pay a copay for your prescriptions, depending on the drug tier and pharmacy used. For example, a standard generic drug has a $40 copay, and a preferred brand drug has a $100 copay. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Alignment Health Advantage PPO (PPO) plan offers a range of benefits, including coverage for inpatient hospital stays with varying copays depending on the type of service and length of stay. The plan also covers outpatient services, such as substance abuse treatment, with copays, and offers coverage for emergency services, primary care visits, and preventive services, often with no copay. Additional benefits include coverage for hearing and vision services with no copay for routine exams and set allowances for eyewear, as well as dental services up to a yearly maximum. The plan also provides coverage for home health services, skilled nursing facilities, and various diagnostic and radiological services, with specific copays or coinsurance amounts depending on the service. Other covered services include ambulance, dialysis, and medical equipment, with the plan offering an over-the-counter allowance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $250 copay for days 1-3, and no copay for days 4-90; for Inpatient Hospital Psychiatric, you'll pay a $120 copay for days 1-10, and no copay for days 11-90. Additional days for Inpatient Hospital Psychiatric are covered up to 40 days.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services with a $200 copay, observation services, and ambulatory surgical center (ASC) services with a $100 copay. Outpatient substance abuse services are covered with a $40 copay for both individual and group sessions, and outpatient blood services are covered with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered under the Alignment Health Advantage PPO (PPO) plan, but requires prior authorization. You will have a $55 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Advantage PPO (PPO) plan, with a $250 copay for both ground and air ambulance services, and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Alignment Health Advantage PPO (PPO) plan. Emergency Services have a $90 copay, and Urgently Needed Services have a $20 copay. Worldwide Emergency Services has a maximum benefit coverage of $10,000, and Worldwide Emergency Transportation is not covered.
Primary Care See details
The Alignment Health Advantage PPO (PPO) plan covers primary care services, including physician services, occupational therapy, and physician specialist services with a $20 copay. Mental health specialty services, including individual and group sessions, are not covered. Physical therapy and speech-language pathology services are covered with no copay or coinsurance, but prior authorization is required. The plan also covers opioid treatment program services with a coinsurance between 20% and 20%.
Preventive Services See details
The Alignment Health Advantage PPO (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, kidney disease education, and other preventive services, with no copay or coinsurance. The plan also covers Fitness Benefits, Personal Emergency Response Systems (PERS), and Remote Access Technologies. However, health education, in-home safety assessments, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, are covered, but prescription hearing aids and OTC hearing aids are not covered. Routine hearing exams and fitting/evaluation for hearing aids are each covered once per year.
Vision Services See details
Vision Services include coverage for routine eye exams with no copay, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $150 every two years, and upgrades are not covered.
Dental Services See details
The Alignment Health Advantage PPO (PPO) plan offers a maximum of $1000 per year for dental services, covering oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments, with limitations on the number of visits and periodicity. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are also covered, while adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, and coinsurance ranges from 0% to 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 under the Alignment Health Advantage PPO (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Alignment Health Advantage PPO (PPO) plan, with Durable Medical Equipment (DME) subject to a 0-20% coinsurance and Prosthetic Devices, and Medical Supplies covered with 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Additionally, Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with all diagnostic services requiring prior authorization and no copay. Radiological Services require prior authorization, with a $15 copay for outpatient X-ray services, a maximum $150 copay for diagnostic radiological services, and 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by the Alignment Health Advantage PPO (PPO) plan with no copay and no coinsurance, but prior authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Alignment Health Advantage PPO (PPO) plan, but require prior authorization. For days 1-20, there is no copay, a $100 copay for days 21-51, and no copay for days 52-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Alignment Health Advantage PPO (PPO) plan's "Other Services" benefit covers Over-the-Counter (OTC) items with a maximum benefit of $10.00 per month, including nicotine replacement therapy and naloxone coverage, but does not cover acupuncture, meal benefits, or several other services. Other 1 has a $75 copay for Personalized Health Risk Screening.
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