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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 2026, 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 2026.
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 features an Enhanced Alternative drug benefit with no prescription drug deductible. During the initial coverage phase, you pay a flat $5 copay for Tier 1 preferred generics and Tier 5 specialty drugs, while Tier 2 standard generics carry a $40 copay at standard pharmacies and mail order. Brand-name and non-preferred medications require a coinsurance of 32% for Tier 3 preferred brands and 33% for Tier 4 non-preferred drugs. These cost-sharing rates apply until your total drug expenses reach $2,100, at which point you enter the next coverage phase. After reaching $2,100 in yearly out-of-pocket costs, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs. Additionally, beneficiaries qualifying for the low-income subsidy will pay a $45 Part D premium.
Additional Benefits
The Alignment Health Advantage PPO (PPO) plan provides robust medical coverage featuring no copays for preventive care, annual physicals, and routine hearing and vision exams. For inpatient hospital stays, members pay a daily copay for the first few days followed by no copay for longer stays, while outpatient services and emergency care require flat copays and no coinsurance. Specialist visits carry a $20 copay, and urgent care is available for a $20 copay. Additional benefits include a $1,000 annual maximum for dental care and a $150 eyewear allowance every two years, both with no deductibles. Skilled nursing facility stays feature no copay for days 1 through 20, and members pay no copay or coinsurance for over-the-counter items. While durable medical equipment and dialysis require up to 20% coinsurance, many diagnostic radiological services are covered with flat copays and no coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Alignment Health Advantage PPO (PPO), excluding upgrades and non-Medicare-covered stays. For acute care, there is a $250 daily copay for days 1 through 3 and no copay for days 4 through 90, while psychiatric care requires a $120 daily copay for days 1 through 10 and no copay for days 11 through 90, both with no coinsurance.
Outpatient Services See details
Alignment Health Advantage PPO (PPO) covers outpatient services with no coinsurance, including outpatient hospital services for a $200 copay, ambulatory surgical center services for a $100 copay, and outpatient substance abuse sessions for a $40 copay. Outpatient blood services are also covered with no deductible, copay, or coinsurance.
Partial Hospitalization See details
Alignment Health Advantage PPO (PPO) covers partial hospitalization benefits with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required for these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Alignment Health Advantage PPO (PPO), which charges a $250 copay and no coinsurance for ground and air ambulance services, with the copay waived upon hospital admission. Transportation services to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
Alignment Health Advantage PPO (PPO) covers emergency services with a $90 copay and no coinsurance, and urgently needed services with a $20 copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $10,000 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered under the Alignment Health Advantage PPO (PPO), excluding podiatry, routine chiropractic, and individual or group mental health specialty sessions. Covered specialist visits require a $20 copay, psychiatric sessions require a $40 copay, and opioid treatment services carry a 20% coinsurance, with most services requiring prior authorization and a doctor referral.
Preventive Services See details
Alignment Health Advantage PPO (PPO) covers preventive services, such as annual physicals, kidney disease education, and glaucoma screenings, with no copay or coinsurance. Additional preventive services are partially covered; however, health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety devices, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Alignment Health Advantage PPO (PPO), which offers one routine hearing exam and one fitting evaluation annually with no deductible. However, prescription hearing aids and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Alignment Health Advantage PPO (PPO) partially covers vision services, which include one routine eye exam every year and a $150 maximum eyewear benefit every two years with no deductibles, though upgrades are not covered.
Dental Services See details
Alignment Health Advantage PPO (PPO) partially covers dental services up to a maximum annual benefit of $1,000 for both in-network and out-of-network care. While preventive and various restorative treatments are covered, adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Alignment Health Advantage PPO (PPO) covers home infusion bundled services with prior authorization, offering Medicare Part B chemotherapy, radiation, and other drugs with no copay and coinsurance ranging from no coinsurance to 20%. Covered Medicare Part B insulin drugs require a $35 copay alongside coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Alignment Health Advantage PPO (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization and a doctor referral are required to receive these covered services.
Medical Equipment See details
Alignment Health Advantage PPO (PPO) partially covers medical equipment with no copays, though diabetic supplies are not covered. Durable medical equipment requires between no coinsurance and 20% coinsurance, while prosthetic devices, medical supplies, and diabetic therapeutic shoes carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by Alignment Health Advantage PPO (PPO), as diagnostic procedures, tests, and lab services are not covered. For covered radiological services, there is a $15 copay and no coinsurance for outpatient X-rays, a $150 copay and no coinsurance for diagnostic radiological services, and a 20% coinsurance with no copay for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under the Alignment Health Advantage PPO (PPO) plan, requiring both a doctor referral and prior authorization. Specific copay and coinsurance cost-sharing details are not specified for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health Advantage PPO (PPO) because none of the sub-services, including 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 Advantage PPO (PPO), requiring prior authorization and a doctor referral. There is no coinsurance for these services, featuring no copay for days 1 through 20 and days 52 through 100, and a $100 copay for days 21 through 51, though additional days beyond Medicare-covered limits are not covered.
Other Services See details
Alignment Health Advantage PPO (PPO) provides partial coverage for other services, while acupuncture, meal benefits, and dual eligible SNPs are not covered. Covered benefits include over-the-counter items and digital health technology support with no copay or coinsurance, as well as personalized health risk screenings which require a $75 copay and no coinsurance.
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