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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 Santa Clara. 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 $50.00. 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 $5150.00 (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 $5150.00 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. During the initial coverage phase, you'll pay a copay for your prescriptions, which varies depending on the drug tier and the pharmacy you use. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Alignment Health Advantage PPO (PPO) plan offers a range of benefits with varying cost structures. Inpatient hospital stays have copays, while outpatient services have copays that vary by service. Emergency services have a $75 copay, and primary care services have no copay, although some specialist services have a copay. Preventive services, routine eye exams, and vision services have no copays. Hearing exams are covered, and dental services are partially covered. Medical equipment and home infusion services have varying coinsurance, while diagnostic services and home health services have no copay.
Inpatient Hospital See details
Inpatient Hospital-Acute has a copay of $75 for days 1-5, and no copay for days 6-90, and Inpatient Hospital Psychiatric has a copay of $120 for days 1-10, and no copay for days 11-90. Additional days for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a $200 copay, and ambulatory surgical center services have a $100 copay. Individual and group sessions for outpatient substance abuse have a copay between $20 and $20.
Partial Hospitalization See details
Partial Hospitalization is covered by the Alignment Health Advantage PPO (PPO) plan, and requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Alignment Health Advantage PPO (PPO) plan. Ground and air ambulance services have a $100 copay, while transportation services to a plan-approved health-related location are covered for up to 26 one-way trips per year, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, including Emergency Services, Urgently Needed Services, and Worldwide Emergency Services. Emergency Services have a $75 copay and no coinsurance, while Worldwide Emergency Services have a maximum plan benefit coverage of $25,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, and Other Health Care Professional services. This plan does not have a copay or coinsurance for Occupational Therapy Services and Physical Therapy and Speech-Language Pathology Services. Individual and group sessions for Psychiatric Services have a $40 copay. Opioid Treatment Program Services have 20% coinsurance. Chiropractic Services and Opioid Treatment Program Services require prior authorization.
Preventive Services See details
The Alignment Health Advantage PPO (PPO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services are covered, but health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams, and fitting/evaluation for hearing aids, each covered once per year. Prescription Hearing Aids, and OTC Hearing Aids are not covered.
Vision Services See details
The Alignment Health Advantage PPO (PPO) plan covers vision services, including routine eye exams with no copay and eyewear with a combined maximum of $200 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are also covered, but upgrades are not covered.
Dental Services See details
Dental Services are partially covered by the Alignment Health Advantage PPO (PPO) plan, with Medicare Dental Services covered, but Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), Oral and Maxillofacial Surgery, and Orthodontics not covered. No cost information is provided for the covered services.
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, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Alignment Health Advantage PPO (PPO) plan. There is no information about the copay or coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered by the Alignment Health Advantage PPO (PPO) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20% and no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetic devices and medical supplies have a 20% coinsurance and no copay, while Diabetic Equipment has a coinsurance for Medicare-covered diabetic supplies. Diabetic therapeutic shoes/inserts have a coinsurance between 20% and 20%, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Alignment Health Advantage PPO (PPO) plan, but some services are not covered. There is no copay for diagnostic services, and coinsurance may apply for therapeutic radiological services, up to 20%.
Home Health Services See details
Home Health Services are covered by the Alignment Health Advantage PPO (PPO) plan with no copay or coinsurance; however, additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but not in practice. Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered by the Alignment Health Advantage PPO (PPO) plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Alignment Health Advantage PPO (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $50. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
Under the Alignment Health Advantage PPO (PPO) plan, acupuncture, meal benefits, and several other services are not covered. Over-the-counter (OTC) items are covered with a maximum benefit coverage amount of $20.00 every month, and "Other 1" services have a $75 copay.
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