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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 Santa Clara. 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 $75.00. 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) Medicare plan offers an Enhanced Alternative drug benefit with no prescription drug deductible. If you qualify for Extra Help or the low-income subsidy, your Part D drug costs are reduced to nothing. This plan is designed to make prescription coverage affordable and easy to understand from day one. During the initial coverage phase, standard retail and mail-order options feature a low $3 copay for Tier 1 preferred generics and Tier 5 specialty drugs, alongside a $40 copay for Tier 2 standard generics. For higher tiers, you will pay 32% coinsurance for Tier 3 preferred brands and 33% coinsurance for Tier 4 non-preferred drugs. Once your annual out-of-pocket drug costs reach $2,100, you enter the catastrophic coverage phase and pay nothing for covered Part D prescriptions.
Additional Benefits
The Alignment Health Advantage PPO (PPO) offers robust coverage for essential medical needs, featuring no copay for preventive services like annual physicals. If you require inpatient hospital care, you will pay a $75 daily copay for the first five days, while outpatient hospital services carry a $200 copay with no coinsurance. Emergency room visits require a $75 copay, whereas urgently needed services are available with no copay or coinsurance. For routine care, the plan provides one routine eye exam and one routine hearing exam annually with no deductible, plus a $200 annual allowance for eyewear. Skilled nursing facility stays are covered with no copay for the first 20 days, followed by a $50 daily copay for days 21 through 100. Additionally, members benefit from up to $20 monthly for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
Alignment Health Advantage PPO (PPO) partially covers inpatient hospital benefits, requiring a $75 daily copay for days 1 through 5 of acute stays and a $120 daily copay for days 1 through 10 of psychiatric stays, with no copay for subsequent days and no coinsurance. Upgrades for acute stays and non-Medicare-covered stays are not covered under this plan.
Outpatient Services See details
Alignment Health Advantage PPO (PPO) covers outpatient services with no coinsurance, including outpatient hospital services for a $200 copay and ambulatory surgical center services for a $100 copay. Outpatient substance abuse sessions require a $20 copay, and outpatient blood services are covered with no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by Alignment Health Advantage PPO (PPO) with a $55.00 copay and no coinsurance. Prior authorization and a doctor referral are required to access this benefit.
Ambulance and Transportation Services See details
Alignment Health Advantage PPO (PPO) partially covers ambulance and transportation services, with prior authorization required for both. Ground and air ambulance services require a $100 copay and no coinsurance, which is waived if you are admitted to the hospital. Transportation is limited to 26 one-way trips per year to plan-approved locations, whereas transportation to any health-related location is not covered.
Emergency Services See details
Alignment Health Advantage PPO (PPO) partially covers emergency services, featuring a $75 copay and no coinsurance for emergency room visits, and no copay or coinsurance for urgently needed services. Worldwide emergency and urgent care are covered up to a $25,000 maximum limit, though worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits are partially covered by Alignment Health Advantage PPO (PPO), as podiatry and routine chiropractic care are not covered, and while some mental health specialty services are covered, individual and group sessions are excluded. Covered services include psychiatric care with a $40 copay and opioid treatment with a 20% coinsurance.
Preventive Services See details
Preventive services are covered by Alignment Health Advantage PPO (PPO) with no copay or coinsurance, including annual physical exams, kidney disease education, and Medicare-covered zero-dollar services. Additional preventive benefits are only partially covered, offering memory fitness but excluding services like health education, personal emergency response systems, and in-home safety assessments.
Hearing Services See details
Hearing Services are partially covered by Alignment Health Advantage PPO (PPO), which includes one routine hearing exam and one fitting and evaluation for hearing aids every year with no deductible. However, prescription hearing aids (including inner ear, outer ear, and over the ear types) and over-the-counter hearing aids are not covered.
Vision Services See details
Alignment Health Advantage PPO (PPO) partially covers vision services, offering no deductible for one routine eye exam per year and a $200 annual combined limit for in-network eyewear like contacts and eyeglasses. Upgrades are not covered under this plan.
Dental Services See details
Alignment Health Advantage PPO (PPO) partially covers dental services, specifically covering Medicare dental services with prior authorization, though no copay or coinsurance details are specified. Sub-services that are not covered under this plan include orthodontics, restorative services, endodontics, periodontics, prosthodontics, implants, maxillofacial prosthetics, oral and maxillofacial surgery, and adjunctive general services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Alignment Health Advantage PPO (PPO), requiring prior authorization and featuring 0% to 20% coinsurance with no copay for chemotherapy, radiation, and other Part B drugs. For Medicare Part B insulin drugs, there is a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Alignment Health Advantage PPO (PPO), but members must obtain a doctor referral and prior authorization before receiving treatment. Specific copay and coinsurance costs for these services are not detailed in the plan benefits.
Medical Equipment See details
Alignment Health Advantage PPO (PPO) covers durable medical equipment with no copay and no coinsurance to 20% coinsurance, as well as prosthetics and medical supplies with no copay and 20% coinsurance. Diabetic equipment is partially covered, offering therapeutic shoes and inserts with no copay and 20% coinsurance, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Alignment Health Advantage PPO (PPO), with therapeutic radiological services requiring no copay and a 20% coinsurance. Diagnostic procedures and tests, lab services, diagnostic radiological services, and outpatient X-ray services are not covered.
Home Health Services See details
Home health services are covered under the Alignment Health Advantage PPO (PPO) plan, requiring prior authorization and a doctor referral. Specific copay and coinsurance details are not provided in the plan benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Alignment Health Advantage PPO (PPO) plan, with no copay or coinsurance coverage provided for cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are partially covered by Alignment Health Advantage PPO (PPO), requiring a doctor referral and prior authorization, though additional days beyond Medicare-covered services are not covered. Covered stays feature no copay and no coinsurance for days 1 through 20, followed by a $50 copay and no coinsurance for days 21 through 100.
Other Services See details
Alignment Health Advantage PPO (PPO) partially covers Other Services, excluding acupuncture, meal benefits, and Dual Eligible SNPs with Highly Integrated Services. Covered benefits include digital health technology support and up to $20 monthly for OTC items with no copay or coinsurance, as well as personalized health risk screenings for a $75 copay and no coinsurance.
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