Alignment Health AVA Instacart (HMO-POS)
H3815 - 026 - 0
(4 / 5)
Alignment Health AVA Instacart (HMO-POS) is a Medicare Advantage (Part C) Plan by Alignment Health Plan.
This page features plan details for 2024 Alignment Health AVA Instacart (HMO-POS) H3815 – 026 – 0 available in LA, OC, SD, SC, Stanislaus.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Alignment Health AVA Instacart (HMO-POS) is offered in the following locations.
Plan Overview
Alignment Health AVA Instacart (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Alignment Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $1,999 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Alignment Health AVA Instacart (HMO-POS) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Alignment Health AVA Instacart (HMO-POS) qualifies for a monthly Medicare Give Back Benefit of $50.00.
| Premium Reduction: | $50.00 |
Premium Breakdown
Alignment Health AVA Instacart (HMO-POS) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $50.00 | $124.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Alignment Health AVA Instacart (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $0.00 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $3.00 copay | $3.00 copay | ||
| 3 (Preferred Brand) | $40.00 copay | $40.00 copay | ||
| 4 (Non-Preferred Drug) | $93.00 copay | $93.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | ||
| 6 (Select Care Drugs) | $3.00 copay | $3.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $9.00 copay | $9.00 copay | ||
| 3 (Preferred Brand) | $120.00 copay | $120.00 copay | ||
| 4 (Non-Preferred Drug) | $279.00 copay | $279.00 copay | ||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $3.00 copay | $3.00 copay | ||
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | ||
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Alignment Health AVA Instacart (HMO-POS) also provides the following benefits.
| $0 |
| In-network | No |
| $1,999 In-network |
| Yes |
| In-network | No |
| In-network | $100 copay per visit (Authorization is required.) (Referral is required.) |
| In-network Primary | $35 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $35 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is required.) (Referral is required.) |
| out-of-network Specialist | $35 copay per visit (Authorization is required.) (Referral is required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| In-network Non-routine services | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic services | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | $20-350 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | $15-295 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | $15-375 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | $25-140 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $20-425 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| In-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is required.) (Referral is required.) |
| In-network | $115 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $35 copay (Authorization is required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| In-network | $0 per day for days 1 through 4 $100 per day for days 5 through 10 $0 per day for days 11 through 90 (Authorization is required.) (Referral is required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is required.) |
| In-network Inpatient hospital – psychiatric | $120 per day for days 1 through 10 $0 per day for days 11 through 90 (Authorization is required.) (Referral is required.) |
| out-of-network Inpatient hospital – psychiatric | Not Applicable (Authorization is required.) (Referral is required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is required.) (Referral is required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is required.) (Referral is required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is required.) (Referral is required.) |
| In-network | $0 per day for days 1 through 20 $50 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
| out-of-network | Not Applicable (Authorization is required.) (Referral is required.) |
| Monthly Premium | $27.00 |
| Deductible | nan |
Ready to sign up for Alignment Health AVA Instacart (HMO-POS) ?
Table of Contents
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