Alignment Health Sutter Advantage (HMO)
H3815 - 023 - 0
(4 / 5)
Alignment Health Sutter Advantage (HMO) is a Medicare Advantage (Part C) Plan by Alignment Health Plan.
This page features plan details for 2024 Alignment Health Sutter Advantage (HMO) H3815 – 023 – 0 available in Sonoma, San Mateo, San Francisco Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Alignment Health Sutter Advantage (HMO) is offered in the following locations.
Plan Overview
Alignment Health Sutter Advantage (HMO) offers the following coverage and cost-sharing.
| Insurer: | Alignment Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Alignment Health Sutter Advantage (HMO) ?
Premium Breakdown
Alignment Health Sutter Advantage (HMO) has a monthly premium of $48.00. 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 | $26.00 | $22.00 | $0.00 | $222.70 |
- 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 Sutter Advantage (HMO) 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 |
|---|---|
| $22.00 | $ |
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) | $5.00 copay | $5.00 copay | ||
| 3 (Preferred Brand) | $40.00 copay | $40.00 copay | ||
| 4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | ||
| 6 (Select Care Drugs) | $5.00 copay | $5.00 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) | $15.00 copay | $15.00 copay | ||
| 3 (Preferred Brand) | $120.00 copay | $120.00 copay | ||
| 4 (Non-Preferred Drug) | $300.00 copay | $300.00 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) | $5.00 copay | $5.00 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 Sutter Advantage (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,900 In-network |
| Yes |
| In-network | No |
| $250 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $5 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $25 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $15 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Restorative services | $20-350 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Endodontics | $15-295 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Periodontics | $15-375 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Extractions | $25-140 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $20-425 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| 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.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $0 copay (Authorization is required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| $225 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| 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.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is required.) |
| $0 per day for days 1 through 20 $160 per day for days 21 through 51 $0 per day for days 52 through 100 (Authorization is required.) (Referral is required.) |
| Monthly Premium | $27.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $27.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Alignment Health Sutter Advantage (HMO) ?
Table of Contents
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