Balance (PPO)
H4961 - 006 - 0
(0 / 5)
Balance (PPO) is a Medicare Advantage Plan by Alignment Health Plan.
This page features plan details for 2022 Balance (PPO) H4961 – 006 – 0 available in San Joaquin and Stanislaus.
IMPORTANT: This page features the 2022 version of this plan. See the 2025 version using the link below:
Locations
Balance (PPO) is offered in the following locations.
Plan Overview
Balance (PPO) offers the following coverage and cost-sharing.
| Insurer: | Alignment Health Plan |
| Health Plan Deductible: | $0 |
| MOOP: | $2,850.00 |
| Drugs Covered: | Yes |
Ready to sign up for Balance (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Balance (PPO) 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 |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $ |
- 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
Balance (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| 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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
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 $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
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 |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
| 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 $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Balance (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | Not covered |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
Dental (preventive)
| Cleaning: | Not covered |
| Dental x-ray(s): | Not covered |
| Fluoride treatment: | Not covered |
| Oral exam: | Not covered |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 30% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0 copay |
| Diagnostic tests and procedures: | Out-of-Network: 30% coinsurance |
| Lab services: | In-Network: $0 copay |
| Lab services: | Out-of-Network: 30% coinsurance |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 30% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $25 copay per visit |
| Specialist: | In-Network: $0 copay (authorization required) |
| Specialist: | Out-of-Network: $25 copay per visit (authorization required) |
Emergency care/Urgent care
| Emergency: | $75 copay per visit (always covered) |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $0 copay (authorization required) |
| Foot exams and treatment: | Out-of-Network: 30% coinsurance (authorization required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $100 copay | |
| Out-of-Network: 30% coinsurance |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization required) |
| Fitting/evaluation: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Hearing aids – inner ear: | Not covered |
| Hearing aids – outer ear: | Not covered |
| Hearing aids – over the ear: | Not covered |
| Hearing exam: | In-Network: $0 copay (authorization required) |
| Hearing exam: | Out-of-Network: 30% coinsurance (authorization required) |
Hospital coverage (inpatient)
| In-Network: $0 copay (authorization required) | |
| Out-of-Network: 30% per stay (authorization required) |
Hospital coverage (outpatient)
| In-Network: $50 copay per visit (authorization required) | |
| Out-of-Network: 25% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $5,150 In and Out-of-network $2,850 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay (authorization required) |
| Diabetes supplies: | Out-of-Network: 30% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 0-20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 30% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 30% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 30% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 30% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $120 per day for days 1 through 10 $0 per day for days 11 through 90 $0 per day for days 91 through 130 (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 30% per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) |
| Outpatient group therapy visit: | In-Network: $0 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: 30% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) |
| Outpatient individual therapy visit: | In-Network: $0 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: 30% coinsurance (authorization required) |
Optional supplemental benefits
| Yes |
Preventive care
| In-Network: $0 copay (authorization required) | |
| Out-of-Network: 30% coinsurance (authorization required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $0 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 30% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $0 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 30% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $50 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 30% per stay (authorization required) |
Transportation
| In-Network: $0 copay (limits may apply) (authorization required) (referral required) | |
| Out-of-Network: 30% coinsurance (limits may apply) (authorization required) (referral required) |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization required) |
| Contact lenses: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglass lenses: | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | Out-of-Network: 30% coinsurance (limits may apply) (authorization required) |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) |
| Routine eye exam: | Out-of-Network: 30% coinsurance (limits may apply) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization required) |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $29.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Balance (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST