Sutter Advantage (HMO) is a Medicare Advantage (Part C) Plan by Alignment Health Plan.
This page features plan details for 2022 Sutter Advantage (HMO) H3815 – 019 – 0 available in Sacramento, Placer & Yolo Counties.
Sutter Advantage (HMO) is offered in the following locations.
Sutter Advantage (HMO) offers the following coverage and cost-sharing.
Insurer: | Alignment Health Plan |
Health Plan Deductible: | $0 |
MOOP: | $4,900.00 |
Drugs Covered: | Yes |
Ready to sign up for Sutter Advantage (HMO) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $0.00 | $19.00 | $0.00 | $189.10 |
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: | $4,430.00 |
Catastrophic Coverage Limit: | $7,050.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | Yes |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$19.00 | $14.20 | $9.50 | $4.70 | $0.00 |
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.
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
---|---|---|---|---|
6 (Select Care Drugs) | $5.00 copay | $5.00 copay |
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% |
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) |
Sutter Advantage (HMO) also provides the following benefits.
In-Network: No |
Diagnostic services: | $0 copay (authorization required) (referral required) |
Endodontics: | $15-295 copay (authorization required) (referral required) |
Extractions: | $25-140 copay (authorization required) (referral required) |
Non-routine services: | $0 copay (authorization required) (referral required) |
Periodontics: | $15-375 copay (authorization required) (referral required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | $20-425 copay (authorization required) (referral required) |
Restorative services: | $20-350 copay (authorization required) (referral required) |
Cleaning: | $0 copay (limits may apply) (authorization required) (referral required) |
Dental x-ray(s): | $0 copay (limits may apply) (authorization required) (referral required) |
Fluoride treatment: | $0 copay (limits may apply) (authorization required) (referral required) |
Oral exam: | $0 copay (limits may apply) (authorization required) (referral required) |
Diagnostic radiology services (e.g., MRI): | $150 copay (authorization required) (referral required) |
Diagnostic tests and procedures: | $0 copay |
Lab services: | $0 copay |
Outpatient x-rays: | $15 copay (authorization required) (referral required) |
Primary: | $5 copay per visit |
Specialist: | $25 copay per visit (authorization required) (referral required) |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $0 copay |
Foot exams and treatment: | $0 copay (authorization required) (referral required) |
Routine foot care: | Not covered |
$250 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral required) |
Hearing aids – inner ear: | Not covered |
Hearing aids – outer ear: | Not covered |
Hearing aids – over the ear: | Not covered |
Hearing exam: | $0 copay (authorization required) (referral required) |
$150 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond (authorization required) (referral required) |
$195 copay per visit (authorization required) (referral required) |
$4,900 In-network |
Diabetes supplies: | $0 copay (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Chemotherapy: | 20% coinsurance (authorization required) |
Other Part B drugs: | 20% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | $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) (referral required) |
Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
Outpatient group therapy visit: | $0 copay (authorization required) (referral required) |
Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
Outpatient individual therapy visit: | $0 copay (authorization required) (referral required) |
Yes |
$0 copay (authorization required) |
Occupational therapy visit: | $0 copay (authorization required) (referral required) |
Physical therapy and speech and language therapy visit: | $0 copay (authorization required) (referral 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 required) (referral required) |
Not covered |
Contact lenses: | $0 copay (limits may apply) (authorization required) |
Eyeglass frames: | $0 copay (limits may apply) (authorization required) |
Eyeglass lenses: | $0 copay (limits may apply) (authorization required) |
Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization required) |
Other: | Not covered |
Routine eye exam: | $0 copay (limits may apply) |
Upgrades: | Not covered |
Covered (authorization required) (referral required) |
Comprehensive dental: | Monthly Premium: | $29.00 |
Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Sutter Advantage (HMO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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