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Alignment Health Balance (PPO)

H4961 - 006 - 0
4.5 out of 5 stars (4.5 / 5)

Alignment Health Balance (PPO) is a Medicare Advantage Plan by Alignment Health Plan.

This page features plan details for 2025 Alignment Health Balance (PPO) H4961 – 006 – 0 available in San Joaquin and Stanislaus.

Locations

Alignment Health Balance (PPO) is offered in the following locations.

California
San Joaquin County, California
Stanislaus County, California

Click to see more locations

Plan Overview

Alignment Health Balance (PPO) offers the following coverage and cost-sharing.

Insurer:Alignment Health Plan
Health Plan Deductible:$0
MOOP:$5,150 In and Out-of-network
$2,850 In-network
Drugs Covered:Yes

Ready to sign up for Alignment Health 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

Alignment Health Balance (PPO) has a monthly premium of $41.00. 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
$185.00 $41.00 $0.00 $ $
Please Note:
  • 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 Balance (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

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 DLIS Full
$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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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 Balance (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0 copay (Authorization Required)
  • Lab services
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)

Doctor visits

  • Specialist
    • In-Network: $0 copay
  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $25 copay per visit
  • Specialist
    • Out-of-Network: $25 copay per visit

Emergency care/Urgent care

  • Emergency
    • $75 copay per visit (always covered)
  • Urgent care
    • $0 copay

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $0 copay
    • Out-of-Network: 30% coinsurance

Ground ambulance

    • In-Network: $100 copay
    • Out-of-Network: 30% coinsurance

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Hearing aids – outer ear
    • Not covered
  • Hearing aids – over the ear
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $0 copay
    • Out-of-Network: 30% coinsurance
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Hearing aids – inner ear
    • Not covered

Inpatient hospital coverage

    • Out-of-Network: 20% per stay (Authorization Required)
    • In-Network: $75 per day for days 1 through 3
      $0 per day for days 4 through 90 (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)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit
    • In-Network: $0 copay
  • Outpatient individual therapy visit
    • Out-of-Network: 30% coinsurance
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: 30% coinsurance
  • Inpatient hospital – psychiatric
    • In-Network: $120 per day for days 1 through 10
      $0 per day for days 11 through 90 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 30% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: 30% coinsurance
  • Outpatient individual therapy visit
    • In-Network: $0 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 25% coinsurance per visit (Authorization Required)
    • In-Network: $200 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: 30% coinsurance
    • In-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Occupational therapy visit
    • In-Network: $0 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 30% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $50 per day for days 21 through 100 (Authorization Required)

Transportation

    • Out-of-Network: 30% coinsurance (Limits Apply, Authorization Required)
    • In-Network: $0 copay (Limits Apply, Authorization Required)

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Upgrades
    • Not covered
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Contact lenses
    • Out-of-Network: 30% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Enhanced Dental

Comprehensive Dental

  • Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Prosthodontics, fixed, Oral and Maxillofacial Surgery
    • Monthly Premium: $36.00
    • Max Coverage: $1500.00
    • Coverage Periodicity: Every year

Diagnostic and Preventive Dental

  • Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), Fluoride Treatment
    • Monthly Premium: $36.00
    • Max Coverage: $1500.00
    • Coverage Periodicity: Every year

Ready to sign up for Alignment Health 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

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