Go Back

Alignment Health My Choice Select (HMO)

H3815 - 049 - 0

(4 / 5)

Alignment Health My Choice Select (HMO) is a Medicare Advantage Plan by Alignment Health Plan.

This page features plan details for 2025 Alignment Health My Choice Select (HMO) H3815 – 049 – 0 available in Los Angeles, Orange, Riverside, San Bernardino.

Locations

Alignment Health My Choice Select (HMO) is offered in the following locations.

California

Los Angeles County, California

Orange County, California

Click to see more locations

Plan Overview

Alignment Health My Choice Select (HMO) offers the following coverage and cost-sharing.

Insurer:	Alignment Health Plan
Health Plan Deductible:	$0
MOOP:	$798 In-network
Drugs Covered:	Yes

Ready to sign up for Alignment Health My Choice Select (HMO) ?

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 My Choice Select (HMO) 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
$185.00	$0.00	$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 My Choice Select (HMO) 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 D	LIS 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.

30 Day

60 Day

90 Day

30 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$5.00 Copay	$5.00 Copay
3) Preferred Brand	$30.00 Copay	$30.00 Copay
4) Non-Preferred Drug	$100.00 Copay	$100.00 Copay
6) Select Care Drugs	$3.00 Copay	$3.00 Copay

60 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$10.00 Copay	$10.00 Copay
3) Preferred Brand	$60.00 Copay	$60.00 Copay
4) Non-Preferred Drug	$200.00 Copay	$200.00 Copay
6) Select Care Drugs	$6.00 Copay	$6.00 Copay

90 Day

Tier	Std. Pharm	Std. Mail
1) Preferred Generic
2) Generic	$15.00 Copay	$12.50 Copay
3) Preferred Brand	$90.00 Copay	$75.00 Copay
4) Non-Preferred Drug	$300.00 Copay	$300.00 Copay
6) Select Care Drugs

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 My Choice Select (HMO) also provides the following benefits.

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

- In-Network: No

Comprehensive Dental

Endodontics
- In-Network: No Coins – 25.00-350.00 Copay (Limits Apply)
Oral and Maxillofacial Surgery
- In-Network: No Coins – 25.00-250.00 Copay (Limits Apply)
Periodontics
- In-Network: No Coins – 15.00-550.00 Copay (Limits Apply)
Prosthodontics, fixed
- In-Network: No Coins – 40.00-400.00 Copay (Limits Apply)
Prosthodontics, removable
- In-Network: No Coins – 20.00-570.00 Copay (Limits Apply)
Restorative Services
- In-Network: No Coins – 20.00-400.00 Copay (Limits Apply)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures
- $0 copay
Outpatient x-rays
- $0 copay (Authorization Required, Referral Required)
Diagnostic radiology services (e.g., MRI)
- $0 copay (Authorization Required, Referral Required)
Lab services
- $0 copay

Doctor visits

Primary
- $0 copay
Specialist
- $0 copay (Authorization Required, Referral Required)

Emergency care/Urgent care

Urgent care
- $0 copay
Emergency
- $70 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $0 copay (Authorization Required, Referral Required)
Routine foot care
- $0 copay (Authorization Required, Referral Required)

Ground ambulance

- $75 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $0 copay
Fitting/evaluation
- $0 copay (Limits Apply)
Hearing aids
- $195-1,750 copay (Limits Apply)

Inpatient hospital coverage

- $0 copay (Authorization Required, Referral Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $798 In-network

Medical equipment/supplies

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)
Diabetes supplies
- $0 copay (Authorization Required)

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- $120 per day for days 1 through 10
  $0 per day for days 11 through 90 (Authorization Required, Referral Required)
Outpatient individual therapy visit
- $0 copay (Authorization Required, Referral Required)
Outpatient individual therapy visit with a psychiatrist
- $20 copay (Authorization Required, Referral Required)
Outpatient group therapy visit with a psychiatrist
- $20 copay (Authorization Required, Referral Required)
Outpatient group therapy visit
- $0 copay (Authorization Required, Referral Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $0 copay (Authorization Required, Referral Required)

Preventive care

- $0 copay

Rehabilitation services

Occupational therapy visit
- $0 copay (Authorization Required, Referral Required)
Physical therapy and speech and language therapy visit
- $0 copay (Authorization Required, Referral Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $30 per day for days 21 through 100 (Authorization Required, Referral Required)

Transportation

- $0 copay (Limits Apply, Authorization Required)

Vision

Upgrades
- Not covered
Eyeglass lenses
- $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Other
- Not covered
Contact lenses
- $0 copay (Limits Apply)
Eyeglass frames
- $0 copay (Limits Apply)
Routine eye exam
- $0 copay (Limits Apply)

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

- Covered (Authorization Required)