Saint Alphonsus Health Plan No Premium Choice (PPO)
H3828 - 001 - 0
(0 / 5)
Saint Alphonsus Health Plan No Premium Choice (PPO) is a Medicare Advantage Plan by Saint Alphonsus Health Plan.
This page features plan details for 2024 Saint Alphonsus Health Plan No Premium Choice (PPO) H3828 – 001 – 0 available in Select Counties in Idaho.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Saint Alphonsus Health Plan No Premium Choice (PPO) is offered in the following locations.
Plan Overview
Saint Alphonsus Health Plan No Premium Choice (PPO) offers the following coverage and cost-sharing.
| Insurer: | Saint Alphonsus Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,100 In and Out-of-network $6,100 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $150.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Saint Alphonsus Health Plan No Premium Choice (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
Saint Alphonsus Health Plan No Premium Choice (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 |
|---|---|---|---|---|
| $174.70 | $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
Saint Alphonsus Health Plan No Premium Choice (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $150.00 |
| 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 |
|---|---|
| $0.00 | $ |
Initial Coverage Phase
After you pay your $150.00 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 | $10.00 copay | $0.00 copay | |
| 2 (Generic) | $10.00 copay | $20.00 copay | $0.00 copay | |
| 3 (Preferred Brand) | $45.00 copay | $47.00 copay | $45.00 copay | |
| 4 (Non-Preferred Drug) | $95.00 copay | $100.00 copay | $95.00 copay | |
| 5 (Specialty Tier) | 30% | 30% | 30% |
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) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 copay | |
| 2 (Generic) | $30.00 copay | $60.00 copay | $0.00 copay | |
| 3 (Preferred Brand) | $135.00 copay | $141.00 copay | $90.00 copay | |
| 4 (Non-Preferred Drug) | $285.00 copay | $300.00 copay | $190.00 copay | |
| 5 (Specialty Tier) |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay | $0.00 copay | |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 copay | |
| Generic drugs | ||||
| Brand-name 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
Saint Alphonsus Health Plan No Premium Choice (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,100 In and Out-of-network $6,100 In-network |
| Yes |
| In-network | No |
| In-network | $5-275 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network | 30% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $30 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $60 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $30 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 30% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $15 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient x-rays | $20 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $60-899 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $60-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fluoride treatment | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic services | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Restorative services | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Endodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Endodontics | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Periodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Periodontics | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Extractions | $0 copay or 50-70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass frames | $0-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglass lenses | $0-50 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $250 copay (Not applicable.) (Not applicable.) |
| out-of-network | $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $60 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| out-of-network Diabetes supplies | 30% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $35 copay or 0-30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $35 copay or 0-30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $35 copay or 0-30% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 30% per stay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $60 copay (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 56 $0 per day for days 57 through 100 (Authorization is not required.) (Referral is not required.) |
| out-of-network | 30% per stay (Authorization is not required.) (Referral is not required.) |
| Monthly Premium | $21.00 |
| Deductible | nan |
| Monthly Premium | $49.00 |
| Deductible | nan |
Optional Benefits
Package #1
| Comprehensive dental: | Monthly Premium: | $21.00 |
| Comprehensive dental: | Deductible: | N/A |
Package #2
| Comprehensive dental: | Monthly Premium: | $49.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Saint Alphonsus Health Plan No Premium Choice (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
Table of Contents
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