2022 My Choice (PPO)

My Choice (PPO) H4961-003 is a 2022 Medicare Advantage Plan or Part-C by Alignment Health Plan available to residents in California. This plan includes additional prescription drug (Part-D) coverage. The My Choice (PPO) has a monthly premium of $97.00 and has an in-network maximum out-of-pocket limit of $4,200 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,200 out-of-pocket. This can be a extremely nice safety net.

My Choice (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Alignment Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for My Choice (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Alignment Health Plan and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Alignment Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Alignment Health Plan Medicare Advantage Plan Costs

My Choice (PPO) Part-C Premium

Alignment Health Plan charges a $90.90 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H4961-003 Part-D Deductible and Premium

My Choice (PPO) has a monthly drug premium of $6.10 and a $0.00 drug deductible. This Alignment Health Plan plan offers a $6.10 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Alignment Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $6.10 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Alignment Health Plan Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Alignment Health Plan plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The My Choice (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $1.50 for 75% low income subsidy $3.00 for 50% and $4.60 for 25%.

H4961-003 Formulary or Drug Coverage

My Choice (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 My Choice (PPO) H4961-003 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$0
Tier 2	NA	$5
Tier 3	NA	$40
Tier 4	NA	$100
Tier 5	NA	33%
Tier 6	NA	$5

*Initial Coverage Phase and 30 day supply

2021 My Choice (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

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

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$150 copay
Diagnostic tests and procedures	$0 copay
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Lab services	30% coinsurance (Out-of-Network)
Lab services	$0 copay
Outpatient x-rays	$15 copay
Outpatient x-rays	30% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$5 copay per visit
Primary	25% coinsurance per visit (Out-of-Network)
Specialist	$35 copay per visit
Specialist	25% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$85 copay per visit (always covered)
Urgent care	$0-10 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Foot exams and treatment	30% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$250 copay
30% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	30% coinsurance (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	30% coinsurance (Out-of-Network)
Hearing exam	$0 copay

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Inpatient Hospital Coverage

$150 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond
30% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	30% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	30% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$250 per stay $120 per day for days 1 through 10 $0 per day for days 11 through 90 $0 per day for days 91 through 130
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$6,000 In and Out-of-network $4,200 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

25% coinsurance per visit (Out-of-Network)
$195 copay per visit

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Package #1

Deductible
Monthly Premium	$22.70

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Preventive Care

$0 copay
30% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	$0 copay
Occupational therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$0 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $160 per day for days 21 through 51 $0 per day for days 52 through 100
30% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.