Align ChoiceElite (PPO) H8385-001 is a 2023 Medicare Advantage Plan or Part-C by Sanford Health Plan available to residents in South Dakota and Iowa. This plan includes extra prescription drug (Part-D) coverage. Sanford Health Plan Align ChoiceElite (PPO) has a monthly premium of $49.00 and has an in-network maximum out-of-pocket limit of $3,750 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,750 out-of-pocket. This can be an extremely nice safety net.

Sanford Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Align ChoiceElite (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Sanford Health Plan and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Sanford Health Plan except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in South Dakota or Medicare Advantage in Iowa.

2023 Sanford Health Plan Medicare Advantage Plan Overview

What type of plan is Align ChoiceElite (PPO)

Align ChoiceElite (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.

How much does Align ChoiceElite (PPO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Sanford Health Plan charges a $49.00 consolidated premium. The Part C premium is $10.40 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Align ChoiceElite (PPO) has a monthly drug premium of $38.60 and a $150.00 drug deductible. This Sanford Health Plan plan offers a $38.60 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. This Premium covers any enhanced plan benefits offered by Sanford Health Plan above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $38.60. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Sanford Health Plan Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This Sanford Health Plan plan does not offer extra coverage through the gap.

Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Align ChoiceElite (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.60 for 75% low-income subsidy $19.30 for 50% and $28.90 for 25%.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Align ChoiceElite (PPO) by Sanford Health Plan MOOP is $3,750. Once you spend $3,750 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Align ChoiceElite (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.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$2
Tier 2	$4	$10
Tier 3	$42	$47
Tier 4	$100	$100
Tier 5	30%	30%

The complete Align ChoiceElite (PPO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Align ChoiceElite (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Sanford Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

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

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Contact lenses

In-Network Vision	$0 copay
Out-of-Network Vision	0-50% coinsurance

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Eyeglass frames

Vision	Not covered

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Eyeglass lenses

Vision	Not covered

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Eyeglasses (frames and lenses)

In-Network Vision	$0 copay
Out-of-Network Vision	0-50% coinsurance

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Other

Vision	Not covered

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Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	0-50% coinsurance

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Upgrades

In-Network Vision	$0 copay
Out-of-Network Vision	0-50% coinsurance

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $184 per day for days 21 through 42 $0 per day for days 43 through 100
Out-of-Network Skilled Nursing Facility	$184 per stay $0 per day for days 1 through 20 $184 per day for days 21 through 100

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Occupational therapy visit

In-Network Rehabilitation services	$30 copay
Out-of-Network Rehabilitation services	$10-90 copay or 20% coinsurance

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Physical therapy and speech and language therapy visit

Out-of-Network Rehabilitation services	$10-90 copay or 20% coinsurance
In-Network Rehabilitation services	$40 copay

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Cleaning

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	50% coinsurance

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Dental x-ray(s)

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
Out-of-Network Outpatient hospital coverage	$10-450 copay or 20% coinsurance per visit
In-Network Outpatient hospital coverage	$0-150 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

In-Network Mental health services	$350 per stay
Out-of-Network Mental health services	In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90

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Outpatient group therapy visit

Out-of-Network Mental health services	$10-90 copay or 20% coinsurance
In-Network Mental health services	$0 copay

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Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	$10-90 copay or 20% coinsurance
In-Network Mental health services	$0 copay

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Outpatient individual therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$10-90 copay or 20% coinsurance

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$10-90 copay or 20% coinsurance

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Chemotherapy

In-Network Medicare Part B drugs	$100 copay or 20% coinsurance
Out-of-Network Medicare Part B drugs	0-20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	0-20% coinsurance

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Diabetes supplies

Out-of-Network Medical equipment/supplies	0-20% coinsurance per item
In-Network Medical equipment/supplies	$0 copay

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Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	0-20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	0-20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$3,750 In and Out-of-network $3,750 In-network
Out-of-Network Inpatient hospital coverage	In 2023 the amounts for each benefit period are: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
In-Network Inpatient hospital coverage	$350 per stay

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Fitting/evaluation

Hearing	Not covered

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Hearing aids

Out-of-Network Hearing	0-50% coinsurance
In-Network Hearing	$0 copay

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Hearing exam

Out-of-Network Hearing	0-50% coinsurance
In-Network Hearing	$0 copay

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Health plan deductible	$0
In-Network Ground ambulance	$240 copay
Out-of-Network Ground ambulance	$240 copay

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Foot exams and treatment

In-Network Foot care (podiatry services)	$0-30 copay
Out-of-Network Foot care (podiatry services)	$10-90 copay or 20% coinsurance

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

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

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Urgent care

Emergency care/Urgent care	$30 copay per visit (always covered)

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$10-90 copay or 20% coinsurance per visit

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Specialist

Out-of-Network Doctor visits	$10-90 copay or 20% coinsurance per visit
In-Network Doctor visits	$0 copay

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-165 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$10-450 copay or 20% coinsurance

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$10-450 copay or 20% coinsurance

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$10-450 copay or 20% coinsurance

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$15 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$10-450 copay or 20% coinsurance

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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Extractions

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

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Prosthodontics, other oral/maxillofacial surgery, other services

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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Restorative services

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Align ChoiceElite (PPO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.