2022 Balance (PPO)

Balance (PPO) H4961-006 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 Balance (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $2,850 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,850 out-of-pocket. This can be a extremely nice safety net.

Balance (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 Balance (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

Balance (PPO)
Plan ID:
Provider:Alignment Health Plan
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $2,850
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H4961-007
New Plan: 2023 H4961-007

Balance (PPO) Part-C Premium

Alignment Health Plan charges a $0.00 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.

H4961-006 Part-D Deductible and Premium

Balance (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Alignment Health Plan plan offers a $0.00 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 $0.00 . 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.

H4961-006 Formulary or Drug Coverage

Balance (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 Balance (PPO) H4961-006 Formulary here.

Drug Tier Copay
Tier 1 NA $0
Tier 2 NA $3
Tier 3 NA $40
Tier 4 NA $93
Tier 5 NA 33%
Tier 6 NA $3
*Initial Coverage Phase and 30 day supply

2021 Balance (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

Additional Benefits


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



Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI) 30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI) $0 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 $0 copay
Outpatient x-rays 30% coinsurance (Out-of-Network)

Doctor Visits

Primary 25% coinsurance per visit (Out-of-Network)
Primary $0 copay
Specialist $0 copay
Specialist 25% coinsurance per visit (Out-of-Network)

Emergency care/Urgent Care

Emergency $75 copay per visit (always covered)
Urgent care $0-10 copay per visit (always covered)

Foot Care (podiatry services)

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

Ground Ambulance

$100 copay
30% coinsurance (Out-of-Network)


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

Inpatient Hospital Coverage

30% per stay (Out-of-Network)
$0 copay

Medical Equipment/Supplies

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

Medicare Part B Drugs

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

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 $40 copay
Outpatient group therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
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


$5,150 In and Out-of-network
$2,850 In-network



Optional supplemental benefits


Outpatient Hospital Coverage

25% coinsurance per visit (Out-of-Network)
$50 copay per visit

Package #1

Monthly Premium $22.70

Preventive Care

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

Preventive Dental

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

Rehabilitation Services

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

Skilled Nursing Facility

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


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


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

Wellness Programs (e.g. fitness nursing hotline)


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Coverage Area for Balance (PPO)

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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.

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