2026 Alignment Health Retiree Options MAPD (PPO)
2026 Alignment Health Retiree Options MAPD (PPO) Plan Details
Contract/PBP# H4961-801-009
Alignment Health Plan Retiree Options (PPO) is a Medicare Advantage Plan with Part D, that provides coverage from any provider who accepts Medicare and is willing to bill Alignment Health. Copays for services are the same In-Network and Out-of-Network.
Alignment Health is required to cover all Part A and Part B services. However, cost sharing and provider access in this plan differ from Original Medicare.
This document is a summary. Please refer to the plan Evidence of Coverage (EOC) * coming soon * for more details.
Basics
Deductible:
$0
Office co-pay:
$0 copay
Coinsurance:
Alignment Health's plan is a copay structure. Therefore, "coinsurance" is not available.
Out-of-Pocket Maximum:
$1,000
Overall Lifetime Maximum Benefit:
No Maximum
Maternity
Maternity Hospital Stay:
Medicare-Approved: $0 copay
Baby's First Exam:
Not covered
Birthing Centers:
Medicare Approved: $0 copay
Midwives:
Medicare Approved Only
Prenatal and Postnatal Physician Office Visits:
Medicare Approved: $0 copay
Doctor Delivery Charge:
Covered the same as all other inpatient surgery
Reproductive Health:
Medicare Approved: $0 copay
Mental Health/Autism/Substance Abuse
Mental Health:
In and Out-of-Network
$0.00 copay for each Medicare-covered individual or group therapy visit with a mental health professional.
$0.00 copay for each Medicare-covered individual or group therapy visit with a psychiatrist.
$0.00 copay for each Medicare-covered individual or group therapy visit with a mental health professional.
$0.00 copay for each Medicare-covered individual or group therapy visit with a psychiatrist.
Substance Abuse:
In and Out-of-Network
$0.00 copay for each Medicare-covered individual and group substance abuse outpatient treatment visit.
$0.00 copay for each Medicare-covered individual and group substance abuse outpatient treatment visit.
Prescription Drugs
Pharmacy (Retail):
Retail: 30/60/90 days:
T1: Preferred Generic: $10/$20/$20
T2: Generic: $10/$20/$20
T3: Preferred Brand: $30/$60/$60
T4: Non-Preferred: $75/$150/$150
T5: Specialty: $30 (one month only)
T6: Select Care: $10/$20/$0
Covered Insulins ONLY - Member won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
T1: Preferred Generic: $10/$20/$20
T2: Generic: $10/$20/$20
T3: Preferred Brand: $30/$60/$60
T4: Non-Preferred: $75/$150/$150
T5: Specialty: $30 (one month only)
T6: Select Care: $10/$20/$0
Covered Insulins ONLY - Member won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
Mail order drug program:
Mail Order: 90-100 days
T1: Preferred Generic: $20
T2: Generic: $20
T3: Preferred Brand: $60
T4: Non-Preferred: $150
T5: Specialty: Not Covered
T6: Select Care: $0
T1: Preferred Generic: $20
T2: Generic: $20
T3: Preferred Brand: $60
T4: Non-Preferred: $150
T5: Specialty: Not Covered
T6: Select Care: $0
Birth Control Pills:
Included in Prescription Drug benefit
Preventive Care
Physical exams for adults:
$0
Physical exams for children:
Not covered
Pap smears:
$0
Mammograms:
$0
Immunizations:
$0
Prostate Specific Antigen test - PSA:
$0
Well-woman visits:
$0
Other Services
Acupuncture:
In Network & Out-of-Network
$0 copay for 24 Routine visits every year(combined with Chiropractic)
$0 copay for 24 Routine visits every year(combined with Chiropractic)
Allergy Tests:
$0 copay
Allergy Treatment:
$0 copay
Alternative Medicine:
Not covered
Ambulance charges:
$0 copay for Medicare-covered ground ambulance benefits.
$0 copay for Medicare-covered air ambulance benefits.
$0 copay for Medicare-covered air ambulance benefits.
Benefit Perks:
- Fitness Benefit.
- Telehealth services
- OTC Items: $20/mo., no rollover
- ACCESS-On-Demand Black Card
- Telehealth services
- OTC Items: $20/mo., no rollover
- ACCESS-On-Demand Black Card
CT and PET Scans (Complex Imaging):
$0 copay. May require approval in advance.
Chiropractors:
Network & Out-of-Network
$0 copay for 24 Routine visits every year(combined with Acupuncture)
$0 copay for 24 Routine visits every year(combined with Acupuncture)
Christian Science Practitioners:
Not covered
Cosmetic Surgery:
Not covered
Dental Treatment:
Medicare covered only
Emergency Room:
$100. Waived if admitted within 48 hrs.
Includes worldwide coverage. Emergency and Urgently Needed care outside of the U.S. is limited to $25,000.00 per calendar year combined benefit with urgently needed care.
Includes worldwide coverage. Emergency and Urgently Needed care outside of the U.S. is limited to $25,000.00 per calendar year combined benefit with urgently needed care.
Urgent Care:
$0
Hearing Care:
$0 for exam/yr.
$195.00 - $1,750.00 copay per hearing aid. 2 hearing aids every year.
$195.00 - $1,750.00 copay per hearing aid. 2 hearing aids every year.
Home Health Care:
$0
Hospice Care:
$0
Hospital Stay:
In-Network & Out-of-Network
$0 copay
(unlimited days per admission)
$0 copay
(unlimited days per admission)
Infertility Treatment:
Not covered
Laboratory Charges:
$0
Magnetic Resonance Imaging (MRI) (Complex Imaging):
$0 copay. May require approval in advance.
Meals:
Not covered
Durable Medical Equipment:
$0
Occupational Therapy:
$0
Organ Transplants:
Contact Alignment Health for information on transplant coverage benefits.
Skilled Nursing:
$0 for days 1- 100. No prior hospital stay required.
Physical Therapy:
$0
Surgery : Facility Charges:
$0
Surgery : Physician Services:
$0
Transgender Services:
Not covered
Transportation:
Not covered
Travel and Lodging:
Contact the plan for details
Vasectomy:
Not covered
Vision care:
$0 copay for exam/yr.
$0 copay for glasses/contacts every year. ($150 coverage limit)
$0 copay for glasses/contacts every year. ($150 coverage limit)
X-rays (Basic Imaging):
$0