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Alignment Health Plan

Plan ID: H5472-3-0

Alignment Health smartHMO (HMO-POS)

2024 Alignment Health smartHMO (HMO-POS) H5472 — 003 — 0 is a Medicare Advantage plan with drug coverage.

Learn more about Alignment Health smartHMO (HMO-POS) H5472 - 003 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

$0.00 /mo

Monthly premium

Health deductible

$545.00

Drug deductible

$5000.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 Alignment Health smartHMO (HMO-POS) H5472 — 003 — 0 is a Local HMO offered in El Paso, Hudspeth by Alignment Health Plan. It has a monthly premium of $0.00 and includes a Part B premium discount of $164.90.

Premium Breakdown

Standard Part B Premium

$174.70

Part B premium reduction

- $164.90

Monthly Plan Premium

$0.00

Total Premium:

$9.80

Note:

The standard Part B premium for 2024 is $174.70. Your Part B premium may differ based on factors including late enrollment, income, and disability status. Higher-income beneficiaries may pay an income-related monthly adjustment amount (IRMAA). The Part B premium is required to be paid by everyone enrolled in Medicare Part B.

Special needs plan type

Out-of-pocket maximum

$5000.00

Plan Organization:

Alignment Health Plan

Plan Type:

Local HMO

Location:

El Paso, Hudspeth

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Plan Doctors Only (some exceptions)

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Drug deductible

$545

Note:

This plan does not charge an annual deductible for all drugs. The $545.00 annual deductible only applies to drugs in certain tiers.

Other Plan Notes

This plan does not charge an annual deductible for all drugs. The $545 annual deductible only applies to drugs on certain tiers.

Sign up for Alignment Health smartHMO (HMO-POS)

Enroll online

Call to enroll

Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Alignment Health smartHMO (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced

Prescription drug deductible

$545.00

Increased initial coverage limit

Additional gap coverage

Yes

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$0.00	$0.00	$0.00	$0.00	$0.00

Initial Coverage Phase

After you pay your $545.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	$0.00 copay	-	$0.00 copay
2. Standard Generic	-	$0.00 copay	-	$0.00 copay
3. Preferred Brand	-	$45.00 copay	-	$45.00 copay
4. Non-Preferred Drug	-	$100.00 copay	-	$100.00 copay
5. Specialty Tier	-	25%	-	25%

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

30 Days

60 Days

90 Days

Tier	Preffered Pharmacy	Standard Pharmacy	Preffered Mail	Standard Mail
Preferred Generic	-	$0.00 copay	-	$0.00 copay
Select Care Drugs	-	$5.00 copay	-	$5.00 copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

Additional Benefits

Alignment Health smartHMO (HMO-POS) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

Not covered

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

Not covered

Preventive dental

Oral exam

In-Network: $0 copay

Cleaning

In-Network: $0 copay

Fluoride treatment

In-Network: $0 copay

Dental x-ray(s)

In-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $0 copay

Lab services

In-Network: $0 copay

Diagnostic radiology services (eg, MRI)

In-Network: $0 copay

Outpatient x-rays

In-Network: $0 copay

Doctor visits

Primary

In-Network: $0 copay

Specialist

In-Network: $20 copay per visit

Emergency care/Urgent care

Emergency

$120 copay per visit (always covered)

Urgent care

$20 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $5 copay

Routine foot care

Not covered

Ground ambulance

Service

In-Network: $200 copay

Hearing

Hearing exam

In-Network: $0 copay

Fitting/evaluation

In-Network: $0 copay

Hearing aids - inner ear

Not covered

Hearing aids - outer ear

Not covered

Hearing aids - over the ear

Not covered

Inpatient hospital coverage

Service

In-Network: $300 per day for days 1 through 3 $0 per day for days 4 through 90

Out-Of-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90

Outpatient hospital coverage

Service

In-Network: $200 copay per visit

Outpatient prescription drugs

Alignment Health smartHMO (HMO-POS) does not provide this type of benefit.

Optional benefits

Alignment Health smartHMO (HMO-POS) does not provide this type of benefit.

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 20% coinsurance per item

Diabetes supplies

In-Network: $0 copay

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Part B Insulin drugs

In-Network: 0-20% coinsurance (up to $35)

Mental health services

Inpatient hospital - psychiatric

In-Network: $120 per day for days 1 through 10 $0 per day for days 11 through 90

Out-Of-Network: Not Applicable

Outpatient group therapy visit with a psychiatrist

In-Network: $20 copay

Outpatient individual therapy visit with a psychiatrist

In-Network: $20 copay

Outpatient group therapy visit

In-Network: $10 copay

Outpatient individual therapy visit

In-Network: $10 copay

Preventive care

Service

In-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: $0 copay

Physical therapy and speech and language therapy visit

In-Network: $0 copay

Skilled Nursing Facility

Service

In-Network: $20 per day for days 1 through 20 $100 per day for days 21 through 100

Out-Of-Network: Not Applicable

Transportation

Service

Not covered

Vision

Routine eye exam

In-Network: $0 copay

Other

Not covered

Contact lenses

In-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Eyeglass frames

In-Network: $0 copay

Eyeglass lenses

In-Network: $0 copay

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Enroll Online

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