Alignment Health Balance Plus 004 (PPO)
Available to residents of San Joaquin County, CA for 2027. Contract H8832, plan 004, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in San Joaquin County
- Plan website
- Browse the Alignment Health Balance Plus 004 (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every CA plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $7.30 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $7.30? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,850.00? |
| In- and out-of-network out-of-pocket maximum | $11,950.00 |
| Drug deductible | $700.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H8832-004-0 |
| Offered by | Alignment Health Plan |
| Parent organization | Alignment Healthcare USA, LLC |
| Formulary tiers | 6 |
| Formulary exception tier | 4? |
| Pharmacy search | www.alignmenthealthplan.com |
| Member services | (888)979-2247TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H8832 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | 20% coinsurance | 20% coinsurance |
| Specialist | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Other health care professional | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Additional telehealth services | $0–$20 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | 20% coinsurance |
| Annual physical exam | 20% coinsurance | 20% coinsurance |
| Kidney disease education | 20% coinsurance | 20% coinsurance |
| Glaucoma screening | $0 copay | 20% coinsurance |
| Diabetes self-management training | $0 copay | 20% coinsurance |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Lab services | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient x-rays | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Emergency and urgent care | ||
| Emergency room | 20% coinsurance | — |
| Urgent care | $0 copay | — |
| Worldwide emergency coverage | $0 copay · $25,000 plan limit | — |
| Worldwide urgent care | $0 copay · $25,000 plan limit | — |
| Worldwide emergency transportation | Not covered | — |
| Hospital care | ||
| Inpatient hospital stay | Original Medicare cost-sharing; Original Medicare cost-sharing(authorization and referral required) | 20% coinsurance per stay |
| Outpatient hospital services | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient observation | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Ambulatory surgical center | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient blood services | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | Original Medicare cost-sharing; Original Medicare cost-sharing(authorization and referral required) | 20% coinsurance per stay |
| Home health care | $0 copay(authorization and referral required) | 20% coinsurance |
| Kidney dialysis | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Physical therapy and speech-language therapy | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Cardiac rehabilitation | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Pulmonary rehabilitation | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing; Original Medicare cost-sharing(authorization and referral required) | 20% coinsurance per stay |
| Outpatient mental health, individual session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient mental health, group session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Psychiatrist, individual session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Psychiatrist, group session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Partial hospitalization | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Intensive outpatient program | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient substance use, individual session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Outpatient substance use, group session | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Opioid treatment program | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Air ambulance | 20% coinsurance(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 20% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 20% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 20% coinsurance |
| Diabetes supplies | $0 copay(authorization required) | 20% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 20% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Routine chiropractic care | $0 copay(authorization and referral required) | 20% coinsurance |
| Acupuncture | $0 copay(authorization and referral required) | 20% coinsurance |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance(authorization and referral required) | 20% coinsurance |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | 20% coinsurance(authorization required) | 20% coinsurance |
| Oral exams | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Cleanings | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Fluoride treatment | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Dental x-rays | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Other diagnostic dental services | Not covered | — |
| Other preventive dental services | Not covered | — |
| Comprehensive dental plan limit | $175 plan limit every three months | — |
| Restorative services (fillings, crowns) | $0 copay(authorization required) | 20% coinsurance |
| Endodontics (root canals) | $0 copay(authorization required) | 20% coinsurance |
| Periodontics (gum disease) | $0 copay(authorization required) | 20% coinsurance |
| Dentures and other removable prosthodontics | $0 copay(authorization required) | 20% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | $0 copay(authorization required) | 20% coinsurance |
| Oral and maxillofacial surgery | $0 copay(authorization required) | 20% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | Not covered | — |
| Vision? | ||
| Eye exam (Medicare-covered) | $0 copay | 20% coinsurance |
| Routine eye exam | $0 copay(limits apply) | 20% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | 20% coinsurance |
| Eyewear plan limit | $500 plan limit every two years | — |
| Contact lenses | $0 copay(limits apply) | 20% coinsurance |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | 20% coinsurance |
| Eyeglass lenses | $0 copay(limits apply) | 20% coinsurance |
| Eyeglass frames | $0 copay(limits apply) | 20% coinsurance |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $0 copay | 20% coinsurance |
| Routine hearing exam | $0 copay(limits apply) | 20% coinsurance |
| Hearing aid fitting and evaluation | $0 copay(limits apply) | 20% coinsurance |
| Hearing aids (all types) | $0 copay(limits apply) | 20% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 20% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Not covered | — |
| Meals after a hospital stay or for a chronic condition | $0 copay | 20% coinsurance |
| Fitness benefit | $0 copay(authorization required, limits apply) | $0 copay |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | Not covered | — |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | $0 copay(authorization required, limits apply) | 20% coinsurance |
| Support for caregivers | $0 copay(authorization required, limits apply) | 20% coinsurance |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | 25% |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 28% |
| Tier 5 · Specialty Tier | 25% |
| Tier 6 · Select Care Drugs | $5.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 28% | 28% | 28% | 28% | 28% | 28% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $5.00 | $5.00 | $5.00 | $0.00 | $0.00 | $0.00 |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 5 out of 5 stars for Breast Cancer Screening | too new |
| Colorectal Cancer Screening · C02 | 5 out of 5 stars for Colorectal Cancer Screening | too new |
| Annual Flu Vaccine · C03 | 4 out of 5 stars for Annual Flu Vaccine | too new |
| Managing Chronic (Long Term) Conditions | ||
| Diabetes Care – Eye Exam · C11 | 3 out of 5 stars for Diabetes Care – Eye Exam | too new |
| Diabetes Care – Blood Sugar Controlled · C12 | 5 out of 5 stars for Diabetes Care – Blood Sugar Controlled | too new |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 3 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | too new |
| Controlling High Blood Pressure · C14 | 5 out of 5 stars for Controlling High Blood Pressure | too new |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 3 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | too new |
| Transitions of Care · C19 | 4 out of 5 stars for Transitions of Care | too new |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 4 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | too new |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 3 out of 5 stars for Getting Needed Care | too new |
| Customer Service · C23 | 2 out of 5 stars for Customer Service | too new |
| Rating of Health Care Quality · C24 | 3 out of 5 stars for Rating of Health Care Quality | too new |
| Rating of Health Plan · C25 | 3 out of 5 stars for Rating of Health Plan | too new |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 2 out of 5 stars for Complaints about the Health Plan | too new |
| Members Choosing to Leave the Plan · C28 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 2 out of 5 stars for Complaints about the Drug Plan | too new |
| Members Choosing to Leave the Plan · D03 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 4 out of 5 stars for Rating of Drug Plan | too new |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | too new |
| Medication Adherence for Diabetes Medications · D08 | 4 out of 5 stars for Medication Adherence for Diabetes Medications | too new |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 5 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | too new |
| Medication Adherence for Cholesterol (Statins) · D10 | 4 out of 5 stars for Medication Adherence for Cholesterol (Statins) | too new |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 5 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | too new |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 3 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 5 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H8832 shares it.
Also available in 2 other CA counties
Benefits in plain text
Alignment Health Balance Plus 004 (PPO) (H8832-004-0) is a 2027 PPO Medicare Advantage plan offered by Alignment Health Plan, available to residents of San Joaquin County, CA.
The monthly premium is $7.30.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,850.00.
The combined in- and out-of-network out-of-pocket maximum is $11,950.00.
The drug deductible is $700.00. Tier 1, 2 and 6 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): 25%; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 28%; tier 5 (Specialty Tier): 25%; tier 6 (Select Care Drugs): $5.00.
CMS gives the plan's contract (H8832) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.