Simpra Advantage Premier (PPO I-SNP) By Simpra Advantage

Simpra Advantage Premier (PPO I-SNP) H4091 003 0 is a 2023 Medicare Advantage Special Needs Plan plan by Simpra Advantage. This plan from Simpra Advantage works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Simpra Advantage and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Simpra Advantage Premier (PPO I-SNP) H4091-003 is an Institutional SNP (I-SNP). An Institutional SNP is for beneficiaries who live in an institution such as a nursing home or require nursing care at home. If you live in an institution like a nursing home or hospital you can join any Medicare SNP you qualify for or switch plans at any time.

2023 Medicare Special Needs Plan Details

The Simpra Advantage Premier (PPO I-SNP) H4091-003 is available to residents to Medicare eligible seniors in Alabama. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Simpra Advantage Premier (PPO I-SNP) 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 Simpra Advantage Premier (PPO I-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Simpra Advantage charges a $21.10 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.

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. Simpra Advantage Premier (PPO I-SNP) has a monthly drug premium of $76.90 and a $150.00 drug deductible. This Simpra Advantage plan offers a $76.90 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 Simpra Advantage 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 $76.90. 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.

Simpra Advantage 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 additional coverage. This Simpra Advantage plan does not offer additional 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 Simpra Advantage Premier (PPO I-SNP) medicare insurance offers a $41.70 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $50.50 for 75% low-income subsidy $59.30 for 50% and $68.10 for 25%.

H4091-003 Formulary and Drug Coverage

Simpra Advantage Premier (PPO I-SNP) 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 Special Needs 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	NA	$4
Tier 2	NA	$15
Tier 3	NA	$45
Tier 4	NA	$95
Tier 5	NA	30%

The complete Simpra Advantage Premier (PPO I-SNP) H4091-003 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Simpra Advantage Premier (PPO I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Simpra Advantage 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)	Not covered

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Contact lenses

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Eyeglass frames

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

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Eyeglass lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

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Eyeglasses (frames and lenses)

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Other

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

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Routine eye exam

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

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Upgrades

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 copay
Out-of-Network Skilled Nursing Facility	$0 copay

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Occupational therapy visit

In-Network Rehabilitation services	$0 copay
Out-of-Network Rehabilitation services	$0 copay

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$0 copay
Out-of-Network Rehabilitation services	$0 copay

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Cleaning

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$30-50 copay per visit
Out-of-Network Outpatient hospital coverage	$50 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	$175 per day for days 1 through 6 $0 per day for days 7 through 90
Out-of-Network Mental health services	$175 per day for days 1 through 6 $0 per day for days 7 through 90

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Outpatient group therapy visit

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$30 copay

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$30 copay

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Outpatient individual therapy visit

In-Network Mental health services	$30 copay
Out-of-Network Mental health services	$30 copay

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Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	$30 copay
In-Network Mental health services	$30 copay

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Chemotherapy

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

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Diabetes supplies

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

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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	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	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$10,000 In and Out-of-network $6,700 In-network
Out-of-Network Inpatient hospital coverage	$175 per day for days 1 through 6 $0 per day for days 7 through 90
In-Network Inpatient hospital coverage	$175 per day for days 1 through 6 $0 per day for days 7 through 90

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Fitting/evaluation

Hearing	Not covered

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Hearing aids

In-Network Hearing	$0 copay
Out-of-Network Hearing	$0 copay

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Hearing exam

In-Network Hearing	$10 copay
Out-of-Network Hearing	$10 copay

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Health plan deductible	$0
Out-of-Network Ground ambulance	20% coinsurance
In-Network Ground ambulance	$150 copay

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Foot exams and treatment

Out-of-Network Foot care (podiatry services)	20% coinsurance
In-Network Foot care (podiatry services)	20% coinsurance

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Routine foot care

In-Network Foot care (podiatry services)	$0 copay
Out-of-Network Foot care (podiatry services)	$0 copay

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Emergency

Emergency care/Urgent care	$90 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	$0 copay

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Specialist

In-Network Doctor visits	$30 copay per visit
Out-of-Network Doctor visits	$30 copay per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$50 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$50 copay

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Diagnostic tests and procedures

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

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Outpatient x-rays

Out-of-Network Diagnostic procedures/lab services/imaging	$5 copay
In-Network Diagnostic procedures/lab services/imaging	$5 copay

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

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Extractions

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Out-of-Network Comprehensive dental	$0 copay
In-Network Comprehensive dental	$0 copay

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Restorative services

In-Network Comprehensive dental	$0 copay
Out-of-Network Comprehensive dental	$0 copay

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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 Special Need 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 Simpra Advantage Premier (PPO I-SNP) requires you to live in that plan’s service area. The service area is listed below:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.