Simpra Advantage (PPO D-SNP)
H4091 - 002 - 0
(4 / 5)
Simpra Advantage (PPO D-SNP) is a Medicare Advantage Special Needs Plan by Simpra Advantage.
This page features plan details for 2024 Simpra Advantage (PPO D-SNP) H4091 – 002 – 0.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Simpra Advantage (PPO D-SNP) is offered in the following locations.
Plan Overview
Simpra Advantage (PPO D-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Dual-Eligible |
| Conditions Covered: |
| Insurer: | Simpra Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $13,300 In and Out-of-network $8,850 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan is a Medicare Special Needs Plan for people with both Medicare and Medicaid. Contact the plan for details.
- Depending on your level of Extra Help, you may pay less for the drugs than the cost sharing amount listed. Look on the Extra Help letters you get, or contact the plan to find out your exact costs.
- This plan's deductible only applies to out-of-network services.
Ready to sign up for Simpra Advantage (PPO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Simpra Advantage (PPO D-SNP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Simpra Advantage (PPO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Basic |
| Additional Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 25% | 25% |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| Generic drugs | ||||
| Brand-name drugs |
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
Simpra Advantage (PPO D-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $13,300 In and Out-of-network $8,850 In-network |
| No |
| In-network | No |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 copay (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Oral exam | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Cleaning | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Dental x-ray(s) | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network | 20% coinsurance (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $0 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | Coming soon (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | Coming soon (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network | Coming soon (Authorization is required.) (Referral is not required.) |
Ready to sign up for Simpra Advantage (PPO D-SNP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST