2020 Simpra Advantage (PPO D-SNP) DS-H4091

Simpra Advantage (PPO D-SNP) By Simpra Advantage

Simpra Advantage (PPO D-SNP) is a 2020 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 (PPO D-SNP) DS-H4091 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.

2020 Medicare Special Needs Plan Details

Plan Name:
Simpra Advantage (PPO D-SNP)
Plan ID:
Special Needs Type: Dual-Eligible
Provider: Simpra Advantage
Plan Year:2020
Plan Type: Local PPO
Monthly Premium C+D: $28.70

The Simpra Advantage (PPO D-SNP) DS-H4091 is available to residents in Alabama, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Simpra Advantage (PPO D-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.

Part-C Premium

Simpra Advantage plan charges a $0.00 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

The Simpra Advantage (PPO D-SNP) plan has a monthly drug premium of $28.70 and a $435.00 drug deductible. This Simpra Advantage plan offers a $28.70 Part D Basic Premium that is 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 $0.00 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 $28.70. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.

Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Simpra Advantage (PPO D-SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.20 for 75% low income subsidy $14.40 for 50% and $21.50 for 25%.

Part C Premium: $0.00
Part D (Drug) Premium: $28.70
Part D Supplemental Premium $0.00
Total Part D Premium: $28.70
Drug Deductible: $435.00
Tiers with No Deductible: 0
Benchmark: below the regional benchmark
Type of Medicare Health Plan: Defined Standard Benefit
Drug Benefit Type: Basic
Full LIS Premium: $0.00
75% LIS Premium: $7.20
50% LIS Premium: $14.40
25% LIS Premium: $21.50
Gap Coverage: No

Gap Coverage

In 2020 once you and your plan provider have spent $4020 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 brand-name drugs and 25% on generic drugs unless your plan offers additional coverage. This Simpra Advantage plan does not offer additional coverage through the gap.

Simpra Advantage Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Simpra Advantage (PPO D-SNP) H4091-002 Formulary here.

Drug Tier Copay
1 NA 15%
*Initial Coverage Phase and 30 day supply

See the 2020 Simpra Advantage Formulary

2019 Plan Services

(*2020 Plan services will be added when available)

Health plan deductible


Emergency care/Urgent care

Emergency $0 copay
Urgent care $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures Out-of-Network 20%
Diagnostic tests and procedures In-Network $0 copay
Lab services Out-of-Network 20%
Lab services In-Network $0 copay
Diagnostic radiology services (e.g., MRI) Out-of-Network 20%
Diagnostic radiology services (e.g., MRI) In-Network $0 copay
Outpatient x-rays Out-of-Network 20%
Outpatient x-rays In-Network $0 copay


Hearing exam Out-of-Network 20%
Hearing exam In-Network $0 copay
Fitting/evaluation Not covered
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered

Preventive dental

Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered

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


Routine eye exam Out-of-Network $0 copay
Routine eye exam In-Network $0 copay
Other Not covered
Contact lenses Out-of-Network $0 copay
Contact lenses In-Network $0 copay
Eyeglasses (frames and lenses) Out-of-Network $0 copay
Eyeglasses (frames and lenses) In-Network $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered

Mental health services

Inpatient hospital - psychiatric Out-of-Network Coming soon
Inpatient hospital - psychiatric In-Network $0 copay
Outpatient group therapy visit with a psychiatrist Out-of-Network 20%
Outpatient group therapy visit with a psychiatrist In-Network $0 copay
Outpatient individual therapy visit with a psychiatrist Out-of-Network 20%
Outpatient individual therapy visit with a psychiatrist In-Network $0 copay
Outpatient group therapy visit Out-of-Network 20%
Outpatient group therapy visit In-Network $0 copay
Outpatient individual therapy visit Out-of-Network 20%
Outpatient individual therapy visit In-Network $0 copay

Skilled Nursing Facility

Out-of-Network Coming soon
In-Network $0 copay

Rehabilitation services

Occupational therapy visit Out-of-Network 20%
Occupational therapy visit In-Network $0 copay
Physical therapy and speech and language therapy visit Out-of-Network 20%
Physical therapy and speech and language therapy visit In-Network $0 copay

Ground ambulance

Out-of-Network 20%
In-Network $0 copay

Other health plan deductibles?

In-Network No


Not covered

Foot care (podiatry services)

Foot exams and treatment Out-of-Network 20%
Foot exams and treatment In-Network $0 copay
Routine foot care Not covered

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network $0 copay
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) In-Network $0 copay
Diabetes supplies Out-of-Network 20% per item
Diabetes supplies In-Network $0 copay

Wellness programs (e.g., fitness, nursing hotline)

Not covered

Medicare Part B drugs

Chemotherapy Out-of-Network 20%
Chemotherapy In-Network $0 copay
Other Part B drugs Out-of-Network 20%
Other Part B drugs In-Network $0 copay

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$10,000 In and Out-of-network
$6,700 In-network

Optional supplemental benefits


Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-Network No

Inpatient hospital coverage

Out-of-Network Coming soon
In-Network $0 copay

Outpatient hospital coverage

Out-of-Network 20% per visit
In-Network $0 copay

Doctor visits

Primary Out-of-Network 20% per visit
Primary In-Network $0 copay
Specialist Out-of-Network 20% per visit
Specialist In-Network $0 copay

Preventive care

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

Coverage Area for Simpra Advantage (PPO D-SNP)

Source: CMS.

Plans as of September 4, 2019.

Star Rating as of October 11, 2019.

Plan Services are 2019 information as reference. 2020 information will be added when released.

Notes: Data are subject to change. All contracts for 2020 have not been finalized. For 2020, 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 2020 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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