Simpra Advantage Premier (PPO I-SNP) H4091-003-000 is a 2021 Medicare Advantage Institutional Special Needs Plan provided by Simpra Advantage.

A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.

Institutional Special Needs Plans are for beneficiaries who live in an institution, such as a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility. If you don't meet this criteria, consider other plan choices in your county.

Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.

This plan has a monthly premium of $100, which covers both the health and drug portions of the plan.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $150.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H4091-003-000
Plan Organization Simpra Advantage
Plan Type Local PPO
Plan Name Simpra Advantage Premier (PPO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $100.00
Total Premium (Includes Part B) $235.50
Monthly Part C Premium $44.50
Monthly Part D Basic Premium $55.50
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $55.50
Monthly Part D Premium Full Assistance $25.30
Monthly Part D Premium 75% Assistance $32.80
Monthly Part D Premium 50% Assistance $40.40
Monthly Part D Premium 25% Assistance $47.90
Part D Drug Deductible $150.00
Annual Drug Deductible $150.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services No - - - Not covered
Endodontics Yes Out-of-Network Yes No $0 copay
Extractions Yes Out-of-Network Yes No $0 copay
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No $0 copay
Restorative services Yes Out-of-Network Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No $50 copay
Diagnostic tests and procedures - Out-of-Network Yes No 20% coinsurance
Lab services - Out-of-Network Yes No $0 copay
Outpatient x-rays - Out-of-Network Yes No $5 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - Out-of-Network Yes No $30 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $30 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No 20% coinsurance
Routine foot care Yes Out-of-Network No No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation No - - - Not covered
Hearing aids Yes Out-of-Network No No $0 copay
Hearing exam - Out-of-Network No No $10 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $175 per day for days 1 through 6$0 per day for days 7 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $10,000 In and Out-of-network$3,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $175 per day for days 1 through 6$0 per day for days 7 through 90
Outpatient group therapy visit - Out-of-Network Yes No $30 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $30 copay
Outpatient individual therapy visit - Out-of-Network Yes No $30 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $30 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $30-50 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No $0 copay
Dental x-ray(s) Yes Out-of-Network No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $0 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes Out-of-Network No No $0 copay
Eyeglass frames Yes Out-of-Network No No $0 copay
Eyeglass lenses Yes Out-of-Network No No $0 copay
Eyeglasses (frames and lenses) Yes Out-of-Network No No $0 copay
Other Yes Out-of-Network No No $0 copay
Routine eye exam Yes Out-of-Network No No $0 copay
Upgrades Yes Out-of-Network No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Autauga County, Alabama, Baldwin County, Alabama, Barbour County, Alabama, Bibb County, Alabama, Blount County, Alabama, Bullock County, Alabama, Butler County, Alabama, Calhoun County, Alabama, Chambers County, Alabama, Cherokee County, Alabama, Chilton County, Alabama, Choctaw County, Alabama, Clarke County, Alabama, Clay County, Alabama, Cleburne County, Alabama, Coffee County, Alabama, Colbert County, Alabama, Conecuh County, Alabama, Coosa County, Alabama, Covington County, Alabama, Crenshaw County, Alabama, Cullman County, Alabama, Dale County, Alabama, Dallas County, Alabama, Dekalb County, Alabama, Elmore County, Alabama, Escambia County, Alabama, Etowah County, Alabama, Fayette County, Alabama, Franklin County, Alabama, Geneva County, Alabama, Greene County, Alabama, Hale County, Alabama, Henry County, Alabama, Houston County, Alabama, Jackson County, Alabama, Jefferson County, Alabama, Lamar County, Alabama, Lauderdale County, Alabama, Lawrence County, Alabama, Lee County, Alabama, Limestone County, Alabama, Lowndes County, Alabama, Macon County, Alabama, Madison County, Alabama, Marengo County, Alabama, Marion County, Alabama, Marshall County, Alabama, Mobile County, Alabama, Monroe County, Alabama, Montgomery County, Alabama, Morgan County, Alabama, Perry County, Alabama, Pickens County, Alabama, Pike County, Alabama, Randolph County, Alabama, Russell County, Alabama, Saint Clair County, Alabama, Shelby County, Alabama, Sumter County, Alabama, Talladega County, Alabama, Tallapoosa County, Alabama, Tuscaloosa County, Alabama, Walker County, Alabama, Washington County, Alabama, Wilcox County, Alabama, Winston County, Alabama

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.