Simpra Advantage Assist (PPO I-SNP) Costs & Coverage, Pike County, Alabama
Simpra Advantage Assist (PPO I-SNP) Costs & Coverage, Pike County, Alabama
Explore the benefits and costs of Simpra Advantage Assist (PPO I-SNP), a 2025 Medicare Special Needs Plan designed to meet your unique healthcare needs. This page provides a comprehensive look at the plan’s benefits and costs, helping you make an informed choice.
Delivery of healthcare services and costs by Simpra Advantage are different than Original Medicare. This private health insurance option, available to qualified individuals in Pike County, AL, may include additional benefits that are not provided by Medicare Part A and Part B.
- Doctor Visits
- Foot Care
- Chiropractic
- Urgent & Emergency
- Mental Health
- Rehab Services
- Equipment & Supplies
- Diag, Lab, Imaging
- Part B Drugs
- Dental
- Hearing Aids
- Vision
- Prescriptions
| Plan ID H4091-003-0 Overview | |
|---|---|
| Health Plan ID: | H4091-003-0 |
| Medicare Advantage Plan Type: | PPO I-SNP |
| Plan Year: | 2025 |
| Monthly Premium: | $86.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | 6,700.00 |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $150.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Pike County, AL |
| Insured By: | Simpra Advantage |
| We're Here to Help You Enroll |
|---|
Health Plan Cost Sharing & Benefits
Simpra Advantage Assist is a Preferred Provider Organization (PPO) plan. As a member of this {plan_type_2} plan, you typically access care through in-network providers, but you have the flexibility to see out-of-network providers if needed. Keep in mind that visits to non-network providers may result in higher out-of-pocket costs.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $30 Copay Prior Authorization Required |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $90 Copay |
| Urgent care: | $30 Copay |
| Ground ambulance: | $150 Copay |
| Inpatient hospital care: | $175.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Skilled Nursing Facility: | Unknown |
This section covers Medicare-approved foot care services, including exams and routine foot care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | 20% Coinsurance |
| Routine Foot Care: | Not Covered |
Understand the coverage for Medicare-approved chiropractic services and routine chiropractic care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | 20% Coinsurance Prior Authorization Required |
| Routine chiropractic: | Not Covered |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $30 Copay |
| Outpatient group therapy: | $30 Copay |
| Inpatient psychiatric hospital care: | $175.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | Not Covered |
| Occupational therapy: | Not Covered |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $50 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $5 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | 20% Coinsurance Prior Authorization Required |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
This section details the dental services covered under your plan including, Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | 20% Coinsurance Prior Authorization Required |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Not Covered |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $30 Copay |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | Eyeglasses: Yes Contact Lenses: Yes Eyeglass Lenses: Yes Eyeglass Frames: Yes Eyewear Upgrades: Yes |
Maximum eyewear benefit: | $230.00 Every year |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
The following table outlines the prescription drug plan premium details of this plan.
| Basic Part D Premium: | $70.20 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $70.20 |
| Low Income Premium Subsidy: | $40.01 |
| Low Income Premium Subsidy CMS Pays: | $40.00 |
| Low Income Subsidy Premium: | $30.20 |
For more information about the Low Income Subsidy, refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $150.00. This is the amount you must pay at the pharmacy before Simpra Advantage begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Simpra Advantage Assist has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Preferred Generic | $4.00 | $4.00 | |
| Generic | $15.00 | $15.00 | |
| Preferred Brand | $45.00 | $45.00 | |
| Non-Preferred Brand | $95.00 | $95.00 | |
| Specialty Tier | 31.00% | 31.00% | |
| *Deductible does not apply. | |||
CMS Rating Marks
The Centers for Medicare & Medicaid Services (CMS) annually rates Medicare Advantage {plan_type_2}s in nine key categories using a 5-star system. These ratings help you gauge the quality of care and service you might receive with this Simpra Advantage plan.
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Not enough data available |
| Managing Chronic (Long Term) Conditions | Not enough data available |
| Member Experience with Health Plan | Not enough data available |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Eligibility for Enrollment in Simpra Advantage Assist
To enroll in Simpra Advantage Assist , you must meet the following three criteria:
- You are eligible for Medicare;
- You reside within the plan’s service area; and
- You require the level of care typically provided in an institutional setting, such as a long-term care nursing facility, for 90 days or more.
This plan accomodates individuals in a long-term care facility. It is also available to people who need the level of care given in a long-term care facility who can remain at home or live in an assisted living facility.
If you live at home and need a similar level of skilled care, you may qualify for an Institutional Equivalent Special Needs Plan (IE-SNP).
SNP Plan Enrollment Periods
After determining your eligibility for Simpra Advantage Assist , it’s important to be aware of the Medicare Enrollment Periods, which determine when you can enroll in or change your plan. Depending on your circumstances, one of the following periods will apply:
- Initial Enrollment Period (IEP): The first time you can enroll in Medicare, typically around your 65th birthday.
- Annual Enrollment Period (AEP): Occurs yearly and allows you to make changes to your Medicare coverage.
- Special Enrollment Periods (SEPs): Special circumstances, such as moving or losing other coverage, may qualify you to enroll outside of the usual periods.
To get a deeper understanding of these enrollment periods, click here to learn more and stay informed about your Medicare choices.
Contact Simpra Advantage
| Website: | Simpra Advantage Plan Page |
|---|---|
| Providers: | Simpra Advantage Providers Page |
| Formulary: | Simpra Advantage Formulary Page |
| Pharmacy: | Simpra Advantage Pharmacy Page |
| New Member Health Plan Help: | (844)637-4770 |
| New Member Health Plan TTY: | (833)312-0044 |
| New Member Part D Help: | (844)637-4770 |
| New Member Part D TTY Users: | (833)312-0044 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered through Medicare.org
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