2019 Simpra Advantage (PPO SNP) H4091-1-0 in AL from SIMPRA Advantage (PPO SNP) | HealthPocket

Simpra Advantage (PPO SNP)

$31/mo

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Zip Code35215
Applicant1/22/1984 Male
Coverage Start1/23/2019
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderSIMPRA Advantage (PPO SNP)
Plan IDH4091-1-0
Plan Year2019
CMS RatingNot Rated
Plan TypePPO SNP
Annual Deductible$415.00

What To Know About This Plan
  • This plan has health and drug coverage

Why We Like This Plan
  • has both Health and Drug Coverage

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$31.40
Health Plan Deductible$1,364 per year for inpatient hospital services and $185 for outpatient services with a total plan deductible of $1,549 per year from in-network and out-of-network providers.
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$10,000 In and Out-of-network
$6,700 In-network
Optional Supplemental BenefitsNo

Benefits

SERVICECOST
Inpatient hospital coverageIn-Network:In 2019 the amounts for each benefit period are:
$1,364 deductible for days 1 through 60
$341 copay per day for days 61 through 90
Out-of-Network:In 2019 the amounts for each benefit period are:
$1,364 deductible for days 1 through 60
$341 copay per day for days 61 through 90
Outpatient hospital coverageIn-Network:20% per visit
Out-of-Network:20% per visit
Doctor visitsPrimary:
In-Network:20% per visit
Out-of-Network:20% per visit
Specialist:
In-Network:20% per visit
Out-of-Network:20% per visit
Preventive careIn-Network:$0 copay
Out-of-Network:$0 copay
Emergency care/Urgent careEmergency:20% per visit (always covered)
Urgent care:20% per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
In-Network:20%
Out-of-Network:20%
Lab services:
In-Network:$0 copay
Out-of-Network:20%
Diagnostic radiology services (e.g., MRI):
In-Network:20%
Out-of-Network:20%
Outpatient x-rays:
In-Network:20%
Out-of-Network:20%
Mental health servicesInpatient hospital - psychiatric:
In-Network:In 2019 the amounts for each benefit period are:
$1,364 deductible for days 1 through 60
$341 copay per day for days 61 through 90
Out-of-Network:In 2019 the amounts for each benefit period are:
$1,364 deductible for days 1 through 60
$341 copay per day for days 61 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network:20%
Out-of-Network:20%
Outpatient individual therapy visit with a psychiatrist:
In-Network:20%
Out-of-Network:20%
Outpatient group therapy visit:
In-Network:20%
Out-of-Network:20%
Outpatient individual therapy visit:
In-Network:20%
Out-of-Network:20%
Skilled Nursing FacilityIn-Network:In 2019 the amounts for each benefit period are:
$0 copay for days 1 through 20
$170.50 copay per day for days 21 through 100
Out-of-Network:In 2019 the amounts for each benefit period are:
$0 copay for days 1 through 20
$170.50 copay per day for days 21 through 100
Rehabilitation servicesOccupational therapy visit:
In-Network:20%
Out-of-Network:20%
Physical therapy and speech and language therapy visit:
In-Network:20%
Out-of-Network:20%
Ground ambulanceIn-Network:20%
Out-of-Network:20%
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
In-Network:20%
Out-of-Network:20%
Routine foot care:
In-Network:$0 copay
Out-of-Network:$0 copay. There may be limits on how much the plan will provide.
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
In-Network:20% per item
Out-of-Network:20% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:20% per item
Out-of-Network:20% per item
Diabetes supplies:
In-Network:20% per item
Out-of-Network:20% per item
Wellness programs (e.g., fitness, nursing hotline)Not covered
Medicare Part B drugsChemotherapy:
In-Network:20%
Out-of-Network:20%
Other Part B drugs:
In-Network:20%
Out-of-Network:20%

Benefits Services

Hearing
Hearing examIn-Network: $0 copay
Out-of-Network: 20%
Fitting/evaluationIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Hearing aidsIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Preventive Dental
Oral examNot covered
CleaningNot covered
Fluoride treatmentNot covered
Dental x-ray(s)Not covered
Comprehensive Dental
Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative servicesNot covered
EndodonticsNot covered
PeriodonticsNot covered
ExtractionsNot covered
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered
Vision
Routine eye examIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
OtherNot covered
Contact lensesIn-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Eyeglasses (frames and lenses)In-Network: $0 copay
Out-of-Network: $0 copay
There may be limits on how much the plan will provide.
Eyeglass framesNot covered
Eyeglass lensesNot covered
UpgradesNot covered

Coverage Area for Simpra Advantage (PPO SNP)

StateAlabama
CountyJefferson

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offereds25% coinsuranceNot offered
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier

60 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered25% coinsuranceNot offered
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered25% coinsuranceNot offered
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand Name
Tier 4: Non-Preferred Brand Name
Tier 5: Specialty Tier

Staying healthy - screenings, tests and vaccines

Breast cancer screeningNot Rated
Colorectal cancer screeningNot Rated
Annual flu vaccineNot Rated
Improving or maintaining physical healthNot Rated
Improving or maintaining mental healthNot Rated
Monitoring physical abilityNot Rated
Adult BMI assessmentNot Rated

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fractureNot Rated
Diabetes care – eye examNot Rated
Diabetes care – kidney disease monitoringNot Rated
Diabetes care – blood sugar controlledNot Rated
Controlling blood pressureNot Rated
Rheumatoid arthritis managementNot Rated
Reducing the risk of fallingNot Rated
Plan all-cause readmissionsNot Rated

Member Experience with Health Plan

Getting needed careNot Rated
Getting appointments and care quicklyNot Rated
Customer serviceNot Rated
Overall rating of health care qualityNot Rated
Overall rating of planNot Rated
Care CoordinationNot Rated

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health planNot Rated
Members choosing to leave the health planNot Rated
Beneficiary access and performance problemsNot Rated
Health plan quality improvementNot Rated

Health Plan Customer Service

Plan makes timely decision about appealsNot Rated
Reviewing appeals decisionsNot Rated
Call center – foreign language interpreter and TTY/TDD availability - MedicalNot Rated

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - DrugsNot Rated
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug planNot Rated
Members choosing to leave the drug planNot Rated
Beneficiary access and performance problemsNot Rated
Drug plan quality improvementNot Rated

Member Experience with Drug Plan

Rating of drug planNot Rated
Getting needed prescription drugsNot Rated

Drug Pricing and Patient Safety

MPF Price AccuracyNot Rated
High risk medicationNot Rated
Part D medication adherence for diabetesNot Rated
Part D medication adherence for hypertensionNot Rated
Part D medication adherence for cholesterolNot Rated
Medication Therapy Management program completion rate Not Rated

Physicians that accept Simpra Advantage (PPO SNP) for Alabama

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan.