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Simpra Advantage Dual Care (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simpra Advantage Dual Care (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simpra Advantage Dual Care (PPO D-SNP) in 2026, please refer to our full plan details page.
Simpra Advantage Dual Care (PPO D-SNP) is a PPO D-SNP plan offered by Associated Care Ventures, Inc. available for enrollment in 2025 to people living in Alabama statewide. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Simpra Advantage Dual Care (PPO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Simpra Advantage Dual Care (PPO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Simpra Advantage Dual Care (PPO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Simpra Advantage Dual Care (PPO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.70. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Simpra Advantage Dual Care (PPO D-SNP) features a defined standard drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you pay cost-sharing during the initial coverage phase until your total drug costs reach $2,100.00. If you qualify for the low-income subsidy, also known as Extra Help, your Part D premium is reduced to $27.70. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase. During this phase, you will have no copay and pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for any excluded drugs covered under an enhanced benefit.
Additional Benefits
The Simpra Advantage Dual Care (PPO D-SNP) plan offers comprehensive medical coverage, with many services requiring no copay and a standard 20% coinsurance. This cost structure applies to outpatient visits, emergency care, specialist services, dialysis, and medical equipment, while inpatient and skilled nursing stays feature no copay and Medicare-defined coinsurance. Additionally, diagnostic lab services and preventive physical exams are fully covered with no copay and no coinsurance. The plan also features valuable supplemental benefits, including up to $2,500 every two years for hearing aids and a $400 annual allowance for eyewear with no copay or coinsurance. Members can access Medicare-covered dental services with no copay and 20% coinsurance up to a $3,000 annual limit, alongside 48 one-way trips per year to approved health locations. Finally, the plan includes a generous over-the-counter reimbursement of up to $235 per month for health-related items.
Inpatient Hospital See details
Inpatient hospital and psychiatric services are partially covered by Simpra Advantage Dual Care (PPO D-SNP) with Medicare-defined coinsurance and no copay, though prior authorization is required. Additional days, non-Medicare-covered stays, and upgrades for acute care are not covered.
Outpatient Services See details
Outpatient services are covered by Simpra Advantage Dual Care (PPO D-SNP) with no copay and a 20% coinsurance. This rate applies to outpatient hospital visits, observation services, ambulatory surgical center services, outpatient substance abuse sessions, and outpatient blood services.
Partial Hospitalization See details
Simpra Advantage Dual Care (PPO D-SNP) covers partial hospitalization services with a 20% coinsurance and no copay. Prior authorization is required for these covered benefits.
Ambulance and Transportation Services See details
Simpra Advantage Dual Care (PPO D-SNP) covers ground and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered, offering up to 48 one-way trips per year to plan-approved health-related locations, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency and urgently needed services are covered by Simpra Advantage Dual Care (PPO D-SNP) with a 20% coinsurance and no copay, with the coinsurance waived if you are admitted to the hospital within three days. However, worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation are not covered.
Primary Care See details
Primary Care benefits are partially covered by Simpra Advantage Dual Care (PPO D-SNP), as podiatry services and routine chiropractic care are not covered. Most covered options, such as specialist visits, physical therapy, occupational therapy, and mental health services, require a 20% coinsurance and no copay, while telehealth benefits range from no coinsurance to 20% coinsurance.
Preventive Services See details
Simpra Advantage Dual Care (PPO D-SNP) preventive services are partially covered, offering Medicare-covered zero-dollar services and annual physical exams with no copay and no coinsurance. Kidney disease education and select screenings, such as glaucoma and diabetes self-management, are covered with a 20% coinsurance and no copay. However, additional benefits like health education, in-home safety, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, fitness, disease management, telemonitoring, remote access, bathroom safety, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered under Simpra Advantage Dual Care (PPO D-SNP), though hearing exams—including routine exams and fitting evaluations—are not covered. The plan covers general prescription and over-the-counter hearing aids up to $2,500 every two years with no copays or coinsurance, though specific inner, outer, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are covered by Simpra Advantage Dual Care (PPO D-SNP), which offers yearly routine eye exams and glaucoma testing with no copay and a 20% coinsurance. Eyewear is partially covered with no copay or coinsurance up to a $400 annual maximum for contact lenses and eyeglasses, but individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Simpra Advantage Dual Care (PPO D-SNP) partially covers dental services with a 20% coinsurance and no copay for Medicare-covered dental care, up to a $3,000 annual maximum benefit for both in-network and out-of-network services. While many preventive and restorative services are covered, adjunctive general services, periodontics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Simpra Advantage Dual Care (PPO D-SNP) covers home infusion bundled services, subject to prior authorization and step therapy. Covered Medicare Part B insulin drugs require a $35 copay and range from no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs carry no copay and range from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Simpra Advantage Dual Care (PPO D-SNP) plan with a 20% coinsurance and no copay.
Medical Equipment See details
Simpra Advantage Dual Care (PPO D-SNP) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic supplies, with no copay and a 20% coinsurance. Prior authorization is required for durable medical equipment and prosthetic devices.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Simpra Advantage Dual Care (PPO D-SNP) with no copays, though prior authorization is required. Lab services feature no coinsurance, while diagnostic procedures, radiological services, and outpatient X-rays are subject to a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Simpra Advantage Dual Care (PPO D-SNP), though prior authorization is required before you can receive these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Simpra Advantage Dual Care (PPO D-SNP) plan, as all associated sub-services, including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation, are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Simpra Advantage Dual Care (PPO D-SNP) partially covers Skilled Nursing Facility (SNF) services with no copay and Medicare-defined coinsurance, requiring prior authorization. While a prior three-day inpatient hospital stay is not required, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Simpra Advantage Dual Care (PPO D-SNP) partially covers Other Services, offering a supplemental benefit of up to $235 per month in reimbursement for over-the-counter (OTC) items. Acupuncture, meal benefits, and highly integrated services for dual-eligible SNPs are not covered under this plan.
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