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Medicare Advantage · Local PPO
Simpra Advantage
Plan year 2026

Simpra Advantage Assist (PPO I-SNP) H4091-003

Monthly premium
$81
+ your Part B premium
Max out-of-pocket
$6,700
in-network annual cap
Primary care
$0
per visit copay
Specialist
$30
per visit
Eligibility required for this I-SNP
The plan must verify that, for 90 days or longer, you have needed or are expected to need the level of care provided in a qualifying institution. Some plans also serve people who need an equivalent institutional level of care while living in the community. Review the official plan documents for the residence, care-level, and enrollment requirements.
Medical coverage is different from long-term room and board

An I-SNP coordinates Medicare-covered care for members who meet its institutional eligibility rules. That eligibility does not mean Medicare pays for long-term custodial care or an ongoing nursing-home stay. Medicare may cover short-term skilled nursing care when its coverage requirements are met; Medicaid, long-term-care insurance, or personal funds may cover other long-term-care costs.

Research nearby nursing homes
The nursing-home finder shows CMS facility information. It does not confirm that a facility participates in this plan. Confirm participation with both the facility and the plan before enrolling.

Your costs at a glanceIn-network, for the 2026 plan year

Rx deductible
$150
Inpatient hospital
Days 1-6: $175/day, Days 7-90: $0/day
Inpatient mental health
Days 1-6: $175/day, Days 7-90: $0/day
Outpatient surgery
$30
–$50
Emergency room
$90
Urgent care
$30

What's included, and what it's actually worth5 benefits included. Tap any card for the detail

Hearing

$2,000hearing aid allowance per 2 years ($10 exam copay)
Hearing aid allowance$2,000 hearing aid allowance per 2 years
Hearing exam$10 copay
This is a supplemental benefit with plan-specific limits. See plan documents for details.

OTC allowance

$235/quarter OTC allowance
Prepaid card$235/quarter OTC allowance

Dental

$750/yr allowance
Annual max$750/yr allowance
This is a supplemental benefit with plan-specific limits. See plan documents for details.

Vision

$230/yr eyewear allowance ($30 exam copay)
Eyewear allowance$230/yr eyewear allowance
Routine eye exam$30 copay
This is a supplemental benefit with plan-specific limits. See plan documents for details.
See more details about this plan
Doctor Visits: PCP$0 copay
In-network$0 copay per visit
Doctor Visits: Specialist$30 copay
In-network$30 copay per visit
Inpatient Hospital$175/day, days 1–6
In-networkDays 1-6: $175/day, Days 7-90: $0/day
Outpatient Surgery$30–$50
In-network$30–$50 per procedure
Mental HealthDays 1-6: $175/day, Days 7-90: $0/day
Inpatient psychiatricDays 1-6: $175/day, Days 7-90: $0/day
MealsMeal benefit

Your coverageCheck your coverageFrom the doctors and prescriptions you added

Your plan's drug tiers30-day retail · after any applicable deductible

Tier 1
$4
Preferred Generic
Tier 2
$15
Generic
Tier 3
$45
Preferred Brand· after deductible
Tier 4
$95
Non-Pref Brand· after deductible
Tier 5
31%
Specialty· after deductible

Our take

Where this plan shines

See your primary doctor for $0.

Things to know before you enroll

This plan’s out-of-pocket maximum is above the national median.
Limited coverage while traveling outside the plan’s service area.
Questions? Talk to a licensed agent at1-866-764-3312 (TTY: 711)

Plan documents

Summary of Benefits (PDF)
Download the plan's official Summary of Benefits document
Check Your Doctors
See if your doctors accept this plan
Documentos en español
Llame al (844)637-4770 (TTY: (833)312-0044) para solicitar documentos en español

Helpful next steps

The Pocket Protector · NPN 21126942 · 1-866-764-3312 (TTY: 711) · thepocketprotector.com

Plan benefits, premiums, and copays may vary by county and plan. You must continue to pay your Medicare Part B premium. Benefits and costs may vary by service area. Contact the plan or CMS for complete details.

We do not offer every plan available in your area. Currently we represent a limited number of organizations which offer a limited number of products in your area. Please contact Medicare.gov, 1-800-MEDICARE (TTY: 1-877-486-2048), or your local State Health Insurance Program (SHIP) to get information on all of your options.

Members may receive a monthly or quarterly allowance in the form of a benefits prepaid card to pay for a wide range of plan-approved items. Unused amounts will expire at the end of the month or quarter.

Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you to contact the plan.

Dental, hearing, vision, and other supplemental benefits may have limitations and restrictions. These benefits vary by plan. Please refer to the plan's Evidence of Coverage for details.

The plan formulary, pharmacy network, and/or copays may change at any time. You will receive notice when necessary.

I-SNP eligibility requires institutional residency or expected institutional care. Benefits vary by county and facility participation.

Benefits shown are based on CMS public plan data. Actual benefits vary by county. Not all plans available in all areas. Speak with a licensed agent before enrolling.

  1. The Pocket Protector represents Medicare Advantage HMO, PPO, and PFFS organizations and stand-alone PDP prescription drug plans that have a Medicare contract. Enrollment depends on the plan's contract renewal.
  2. The Pocket Protector is not connected with or endorsed by the United States government or the federal Medicare program.

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