Simpra Advantage (PPO I-SNP) and Simpra Advantage (PPO D-SNP) provide Medicare Part D prescription drug coverage through Navitus Health Solutions. Navitus Health Solutions is a full-service pharmacy benefit management company committed to lowering drug costs, improving health, and providing superior customer service in a manner that instills trust and confidence.
Together, we make it easier for you to follow your doctor’s orders related to your health care and prescription drug use. For your convenience, there is a complete list of all covered drugs in the plan (a comprehensive formulary). Our Online Formulary (I-SNP) or Online Formulary (D-SNP) lists the Part D drugs covered by Simpra Advantage.
Our formulary is designed to cover the drugs most needed to treat the special needs of our Members. If the drug you are taking is not on the list of covered drugs, read your Prescription Drug Transition Policy and Evidence of Coverage (I-SNP), or Evidence of Coverage (D-SNP) to find out what you can do. This includes instructions for both new and current Members. If you would like help managing your prescription drugs, read about our Medication Therapy Management program and its eligibility requirements. Need to find a participating pharmacy near you? Click here to search our Pharmacy Directory (I-SNP), or Pharmacy Directory (D-SNP).
How much do I pay?
For Part B drugs such as chemotherapy drugs1: 25% of the cost
Other Part B drugs1: 25% of the cost
After you pay your yearly deductible, you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $4,020. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies.
If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020.
After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:
- 5% of the cost, or
- $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs.
If you have questions or want to request additional information, please call Member Services at 1-844-637-4770 (TTY 711). Calls to this number are free.
A coverage determination is decision made by our plan (not the pharmacy) about your prescription drug benefits, including whether a particular drug is covered, whether you have met all the requirements for getting a requested drug, how much you’re required to pay for a drug, and whether to make an exception to a plan rule when you request it.
If a drug is not covered on our plan, you can ask the plan to make an “exception.” An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request.
A coverage determination may be requested by any of the following:
- You or your representative may request a coverage determination.
- Your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) can request a coverage determination for you on your behalf.
A coverage determination may be requested for any of the following:
- Covering a Part D drug for you that is not on our plan’s List of Covered Drugs (Formulary).
- You may ask our plan for an exception if you or your prescriber (your doctor or other health care provider who is legally allowed to write prescriptions) believes you need a drug that isn’t on your drug plan’s list of covered drugs.
- You may ask for an exception if your network pharmacy can’t fill a prescription as written.
- Removing a restriction on the plan’s coverage for a covered drug.
- You may ask for an exception if you or your prescriber believe that a coverage rule (such as a prior authorization) should be waived.
- Changing coverage of a drug to a lower cost-sharing tier. (Tier Exception)
- You may ask for an exception if you think you should pay less for a higher tier drug because you or your prescriber believe you can’t take any of the lower tier drugs for the same condition.
- Request for payment.
- You may ask us to pay for a prescription that you already paid for.
Your doctor or other prescriber must give us a written statement that explains the medical reasons for requesting an exception. For a faster decision, include medical information from your doctor or other prescriber when you ask for the exception.
Our plan can accept or deny your request.
If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true if your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we say no to your request for an exception, you can ask for a review of our decision by making an appeal. If your health requires a quick response, you must ask us to make a “fast decision”.
To request a Medicare Prescription Drug Coverage Determination visit Navitus to login and access the form or A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a coverage determination, including an exception, from Simpra Advantage.
To request a Medicare Prescription Drug Redetermination (Appeals) visit Navitus to login and access the form or A Member, a Member’s representative, or a Member’s prescriber may use this model form to request a redetermination from Simpra Advantage.
You or your representative can request an exception by writing directly to us at Simpra Advantage – Appeals and Grievances Department, PO Box 2190 Glen Allen, VA 23058- 2190, faxing us at 1-800-862-2730, emailing email@example.com, or contacting our Member Services Department at our toll free number at 1-844-637-4770 (TTY 711).
You may also contact our Member Services Department and request the facsimile number for Appeals and Grievances.
Your provider may also request an exception or expedited exception by contacting the Pharmacy Help Desk at 1-866-270-3877 (TTY 711) 24 hours a day, and 7 days a week.
Our plan has seventy-two (72) hours (for a standard request) or twenty-four (24) hours for an expedited request) from the date it gets your request to notify you of its decision.
This section provides specific information of particular importance to our Simpra Advantage Members receiving Part D drug benefits. Below are links to forms applicable to Part D grievances, coverage determinations (including exceptions) and appeals processes.
Request for a Medicare Prescription Drug Coverage Determination
A Member, a Member’s representative, or a Member’s prescriber may use the Medicare Prescription Drug Coverage Determination Form PDF Form | Online Form to request a coverage determination, including an exception, from Simpra Advantage.
Request for a Medicare Prescription Drug Redetermination (Appeals)
A Member, a Member’s representative, or a Member’s prescriber may use the Redetermination of Medicare Prescription Drug Denial Form PDF Form | Online Form to request a redetermination (appeal) from Simpra Advantage.
Request for Reconsideration of Medicare Prescription Drug Denial
A Member or a Member’s representative may use the Request for Reconsideration of Medicare Prescription Drug Denial Form to request a reconsideration with the Independent Review Entity.
Federal regulations at 42 CFR § 423.800 specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan.
To address these situations, CMS created the best available evidence (BAE) policy in 2006. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate.
For more information, please view the best available evidence (BAE) policy.
- I-SNP Online Drug List (Formulary) (Last updated 09/01/2020)
- D-SNP Online Drug List (Formulary) (Last updated 09/01/2020)
- Medicare Prescription Drug Determination Form: PDF Form | Online Form
- Medicare Prescription Drug Reconsideration Form
- Medicare Prescription Drug Redetermination Form: PDF Form | Online Form
- Prescription Utilization Management Prior Authorization Criteria (Last updated 09/01/2020)
- Part B Drug Step Therapy
- Part D Drug Step Therapy Criteria (Last updated 09/01/2020)
- Request for Authorization