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Simply Extra (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Extra (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simply Extra (HMO) in 2025, please refer to our full plan details page.
Simply Extra (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Miami-Dade. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Simply Extra (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Simply Extra (HMO).
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 Simply Extra (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $145.00. You must continue to pay paying your reduced 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3450.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 Simply Extra (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay the following costs for your drugs. For preferred generic and specialty tier drugs, there is no copay. Standard generic drugs have a $47 copay, while preferred brand drugs have a $95 copay at preferred pharmacies and a $100 copay at standard pharmacies. Non-preferred drugs have 33% coinsurance.
Additional Benefits
The Simply Extra (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays. You'll find no copays for many services, such as primary care, preventive services, hearing and vision exams, and dental services. The plan also includes coverage for ambulance, emergency, and home health services, as well as medical equipment and home infusion. Additional benefits include coverage for hearing aids, eyewear, and dental services, with set maximums and no copays for most services. The plan also covers over-the-counter items and offers meal benefits. However, some services like routine chiropractic care, certain therapies, and specific types of hearing aids are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, but require prior authorization and a doctor's referral. For days 1-5, the copay is $85, and there is no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered for up to 3 days. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric, are not covered.
Outpatient Services See details
Outpatient Services are covered by the Simply Extra (HMO) plan, with specific copays depending on the service. Outpatient Hospital Services may have a copay between $0 and $85, Observation Services have an $85 copay, and Ambulatory Surgical Center (ASC) Services have no copay. Outpatient Substance Abuse Services have a $50 copay for both Individual and Group Sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Extra (HMO) plan, with a doctor referral and prior authorization required. There is no copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Simply Extra (HMO) plan, with prior authorization required. Ground ambulance services have a $150 copay, and air ambulance services have 20% coinsurance. Transportation Services to a plan-approved health-related location are covered with no copay, up to 12 one-way trips per year using rideshares, buses, vans, or medical transport. Transportation Services to any health-related location is not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered under the Simply Extra (HMO) plan. Emergency Services have a $135 copay, and Urgently Needed Services have no copay. Worldwide Emergency Services have a maximum plan benefit coverage of $100,000.
Primary Care See details
The Simply Extra (HMO) plan offers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Primary care physician services, chiropractic services, physician specialist services, mental health services (individual and group sessions), podiatry services, additional telehealth benefits, and individual and group psychiatric services have no copay. Occupational therapy services have a $15 copay, and physical therapy and speech-language pathology services have a $15 copay. Opioid treatment program services have a $50 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay and additional preventive services, with no copay for Health Education, Fitness Benefit (Memory Fitness), Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. Annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with no copay, and routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered with a maximum plan benefit of $1000 per year, and prescription hearing aids of all types are covered with no copay, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams and eyewear have no copay. Eyewear has a combined maximum plan benefit coverage amount of $200.00 per year, while upgrades are not covered.
Dental Services See details
Simply Extra (HMO) covers dental services with no copay for most services, including oral exams, dental x-rays, and cleanings, with a maximum benefit of $1,000 per year. Orthodontic services are also covered with no copay, and are covered under Diagnostic and Preventive Dental.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Simply Extra (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered by the Simply Extra (HMO) plan. DME has no copay and a coinsurance between 0% and 20%, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have no copay and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Simply Extra (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $75, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $75, and Therapeutic Radiological Services have a coinsurance of at most 20% and no copay. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Simply Extra (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD are not covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Simply Extra (HMO) plan, requiring prior authorization and a doctor's referral. There is no copay for days 1-20, and a $60 copay for days 21-100. Additional days beyond Medicare coverage and non-Medicare covered stays are not covered.
Other Services See details
Other Services include coverage for over-the-counter items and meal benefits. Over-the-counter items have no copay, and the plan offers a monthly benefit of $40, while meal benefits have no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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