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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 Hernando, Hillsborough, Pasco, Pinellas. 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 a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase, preferred generic drugs have a $20 copay, while preferred brand drugs have a $95 or $100 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Simply Extra (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services like primary care and preventive services often have no copay. The plan also covers services such as vision, dental, and hearing, often with no copay, as well as home health services. Other covered services include ambulance, emergency services, and certain therapies, each with its own copay or coinsurance structure. The plan also provides coverage for home infusion and dialysis services. Overall, the Simply Extra (HMO) plan aims to provide comprehensive coverage, with cost-sharing varying depending on the specific service.
Inpatient Hospital See details
The Simply Extra (HMO) plan covers inpatient hospital stays with a $175 copay for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services are covered by the Simply Extra (HMO) plan. Outpatient Hospital Services have a copay between $0 and $175, Observation Services have a $175 copay, Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services have no copay. Outpatient Substance Abuse Services have a $50 copay for both Individual and Group Sessions.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Extra (HMO) plan, with a $25 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Simply Extra (HMO) plan. Ground ambulance services have a $225 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered with no copay for up to 12 one-way trips per year, but transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Simply Extra (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $135 copay, and Urgently Needed Services have a $30 copay, with no coinsurance for any of these services.
Primary Care See details
The Simply Extra (HMO) plan covers primary care physician services and chiropractic services with no copay, while occupational therapy services have a $25 copay. Physician specialist services have a $30 copay, and physical therapy and speech-language pathology services have a $25 copay. Mental health specialty services and psychiatric services have a $25 copay, while opioid treatment program services have a $50 copay. Additional telehealth benefits have no copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with a doctor referral and no copay. Additional preventive services such as Health Education, Fitness Benefit, and Remote Access Technologies have no copay. The plan does not cover 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, or Counseling Services. Kidney Disease Education Services and Other Preventive Services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered with no copay.
Hearing Services See details
The Simply Extra (HMO) plan covers hearing exams with no copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered up to $500 per year, and OTC hearing aids are also covered up to $500 per year.
Vision Services See details
Vision Services, including routine eye exams and eyewear, are covered under the Simply Extra (HMO) plan. Eye exams and eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, have no copay. Eyewear has a combined maximum plan benefit coverage amount of $100 per year.
Dental Services See details
The Simply Extra (HMO) plan covers dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services with no copay. The plan also covers restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics with no copay. This plan has a maximum benefit of $500 per year for other dental services.
Home Infusion bundled Services See details
The Simply Extra (HMO) plan covers home infusion bundled services, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Simply Extra (HMO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
The Simply Extra (HMO) plan covers medical equipment, including durable medical equipment (DME) with 0-20% coinsurance, and prosthetics/medical supplies with no coinsurance. Diabetic equipment is also covered, with no copay for diabetic supplies and diabetic therapeutic shoes/inserts, and requires prior authorization.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $100, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $100, and Therapeutic Radiological Services have a coinsurance of at least 20% with 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 not in practice as the sub-services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization and a doctor referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered with prior authorization and a doctor's referral. There is no copay for days 1-20, and a $150 copay for days 21-100.
Other Services See details
The Simply Extra (HMO) plan covers Over-the-Counter (OTC) Items and Meal Benefits with no copay. However, 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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