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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 Clay, Duval, St. Johns. 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 $125.00. 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'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, you'll pay a $10 copay for preferred generic drugs at preferred and standard pharmacies, or no copay at standard mail order. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Simply Extra (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $325 copay for days 1-5, with no copay for days 6-90, while outpatient services and home health services typically have no copay. The plan includes coverage for a variety of services, such as primary care, preventive services, hearing, vision, and dental, often with no copay. Additionally, there are benefits like ambulance and transportation services, emergency services, and coverage for durable medical equipment, with some services subject to copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered with a $325 copay for days 1-5, and no copay for days 6-90. Additional days and non-Medicare-covered stays for both acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services are covered by the Simply Extra (HMO) plan, including all outpatient hospital services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $200, and Observation Services have a $200 copay. Individual and group outpatient substance abuse sessions have a $40 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Extra (HMO) plan, requiring prior authorization and a doctor referral. You will have a $40 copay for this benefit.
Ambulance and Transportation Services See details
The Simply Extra (HMO) plan covers ambulance services, with a $250 copay for ground ambulance and 20% coinsurance for air ambulance services. Transportation services to plan-approved health-related locations are covered, with no copay for up to 12 one-way trips per year, using rideshare services, bus/subway, van, or medical transport. Transportation services to any health-related location are 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, while Urgently Needed Services have a $40 copay; all services have no coinsurance. Worldwide Emergency Services has a maximum plan benefit coverage of $100,000.
Primary Care See details
The Simply Extra (HMO) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $40 copay, while physician specialist services have a $35 copay. Mental health specialty services, individual and group psychiatric sessions, and opioid treatment program services each have a $40 copay, while physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits have no copay.
Preventive Services See details
Preventive Services are covered by Simply Extra (HMO), including Medicare-covered zero-dollar preventive services that require prior authorization and a doctor referral. Annual physical exams are not covered. Additional preventive services, including Health Education, Fitness Benefit (Memory Fitness), and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), are covered with no copay. Other services, like In-Home Safety Assessment, Personal Emergency Response System (PERS), and others are not covered.
Hearing Services See details
Hearing Services include hearing exams with no copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with no copay, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams and eyewear. Eye exams and eyewear each have no copay. Eyewear offers a combined maximum plan benefit coverage of $200 per year, and upgrades are not covered.
Dental Services See details
The Simply Extra (HMO) plan covers a range of dental services, including oral exams, x-rays, and cleanings, with no copay, up to a maximum of $1,000 per year. Services like restorative, endodontic, and orthodontic services are also covered with no copay, but may require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Simply Extra (HMO), including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Simply Extra (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
The Simply Extra (HMO) plan covers Durable Medical Equipment (DME) with no copay and a coinsurance between 0% and 20%, but does not cover DME for use outside the home. Prosthetic devices and medical supplies have no copay. Diabetic equipment and supplies are covered with no copay.
Diagnostic and Radiological Services See details
The Simply Extra (HMO) plan covers diagnostic and radiological services, including diagnostic procedures and tests with a copay between $0 and $200, lab services with no copay, diagnostic radiological services with a copay up to $200, therapeutic radiological services with a copay up to $40 and 20% coinsurance, and outpatient x-ray services with no copay. All services require prior authorization and a doctor referral.
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 not covered by the Simply Extra (HMO) plan. Prior authorization and a doctor referral are required for coverage.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor's referral. For days 1-20, there is no copay, and for days 21-100, the copay is $196.
Other Services See details
The Simply Extra (HMO) plan covers Over-the-Counter (OTC) items with no copay and a maximum plan benefit coverage amount of $75.00 every month. The plan also covers a meal benefit with no copay, but acupuncture, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and many other services are not covered.
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