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Simply Extra Platinum (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Extra Platinum (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simply Extra Platinum (HMO) in 2025, please refer to our full plan details page.
Simply Extra Platinum (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Select counties in Tampa Area. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Simply Extra Platinum (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 Platinum (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 Platinum (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 $164.90. 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 $3200.00 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 Platinum (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $20 copay at preferred and standard pharmacies, and no copay at standard mail order pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for covered Part D drugs. However, you may still pay for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Simply Extra Platinum (HMO) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $150 copay for days 1-5, and no copay for days 6-90. The plan also covers outpatient services, primary care, preventive services, and many other services, often with no copay. This plan includes coverage for hearing, vision, and dental services, and provides benefits for ambulance and transportation services. Emergency services have a $120 copay, and the plan covers home health services with no copay. The plan also covers skilled nursing facility services, with no copay for days 1-20, and a $60 copay for days 21-100.
Inpatient Hospital See details
Inpatient Hospital coverage under the Simply Extra Platinum (HMO) plan requires prior authorization and a doctor referral. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you'll pay a $150 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $200, observation services with a $200 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services, including individual and group sessions, are covered with a copay of $25. Outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $25 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
The Simply Extra Platinum (HMO) plan covers ambulance and transportation services. Ground ambulance services have a $250 copay, while 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, including rideshare, bus/subway, van, and medical transport.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Simply Extra Platinum (HMO) plan. Emergency Services has a $120 copay, and Urgently Needed Services has a $30 copay; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $120 copay and a maximum benefit of $100,000.
Primary Care See details
The Simply Extra Platinum (HMO) plan covers Primary Care Physician Services and Chiropractic Services with no copay, and covers Occupational Therapy Services with a $25 copay. Physician Specialist Services have a $30 copay, and Physical Therapy and Speech-Language Pathology Services have a $25 copay. Mental Health, Psychiatric Services, and Opioid Treatment Program Services have a $25 copay for individual and group sessions. Additional Telehealth Benefits have no copay, while 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 such as Health Education, Fitness Benefit, and Remote Access Technologies. Other preventive services, such as 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
Simply Extra Platinum (HMO) covers hearing exams with no copay, and also covers routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a maximum plan benefit of $1000 every year, but inner ear, outer ear, and over-the-ear prescription 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, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are covered. Upgrades are not covered.
Dental Services See details
Dental services, including oral exams, dental x-rays, and other services, are covered with no copay. Other services, such as orthodontics, also have no copay. There is a maximum plan benefit coverage of $1,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Simply Extra Platinum (HMO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with no copay and 0-20% coinsurance, but does not include DME for use outside the home. Prosthetics/Medical Supplies and Diabetic Equipment are also covered, with 20% coinsurance for some prosthetics/medical supplies, and no copay for diabetic supplies and therapeutic shoes/inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, diagnostic procedures/tests with a copay between $0 and $200, lab services with no copay, and outpatient X-ray services with no copay. This plan also covers diagnostic radiological services with a copay of at most $200, and therapeutic radiological services with a coinsurance of at most 20% and a copay of at most $25.
Home Health Services See details
Home Health Services are covered under the Simply Extra Platinum (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 plan does not cover the specific services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, or SET for PAD. Prior authorization and a doctor referral are required for the covered services.
Skilled Nursing Facility (SNF) See details
The Simply Extra Platinum (HMO) plan covers Skilled Nursing Facility (SNF) services with prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $60.
Other Services See details
The Simply Extra Platinum (HMO) plan's "Other Services" benefit covers over-the-counter (OTC) items and a meal benefit, each with 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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