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Simply Level Platinum (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Simply Level Platinum (HMO C-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Simply Level Platinum (HMO C-SNP) in 2026, please refer to our full plan details page.
Simply Level Platinum (HMO C-SNP) is a HMO C-SNP 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 2026.
It's important to know that Simply Level Platinum (HMO C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Simply Level Platinum (HMO C-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Simply Level Platinum (HMO C-SNP).
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 Level Platinum (HMO C-SNP), 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 $2450.00 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 Level Platinum (HMO C-SNP) plan offers a $0 drug deductible, meaning your prescription drug coverage starts immediately without any out-of-pocket deductible costs. You will pay no copay for Tier 1 (Preferred Generic), Tier 2 (Generic), and Tier 6 (Supplemental Drugs) prescriptions for 1-month, 2-month, or 3-month supplies at preferred pharmacies, standard pharmacies, and standard mail order. This makes standard generic and supplemental medications highly accessible and affordable for plan members. For brand-name and specialized medications, Tier 3 (Preferred Brand) drugs require a $47 copay for a 1-month supply at preferred, standard, and standard mail order pharmacies. Tier 4 (Non-Preferred) drugs carry a $95 copay at preferred pharmacies and standard mail order, or a $100 copay at standard pharmacies for a 1-month supply. Tier 5 (Specialty Tier) drugs require a 33% coinsurance for a 1-month supply across preferred, standard, and standard mail order options.
Additional Benefits
The Simply Level Platinum (HMO C-SNP) plan offers robust coverage with no copays for primary care, telehealth, and preventive services. For specialized medical care, members will pay a $30 copay for specialists and a $100 daily copay for the first five days of inpatient hospital stays, with no copay for days six through ninety. Outpatient hospital services range from no copay up to a $200 copay, while emergency care carries a $150 copay that is waived if admitted. This plan also features comprehensive routine benefits, including dental, vision, and hearing services with no copay, featuring annual allowances of $1,200 for dental care and $1,000 for prescription hearing aids. Additionally, members can access home health services, local transportation up to twenty-four trips per year, and select diabetic supplies with no copay or coinsurance. Durable medical equipment and Part B drugs require no copay and a coinsurance ranging up to twenty percent.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Simply Level Platinum (HMO C-SNP) with no coinsurance, requiring a $100 daily copay for days 1 through 5 and no copay for days 6 through 90 for both acute and psychiatric stays. Non-Medicare-covered stays, upgrades for acute stays, and additional psychiatric days are not covered under this benefit.
Outpatient Services See details
Simply Level Platinum (HMO C-SNP) covers outpatient services with no coinsurance, including ambulatory surgical center and outpatient blood services at no copay. Outpatient hospital services range from no copay to a $200 copay, observation services require a $200 copay per stay, and outpatient substance abuse sessions carry a $50 copay.
Partial Hospitalization See details
Partial hospitalization is covered by the Simply Level Platinum (HMO C-SNP) plan with no copay and no coinsurance. Prior authorization and a referral are required for these services.
Ambulance and Transportation Services See details
Simply Level Platinum (HMO C-SNP) covers ground ambulance services with a $250 copay and air ambulance services with 20% coinsurance, both requiring prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 24 one-way trips per year to plan-approved locations, though trips to any health-related location are not covered.
Emergency Services See details
Simply Level Platinum (HMO C-SNP) covers emergency services with a $150 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours. Urgently needed services require a $30 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $100,000 limit with a $150 copay and no coinsurance.
Primary Care See details
Simply Level Platinum (HMO C-SNP) covers primary care, telehealth, and podiatry services with no copay and no coinsurance, though chiropractic services are not covered. Other covered benefits feature no coinsurance alongside copays of $25 for physical, occupational, speech, mental health, and psychiatric therapies, $30 for specialists, and $50 for opioid treatment.
Preventive Services See details
Preventive Services are partially covered by Simply Level Platinum (HMO C-SNP) with no copay and no coinsurance for all covered options, including Medicare-covered preventive care, glaucoma screenings, and diabetes self-management. While supplemental benefits like fitness, health education, and home safety devices (up to $50 monthly) are covered at no cost, other services such as annual physical exams, weight management, and nutritional therapy are not covered.
Hearing Services See details
Simply Level Platinum (HMO C-SNP) provides hearing services with no copay and no coinsurance for Medicare-covered exams, routine annual exams, and fitting evaluations. Prescription hearing aids are covered up to $1,000 annually with no copay or coinsurance, but OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Simply Level Platinum (HMO C-SNP) with no copay and no coinsurance for routine eye exams and eyewear, which includes a $150 annual maximum benefit. Other eye exam services and eyewear upgrades are not covered under this plan.
Dental Services See details
Simply Level Platinum (HMO C-SNP) offers partially covered dental services with no copay and no coinsurance for preventive and comprehensive care, up to a $1,200 annual maximum. Most services are covered, though prior authorization is required for some, while implant services and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Simply Level Platinum (HMO C-SNP) with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance and no copay, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Simply Level Platinum (HMO C-SNP) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Simply Level Platinum (HMO C-SNP) covers durable medical equipment with no copay and 0% to 20% coinsurance, and prosthetic devices and medical supplies with no copay and 20% coinsurance. Diabetic equipment, including supplies and therapeutic shoes, is covered with no copay and no coinsurance, though prior authorization is required for these services.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Simply Level Platinum (HMO C-SNP) with no coinsurance, although prior authorization and referrals are required. Lab services and outpatient X-rays have no copay, diagnostic procedures and tests carry a copay of $0 to $200, and other radiological services start with no copay.
Home Health Services See details
Home Health Services are covered by Simply Level Platinum (HMO C-SNP) with no copay and no coinsurance. Prior authorization and a referral are required to access these services.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Simply Level Platinum (HMO C-SNP) with no coinsurance, although prior authorization and referrals are required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Simply Level Platinum (HMO C-SNP) partially covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization and a referral. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Simply Level Platinum (HMO C-SNP) partially covers other services, providing over-the-counter (OTC) items and a chronic illness meal benefit with no copay and no coinsurance. Acupuncture, naloxone, and certain OTC list drugs are not covered under this benefit.
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