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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 Orange, Osceola, Seminole. 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 $160.00. 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 $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 no deductible for prescription drugs. In the initial coverage phase, you'll pay varying copays for your prescriptions depending on the drug tier and pharmacy. For example, preferred generic drugs have a $10 copay at preferred and standard pharmacies, and no copay via standard mail. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Simply Extra Platinum (HMO) plan provides a wide range of benefits with varying costs. Inpatient hospital stays have a $200 copay for the first 5 days, but no copay after that, while outpatient services and primary care visits have no copay. The plan also includes coverage for emergency services, hearing, vision, and dental, as well as home health and skilled nursing facility stays. Additional benefits include coverage for ambulance services with a $250 copay for ground transport, and 20% coinsurance for air transport, and transportation services with no copay for up to 12 one-way trips per year to plan-approved locations. The plan also covers over-the-counter items with a monthly allowance, and offers coverage for other services like home infusion and dialysis with varying cost-sharing.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric; both have a $200 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered for 3 days with no copay, and Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay of $0-$200, observation services with a $200 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $25 copay for individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Simply Extra Platinum (HMO) plan, with a $25 copay. A doctor referral and prior authorization are required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including all ambulance services and transportation services to plan-approved health-related locations. Ground ambulance services have a $250 copay, and air ambulance services have 20% coinsurance. Transportation services to a plan-approved health-related location include 12 one-way trips per year with no copay. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by the Simply Extra Platinum (HMO) plan. Emergency Services have a $120 copay, and Urgently Needed Services have a $25 copay. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation all have a $120 copay.
Primary Care See details
The Simply Extra Platinum (HMO) plan covers primary care physician services and chiropractic services with no copay, and also covers occupational therapy with a $25 copay. Physician specialist services have a $20 copay, and physical therapy and speech-language pathology services have a $25 copay. Mental health and psychiatric services, as well as opioid treatment program services, have a $25 copay.
Preventive Services See details
Preventive Services are covered, with Medicare-covered services requiring prior authorization and a doctor referral. Annual physical exams are not covered, while Health Education, Fitness Benefit, and Remote Access Technologies have no copay. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are also covered with no copay.
Hearing Services See details
The Simply Extra Platinum (HMO) plan covers hearing exams for a $25 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, with a maximum benefit of $1,000 per year and no copay for Prescription Hearing Aids (all types). Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services include eye exams and eyewear, with no copay for eye exams, contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames. Eyewear has a combined maximum plan benefit coverage of $225.00 every year. Upgrades are not covered.
Dental Services See details
Dental Services, including Medicare Dental Services, Oral Exams, Dental X-Rays, and other services, are covered with no copay. There is a $1,000 maximum benefit per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Simply Extra Platinum (HMO) plan, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while 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 with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has no copay, and a coinsurance between 0% and 20%, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, while Medical Supplies have a 20% coinsurance. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
The Simply Extra Platinum (HMO) plan covers diagnostic and radiological services, including diagnostic procedures and tests with a copay between $0 and $200, lab services with no copay, and outpatient X-ray services with no copay. Therapeutic radiological services have a copay of at most $25 and a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by 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 specific services including 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Simply Extra Platinum (HMO) plan, with prior authorization and a doctor referral required. For days 1-20, there is no copay, and for days 21-100, the copay is $150.00 per day. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Simply Extra Platinum (HMO) plan covers Over-the-Counter (OTC) Items with no copay, and a monthly maximum of $47. The plan also covers a meal benefit with no copay, and does not cover acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services.
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