Simply Extra (HMO)

Simply Extra (HMO) H5471-105 Plan Details
5 out of 5 stars

Simply Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-105

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Simply Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-105

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Simply Extra (HMO) H5471-105 Plan Details
5 out of 5 stars

Simply Extra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H5471-105

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Florida Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $100
Out of Pocket Max In-Network: $3450
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$40.00 copay
Inpatient Hospital Care
In-Network:
Days 1-8: $225.00 per day / Days 9-90: $0.00 per day
Additional Hospital Days: Unlimited additional days
Urgent Care
Urgent Care: $40.00 copay
Urgently Needed Services Copay Waived with Inpatient Admission
Emergency Room Visit
Emergency Care: $135.00 copay
Copay waived if admitted to hospital within 24 hours
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance Transportation
Ground Ambulance: $250.00 copay Per Trip
Air Ambulance: 20% coinsurance

Health Care Services and Medical Supplies

Simply Extra (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Medicare Covered Chiropractic Services: $20.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
0% - 20% coinsurance depending on the equipment
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $25.00 copay - $200.00 copay
Therapeutic Radiological Services: $40.00 copay - 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - $200.00 copay
Diagnostic Radiological Services: $150.00 copay - $200.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-8: $225.00 per day / Days 9-90: $0.00 per day
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $40.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $200.00 copay
Observation Services: $200.00 copay
Ambulatory Surgical Center: $125.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $40.00 copay
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $45 every month. Unused OTC amounts do not roll over from month to month.
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
3 routine foot care visit(s) each year.
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $75.00 per day

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Preventive and Comprehensive Dental Combined Allowance
This plan covers up to a $1,000 allowance for covered preventive and comprehensive dental services every year.

Medicare Covered Dental: $0.00 copay
Preventive Dental Services: $0.00 copay
Comprehensive Dental Services: $0.00 copay

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $225.00 for eyeglasses or contact lenses every year.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $40.00 copay
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam every year. This plan covers 1 routine hearing aid fitting evaluation and a $1,000.00 maximum plan benefit for prescribed hearing aids every year.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services

Prescription Drug Costs and Coverage

The Simply Extra (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $100 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Standard mail order $0.00
  • Standard retail $15.00
Annual Drug Deductible $100 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Standard mail order $0.00
  • Standard retail $30.00
Annual Drug Deductible $100 (excludes Tiers 1 and 2)
Preferred Generic
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Standard mail order $0.00
  • Standard retail $45.00