Simply Freedom Extra (PPO)

Plan too new to be measured* for plan year 2023
$0.00 Monthly Premium

Simply Freedom Extra (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare

Plan ID: H9469-004-000

$0.00 Monthly Premium

Florida Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Florida Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$125.00
Out-of-pocket maximum$6,100.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
Out-of-Network:
$45.00 copay
Specialty doctor visit
Out-of-Network:
$70.00 copay
Inpatient hospital careIn-Network:
Days 1-5: $350.00 per day / Days 6-90: $0.00 per day
Additional Hospital Days: Unlimited additional days
Urgent careUrgent Care: $40.00 copay
Urgently Needed Services Copay Waived with Inpatient Admission
Emergency room visitEmergency Care: $90.00 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 transportationGround Ambulance: $275.00 copay Per Trip
Air Ambulance: $275.00 copay

Health Care Services and Medical Supplies

Simply Freedom Extra (PPO) covers a range of additional benefits. Learn more about Simply Freedom Extra (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
Out-of-Network:
Medicare Covered Chiropractic Services: 40% coinsurance
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:
Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)In-Network:
0% - 20% coinsurance depending on the equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 - $25.00 copay
Therapeutic Radiological Services: $0.00 - $60.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 - $125.00 copay
Diagnostic Radiological Services: $0.00 - $200.00 copay
Home health careIn-Network:
$0.00 copay
Mental health inpatient care
Out-of-Network:
40% coinsurance per stay
Mental health outpatient careIn-Network:
Individual and Group Sessions: $40.00 copay
Outpatient services/surgeryIn-Network:
Outpatient Hospital - Surgery: $300.00 copay
Observation Services: $300.00 copay
Ambulatory Surgical Center: $225.00 copay
Outpatient substance abuse care
Out-of-Network:
40% coinsurance
Podiatry services
Out-of-Network:
Medicare Covered Podiatry Services: $70.00 copay
Skilled Nursing Facility (SNF) care
Out-of-Network:
40% coinsurance per stay

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental care
Out-of-Network:
Medicare Covered Dental Services: $70.00 copay
Preventive Dental: 20% coinsurance
Comprehensive Dental: $0.00 copay

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefits
Out-of-Network:
Medicare Covered Eye Exam: $70.00 copay
Routine Eye Exam: $0.00 copay
Medicare Covered Eye Wear: $70.00 copay
Routine Eye Wear: $0.00 copay

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefitsIn-Network:
Medicare Covered Hearing Exam: $0.00 copay

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programs
Out-of-Network:
40% coinsurance

Prescription Drug Costs and Coverage

The Simply Freedom Extra (PPO) offers prescription drug coverage, with an annual drug deductible of $125.00 (excludes Tiers 1, 2 and 3)

Coverage
Cost
Coverage & Cost
Annual drug deductible$125.00 (excludes Tiers 1, 2 and 3)
Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
  • Tier 2
  • Standard retail $10.00
  • Standard mail order $0.00
  • Tier 3
  • Standard retail $47.00
  • Standard mail order $47.00
  • Annual drug deductible$125.00 (excludes Tiers 1, 2 and 3)
    Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
  • Tier 2
  • Standard retail $20.00
  • Standard mail order $0.00
  • Tier 3
  • Standard retail $94.00
  • Standard mail order $141.00
  • Annual drug deductible$125.00 (excludes Tiers 1, 2 and 3)
    Tier 1
  • Standard retail $0.00
  • Standard mail order $0.00
  • Tier 2
  • Standard retail $30.00
  • Standard mail order $0.00
  • Tier 3
  • Standard retail $141.00
  • Standard mail order $141.00
  • When reviewing Florida Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Florida that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Florida Counties Served

    Charlotte Collier Lee Manatee Sarasota
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