Simply Freedom Extra (PPO)
Simply Freedom Extra (PPO) H9469-004 Plan Details
Simply Freedom Extra (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Simply Healthcare
Plan ID: H9469-004
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$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
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $125 |
| Out of Pocket Max |
In-Network: $6400 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: $0.00 copay Out-of-Network: $45.00 copay |
| Specialty Doctor Visit | In-Network: $40.00 copay Out-of-Network: $70.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $350.00 per day / Days 6-90: $0.00 per day Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Urgent Care | Urgent Care: $40.00 copay Urgently Needed Services Copay Waived with Inpatient Admission |
| Emergency Room Visit | Emergency Care: $100.00 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: $275.00 copay Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Simply Freedom Extra (PPO) 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: $0.00 copay Out-of-Network: Medicare Covered Chiropractic Services: 40% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 40% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 0% - 20% coinsurance depending on the equipment Out-of-Network: 40% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay X-Rays: $0.00 copay - $25.00 copay Therapeutic Radiological Services: $0.00 copay - $60.00 copay Outpatient Diagnostic Procedures/Tests: $0.00 copay - $125.00 copay Diagnostic Radiological Services: $0.00 copay - $200.00 copay Out-of-Network: Lab Services: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 40% coinsurance Outpatient Diagnostic Procedures/Tests: 40% coinsurance Diagnostic Radiological Services: 40% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 40% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-5: $350.00 per day / Days 6-90: $0.00 per day Out-of-Network: 40% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $300.00 copay Observation Services: $300.00 copay Ambulatory Surgical Center: $225.00 copay Out-of-Network: Outpatient Hospital - Surgery: 40% coinsurance Observation Services: 40% coinsurance Ambulatory Surgical Center: 40% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: $40.00 copay Out-of-Network: Medicare Covered Podiatry Services: $70.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day Out-of-Network: 40% coinsurance per stay |
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 $1,000 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 Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $70.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 50% Coinsurance for Non-Medicare Covered Comprehensive Dental 50% |
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. $69.00 maximum eye exam coverage amount. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $100.00 for eyeglasses or contact lenses every year. 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 from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $0.00 copay Out-of-Network: Medicare Covered Hearing Exam: $70.00 copay |
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 Out-of-Network: 40% coinsurance |
Prescription Drug Costs and Coverage
The Simply Freedom Extra (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $125 (excludes Tiers 1, 2 and 3) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $125 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $125 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
| Annual Drug Deductible | $125 (excludes Tiers 1, 2 and 3) |
| Preferred Generic |
|
| Generic |
|
| Preferred Brand |
|
Find Medicare Advantage Plans
Visit MedicareAdvantage.com to compare multiple Medicare Advantage plans, side by side.
