Simply Freedom (PPO) H9469-003-0 Plan Details
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*This plan is new and has not yet been rated by CMS.
Simply Freedom (PPO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
Simply Freedom Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H9469-003-0 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 6,800.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $150.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | Simply Healthcare |
| Summary of Benefits |
|---|
Simply Healthcare Out-of-Pocket Costs
This Simply Healthcare Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H9469-003-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $0 Copay |
| Specialist: | $30 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $100 Copay |
| Urgent care: | $40 Copay |
| Ground ambulance: | $250 Copay |
| Inpatient hospital care: | $350.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $196.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $30 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $0 Copay Prior Authorization Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $30 Copay |
| Outpatient group therapy: | $30 Copay |
| Inpatient psychiatric hospital care: | $350.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $30 Copay Prior Authorization Required |
| Occupational therapy: | $30 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | $0 Copay Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $110 Copay Prior Authorization Required |
| Lab services: | $0 Copay Prior Authorization Required |
| Outpatient x-rays: | $25 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $30 Copay Prior Authorization Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $0 Copay Prior Authorization Required |
| Oral exam | $0 Copay |
| Dental x-rays | $0 Copay |
| Cleaning | $0 Copay |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $2,000.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $0 Copay |
| Routine eye exam (in-network) | $0 Copay 1 Every year |
| Eyewear benefits | None |
Feel free to download our Simply Freedom Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Simply Freedom includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans offer greater coverage than basic plans, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Low Income Premium Subsidy: | $20.30 |
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $150.00. You must pay this amount at the pharmacy before Simply Healthcare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Simply Freedom has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | $0.00 |
| Generic* | $10.00 | $0.00 | $10.00 |
| Preferred Brand* | $42.00 | $42.00 | $47.00 |
| Non-Preferred Drug | 25.00% | 25.00% | 25.00% |
| Specialty Tier | 31.00% | 31.00% | 31.00% |
| Supplemental Drugs | $0.00 | $0.00 | $0.00 |
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Simply Healthcare plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent ratings for Simply Freedom .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
| Managing Chronic (Long Term) Conditions | Plan too new to be measured |
| Member Experience with Health Plan | Plan too new to be measured |
| Complaints and Changes in Plans Performance | Plan too new to be measured |
| Health Plan Customer Service | Plan too new to be measured |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | Plan too new to be measured |
| Member Experience with the Drug Plan | Plan too new to be measured |
| Drug Safety and Accuracy of Drug Pricing |
Plan Availability
Simply Freedom (H9469-003-0) is available in the following locations (click to open):
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- H9469-008-0: Simply Freedom ()
- H9469-002-0: Simply Freedom ()
- H9469-003-0: Simply Freedom ()
- H9469-001-0: Simply Freedom ()
- H9469-007-0: Simply Freedom ()
- H9469-006-0: Simply Freedom ()
- H9469-009-0: Simply Freedom ()
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Simply Healthcare
| Website: | Simply Healthcare Plan Page |
|---|---|
| Providers: | Simply Healthcare Providers Page |
| Formulary: | Simply Healthcare Formulary Page |
| Pharmacy: | Simply Healthcare Pharmacy Page |
| New Member Health Plan Help: | (833)668-2380 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (833)668-2381 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Simply Healthcare, http://shop.simplyhealthcareplans.com/medicare, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "Is Your Test, Item, or Service Covered?", Last Accessed June 3, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.