Simply Level Platinum (HMO C-SNP)
$0.00 /month
Monthly Premium
Among the lowest-premium plans in 2026
$0.00
Annual Deductible
1,025
Drugs Covered
1
States Served
Top Covered Drugs
Most popular medications covered by this plan, ordered by national search frequency. Click any drug to see exact copay, restrictions, and alternatives.
| # | Drug Name | Type | Tier | 30-Day Copay | |
|---|---|---|---|---|---|
| 1 | ISENTRESS RALTEGRAVIR | Brand | Tier 3 | $47.00 | Details |
| 2 | Everolimus | Brand | Tier 5 | 0.3% coinsurance | Details |
| 3 | ISENTRESS RALTEGRAVIR | Brand | Tier 5 | 0.3% coinsurance | Details |
| 4 | NOVOLOG insulin aspart | Brand | Tier 3 | $47.00 | Details |
| 5 | Doxepin Hydrochloride doxepin hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 6 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 3 | $47.00 | Details |
| 7 | Chlorpromazine Hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 8 | Ciprofloxacin | Brand | Tier 1 | $0.00 | Details |
| 9 | Efavirenz, Emtricitabine and Tenofovir Disoproxil Fumarate | Brand | Tier 4 | $95.00 | Details |
| 10 | Levothyroxine Sodium levothyroxine sodium | Brand | Tier 1 | $0.00 | Details |
| 11 | Baclofen | Brand | Tier 1 | $0.00 | Details |
| 12 | Clarithromycin | Brand | Tier 2 | $0.00 | Details |
| 13 | Diltiazem Hydrochloride | Brand | Tier 1 | $0.00 | Details |
| 14 | VARIVAX Varicella Virus Vaccine Live | Brand | Tier 1 | $0.00 | Details |
| 15 | Diazepam | Brand | Tier 3 | $47.00 | Details |
| 16 | Gilotrif afatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 17 | Talzenna talazoparib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 18 | Bupropion Hydrochloride SR SR bupropion hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 19 | Gentamicin Sulfate | Brand | Tier 2 | $0.00 | Details |
| 20 | RECOMBIVAX HB Hepatitis B Vaccine (Recombinant) | Brand | Tier 1 | $0.00 | Details |
Showing 20 of 1,025 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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