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Wellcare Simple Open (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Open (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple Open (PPO) in 2026, please refer to our full plan details page.
Wellcare Simple Open (PPO) is a PPO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in GA. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Wellcare Simple Open (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellcare Simple Open (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Wellcare Simple Open (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13900.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13900.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Wellcare Simple Open (PPO) prescription drug plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs when using preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order options are also available with low copays starting at $5 for Tier 1 drugs. For higher-tier medications, cost-sharing transitions to coinsurance rather than a flat copayment. You will pay 25% coinsurance for Tier 3 preferred brand drugs and Tier 5 specialty drugs, while Tier 4 non-preferred drugs require a 37% coinsurance. This structure helps you easily estimate your out-of-pocket expenses for both generic and brand-name prescriptions.
Additional Benefits
The Wellcare Simple Open (PPO) plan provides comprehensive healthcare coverage with no copay and no coinsurance for primary care visits, routine physicals, and home health services. For specialist visits and physical therapy, members pay a predictable copay ranging from $35 to $40, while emergency room visits require a $115 copay. Inpatient hospital stays feature no coinsurance, with a $475 daily copay for the first five days and no copay for days six through 90. Routine vision and hearing exams are covered with no copay, and the plan includes allowance benefits for prescription hearing aids and eyewear. Preventive dental services also feature no copay, while comprehensive dental care carries a 40% coinsurance up to a $1,000 annual limit. Additionally, members benefit from no copay on over-the-counter items and skilled nursing facility stays for the first 20 days.
Inpatient Hospital See details
Wellcare Simple Open (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required and additional days, upgrades, and non-Medicare-covered stays are not covered. Acute inpatient stays require a $475 copay per day for days 1 through 5 (with no copay for days 6 through 90), while psychiatric stays require a $2,075 copay per admission.
Outpatient Services See details
Wellcare Simple Open (PPO) covers outpatient services with no coinsurance, featuring copays ranging from no copay to $400 for outpatient hospital services, $115 to $400 for observation services, and $250 for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Wellcare Simple Open (PPO) covers partial hospitalization services with a $105.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Wellcare Simple Open (PPO), featuring a $350 copay and no coinsurance for Medicare-approved ground and air ambulance trips, which require prior authorization. However, transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $115 copay and urgently needed services with a $30 copay, both featuring no coinsurance and copays waived if admitted within 24 hours. Worldwide emergency and urgent care are partially covered up to a $50,000 lifetime limit with a $115 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Open (PPO) offers primary care physician services and select telehealth benefits with no copay and no coinsurance. Specialist visits, physical therapy, occupational therapy, and mental health services require copays ranging from $35 to $40 with no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Wellcare Simple Open (PPO), featuring no copay and no coinsurance for annual physicals, fitness benefits, alternative therapies, remote access, and various screenings, while kidney disease education has no copay but a 20% coinsurance. Sub-services that are not covered under this plan include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy-related hair loss, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Wellcare Simple Open (PPO) provides partially covered hearing services, featuring a $40 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are covered up to $500 per ear annually with no copay or coinsurance, though over-the-counter (OTC), inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Wellcare Simple Open (PPO) provides partially covered vision services with no copays and no coinsurance for routine annual eye exams and eyewear, though other eye exam services are not covered. Covered eyewear, including contacts and eyeglasses, is subject to a combined annual maximum benefit of $100, and prior authorization is required.
Dental Services See details
Dental services under the Wellcare Simple Open (PPO) are partially covered, featuring Medicare-covered dental care with a $40 copay and no coinsurance, and preventive services with no copay and no coinsurance. Covered comprehensive services require no copay and a 40% coinsurance up to a $1,000 annual limit, while prosthodontics, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Wellcare Simple Open (PPO) with no copay, though prior authorization is required. Medicare Part B insulin drugs have a $35 copay and no coinsurance, while Part B chemotherapy and other drugs have no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Open (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Open (PPO) covers durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay, and prior authorization is required for most of these medical equipment services.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) covers diagnostic and radiological services with prior authorization, offering diagnostic services with no coinsurance and lab services with no copay. Diagnostic procedures have a copay ranging from $0 to $100, outpatient X-rays require a $50 copay, and therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Wellcare Simple Open (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Wellcare Simple Open (PPO) with no coinsurance, but only some services are covered, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require copays ranging from $20.00 to $40.00.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers skilled nursing facility (SNF) care with no coinsurance, featuring no copay for days 1 to 20 and days 71 to 100, and a $218 daily copay for days 21 to 70. Prior authorization is required, and additional days beyond the standard Medicare-covered 100 days are not covered.
Other Services See details
Wellcare Simple Open (PPO) partially covers other services, which includes over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and other additional services are not covered under this plan.
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