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Wellcare Simple (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select Counties in AZ. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple (HMO) 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 (HMO).
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 (HMO), 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 $420.00 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 Maximum Out-Of-Pocket cost of $2500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 (HMO) plan has a $420 deductible for prescription drugs. After the deductible, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For the initial coverage phase, preferred generic drugs and specialty tier drugs have no copay. Standard generic drugs, preferred brand drugs, and non-preferred drugs have 25%, 41%, and 28% coinsurance, respectively. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $175 copay for days 1-10, with no copay for days 11-90. Outpatient services, primary care, and preventive services often have no copay, while specialist visits and some therapies have a $15 copay. The plan includes coverage for emergency services, ambulance, and transportation services, with copays ranging from $20 to $350. Vision and dental services have no copay for many services, and hearing aids are covered up to $750 per year. Durable medical equipment, dialysis, and some other services have a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage, including acute and psychiatric, requires prior authorization. For days 1-10, the copay is $175 per admission, and there is no copay for days 11-90. Additional days and non-Medicare covered stays for inpatient hospital are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $275, observation services with a copay between $140 and $275, Ambulatory Surgical Center (ASC) Services with a $175 copay, and outpatient substance abuse services with a $25 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $130 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Simple (HMO) plan. Ground and air ambulance services have a $350 copay, and transportation services to a plan-approved health-related location have no copay, with a limit of 12 one-way trips per year via rideshare, bus/subway, or medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Coverage and Worldwide Urgent Coverage, are covered by the Wellcare Simple (HMO) plan. The copay for Emergency Services and Worldwide Emergency Coverage is $140, while the copay for Urgently Needed Services and Worldwide Urgent Coverage is $20 and $140, respectively; there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple (HMO) plan covers primary care physician services with no copay, and chiropractic services with a $15 copay, but routine chiropractic care is not covered. The plan also covers occupational therapy, physician specialist services, physical therapy, and speech-language pathology services for a $15 copay. Mental health and psychiatric individual and group sessions cost a $25 copay. Additional telehealth benefits have a copay ranging from $0-$25, and opioid treatment program services have a $15 copay.
Preventive Services See details
The Wellcare Simple (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and others are not covered. Other services like Alternative Therapies, Glaucoma Screening, and Diabetes Self-Management Training have no copay. Kidney Disease Education Services have a 20% coinsurance.
Hearing Services See details
The Wellcare Simple (HMO) plan covers hearing exams with a $15 copay, routine hearing exams, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $750 per year, and all types of prescription hearing aids are covered with no copay, but inner ear, outer ear, and over-the-ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
The Wellcare Simple (HMO) plan covers vision services, including eye exams with a copay of $0-$15, and eyewear with no copay, subject to a combined maximum benefit of $200 per year. Routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are covered with no copay.
Dental Services See details
The Wellcare Simple (HMO) plan covers dental services, including oral exams with no copay, and Medicare dental services with a $15 copay. Other services like dental x-rays, other diagnostic dental services, cleaning, fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with no copay. However, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit coverage of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple (HMO) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple (HMO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), with a 20% coinsurance and requiring prior authorization. Prosthetics/Medical Supplies, including Medicare-covered prosthetic devices and medical supplies, are covered with a 20% coinsurance. Diabetic Equipment is covered, with Medicare-covered diabetic supplies having no copay and diabetic therapeutic shoes/inserts with a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $275, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $75 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Wellcare Simple (HMO) covers Cardiac Rehabilitation Services, but none of the sub-services are covered. The plan has a copay for the following services: Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
The Wellcare Simple (HMO) plan covers Skilled Nursing Facility (SNF) services, but requires prior authorization. For days 1-20, there is no copay, for days 21-40 the copay is $214, and for days 41-100, there is no copay. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under Other Services, acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered. Over-the-Counter (OTC) Items are covered with no copay. A meal benefit is covered with no copay, but requires a doctor referral.
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