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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 2025, 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 NC. This plan received an overall rating of 3.5 out of 5 stars in 2025.
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 $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 combined Maximum Out-Of-Pocket cost of $8950.00 (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 $8950.00 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:
Sign up for Wellcare Simple Open (PPO)
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Drug Coverage
The Wellcare Simple Open (PPO) plan has a $420.00 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, for preferred generic drugs, you will pay no copay at preferred pharmacies and mail order, and a $10 copay at standard pharmacies. For specialty tier drugs, you will pay no copay regardless of the pharmacy. After your total drug costs reach $2000.00, you will enter the catastrophic coverage phase, where you pay nothing for your Part D covered drugs.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays depending on the service. It provides no copay for primary care visits, preventive services like annual physical exams, and services like home health and dental services, including oral exams, x-rays, and cleanings. The plan also covers hearing and vision services with no copay, and includes coverage for home infusion, dialysis, and durable medical equipment with coinsurance. This plan also has copays for emergency and urgent care, specialist visits, and other services like chiropractic and occupational therapy. There is a $325 copay for ground and air ambulance services. Additional benefits include coverage for prescription hearing aids, and a maximum benefit for eyewear, and OTC items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-6, and no copay for days 7-90; Inpatient Hospital Psychiatric has a $350 copay for days 1-5, and no copay for days 6-90. Additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay of $0 - $400, Observation Services with a copay of $125 - $400, Ambulatory Surgical Center (ASC) Services with a $250 copay, 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 by the Wellcare Simple Open (PPO) plan, and requires prior authorization. The copay for this benefit is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Simple Open (PPO) plan. Ground and air ambulance services have a copay of $325, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Coverage and Urgent Coverage, are covered by the Wellcare Simple Open (PPO) plan. Emergency Services have a $125 copay, while Urgently Needed Services have a $30 copay, and both have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Open (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $20 copay. Physician specialist services, mental health specialty services, and physical therapy and speech-language pathology services each have a $20 copay. Additional telehealth benefits have a copay between $0 and $30, and opioid treatment program services have a $20 copay.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, as well as additional preventive services that may have a copay. This plan also covers kidney disease education services with 20% coinsurance. Other preventive services such as glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following welcome visits are covered with no copay.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $500 per ear per year and no copay, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Wellcare Simple Open (PPO) covers vision services, including eye exams with a copay of $0-$20, and eyewear with a combined maximum plan benefit of $200 per year, with no copay for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams have no copay, and are limited to one per year.
Dental Services See details
The Wellcare Simple Open (PPO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay. Medicare dental services have a $20 copay. Orthodontic services are covered up to a $3,000 maximum per year, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Wellcare Simple Open (PPO) plan. 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 under the Wellcare Simple Open (PPO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
The Wellcare Simple Open (PPO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance, and Prosthetic Devices, Medical Supplies, and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance. Diabetic Supplies have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay for Medicare-covered diagnostic procedures, tests, and lab services ranging from $0 to $100. Radiological services are also covered, with a copay for Medicare-covered diagnostic and therapeutic radiological services, and coinsurance for Medicare-covered X-ray services. Outpatient X-Ray services have a $25 copay, Diagnostic Radiological Services have a copay of at most $280, and Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Open (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. The copay for covered services is not specified in this snippet.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Open (PPO) plan, but require prior authorization. For days 1-20 and 61-100, there is no copay, and for days 21-60, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with no copay, and a maximum benefit of $107 every three months. Acupuncture, Meal Benefit, 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.
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