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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 NC. 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 $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:
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Drug Coverage
The Wellcare Simple Open (PPO) plan features an annual prescription drug deductible of $615. Beneficiaries enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs filled at preferred pharmacies or through preferred mail order. Additionally, Tier 6 select care drugs are fully covered with no copay at both preferred and standard pharmacies. For brand-name and specialty medications, Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance. Tier 4 non-preferred drugs carry a 35% coinsurance at preferred pharmacies, rising to 37% coinsurance at standard pharmacies. Standard pharmacies also charge copays ranging from $5 to $30 for Tier 1 and Tier 2 medications depending on the supply.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, home health care, and many preventive services. For hospital stays, members pay daily copays for the first few days of inpatient care with no coinsurance, while outpatient services range from no copay up to a $400 copay. Emergency room visits require a $130 copay, and specialist visits are available with a flat $20 copay and no coinsurance. This plan also provides strong supplemental coverage, including routine dental, vision, and hearing exams with no copay and no coinsurance. Members benefit from annual allowances for hearing aids, eyewear, and comprehensive dental care with no copays or coinsurance. Additionally, essential medical equipment, prosthetic devices, and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
Wellcare Simple Open (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $325 daily copay for days 1-6 of acute stays and a $350 daily copay for days 1-5 of psychiatric stays, with no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple Open (PPO) covers outpatient services with no coinsurance, featuring copays of $0 to $400 for hospital services, $130 to $400 per stay for observation services, and $250 for ambulatory surgical center services. Outpatient substance abuse sessions require a $25 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Wellcare Simple Open (PPO) covers partial hospitalization services with a $140.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers Medicare-approved ground and air ambulance services with a $350 copay and no coinsurance, though prior authorization is required. Routine transportation services, including trips to plan-approved or any health-related locations, are not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $130 copay and no coinsurance, and urgently needed services with a $30 copay and no coinsurance, with copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered up to a $50,000 maximum with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Open (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, physical therapy, occupational therapy, and opioid treatment services require a $20 copay and no coinsurance. Mental health and psychiatric sessions carry a $25 copay and no coinsurance, telehealth services have a $0 to $30 copay and no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) covers preventive services, including annual physical exams, fitness benefits, alternative therapies, and remote access technologies, with no copay and no coinsurance, though kidney disease education requires a 20% coinsurance and no copay. This benefit is partially covered, as several services such as health education, weight management, nutritional/dietary benefits, and in-home safety assessments are not covered.
Hearing Services See details
Wellcare Simple Open (PPO) covers Medicare-covered hearing exams with a $20 copay and no coinsurance, while routine exams and fittings are covered with no copay and no coinsurance. Prescription hearing aids are covered with no copay or coinsurance up to a $500 annual maximum per ear, but OTC hearing aids and inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Wellcare Simple Open (PPO), featuring eye exams with a $0 to $20 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear benefits, including lenses, frames, and contact lenses, have no copay or coinsurance up to a combined maximum benefit of $200 per year.
Dental Services See details
Wellcare Simple Open (PPO) partially covers dental services, offering Medicare-covered dental care for a $20 copay and no coinsurance, and preventive services with no copay and no coinsurance. Covered comprehensive services also feature no copay and no coinsurance up to a $4,000 annual maximum, though 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, subject to prior authorization. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Wellcare Simple Open (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered under the Wellcare Simple Open (PPO) plan, offering durable medical equipment, medical supplies, and prosthetic devices with no copay and a 20% coinsurance. Diabetic supplies are available with no copay, while diabetic therapeutic shoes and inserts incur a 20% coinsurance, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) covers diagnostic services with no coinsurance, offering lab services with no copay and diagnostic tests with a copay ranging from $0 to $100. Radiological services are also covered, featuring a $0 minimum copay for diagnostic radiology, a $25 copay for outpatient X-rays, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Wellcare Simple Open (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Wellcare Simple Open (PPO) offers no coinsurance for cardiac rehabilitation, and while some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice. These non-covered services require copays ranging from $25 to $50 depending on the specific therapy.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and days 51 through 100, a $218 daily copay for days 21 through 50, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Wellcare Simple Open (PPO), which offers over-the-counter (OTC) items with no copay and no coinsurance through reimbursement. Acupuncture and meal benefits are not covered under this plan.
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