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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 Statewide in PA. This plan received an overall rating of 3 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 $10000.00 (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 $10000.00 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 has a $420 deductible for prescription drugs. After the deductible is met, you will pay the following costs for drugs in each tier. For preferred generic drugs, you will pay no copay at preferred pharmacies and mail order, and a $10 copay at standard pharmacies. Standard generic drugs have a 25% coinsurance, while preferred brand drugs have a 39% coinsurance. Non-preferred drugs have a 28% coinsurance, and specialty tier drugs have no copay. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers a range of benefits with varying costs. You'll find no copays for primary care, preventive services like annual physicals, and home health services. The plan also covers inpatient hospital stays, emergency services, outpatient services, and hearing and vision services, with copays ranging from $20 to $400 depending on the service. Additional benefits include coverage for dental services, medical equipment, and diagnostic and radiological services, some with coinsurance requirements. The plan also offers coverage for skilled nursing facilities, with no copay for certain days, as well as ambulance, and partial hospitalization.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including acute and psychiatric care. For acute care, you'll pay a $350 copay for days 1-6, and no copay for days 7-90, with no coinsurance. For psychiatric care, you'll pay a $350 copay for days 1-5, and no copay for days 6-90, with no coinsurance.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $400, Observation Services with a copay between $125 and $400, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services with a $40 copay for both individual and group sessions. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Simple Open (PPO) plan, with a $105 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and Air Ambulance Services have a $320 copay and no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Wellcare Simple Open (PPO) plan with a $125 copay and no coinsurance. Urgently Needed Services have a $40 copay with no coinsurance. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay, while 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 $35 copay. Physician specialist services have a $30 copay, while mental health specialty services and psychiatric services both have a $40 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits have a copay between $0 and $40. Opioid treatment program services have a $30 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and other services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Kidney Disease Education Services have 20% coinsurance. Additional services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System, and others are not covered.
Hearing Services See details
The Wellcare Simple Open (PPO) plan covers hearing exams with a $30 copay, and also covers routine hearing exams and fitting/evaluation for hearing aids with no copay, each limited to one visit per year. Prescription hearing aids are covered up to $750 per year per ear, but inner ear, outer ear, and over-the-ear hearing aids are not covered, and OTC hearing aids are also not covered.
Vision Services See details
The Wellcare Simple Open (PPO) plan covers vision services, including eye exams with a copay between $0 and $30, and eyewear with a combined maximum plan benefit of $200 per year and no copay. Routine eye exams, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered with no copay.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and Other Dental Services, including Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, and Oral and Maxillofacial Surgery, all with no copay, and Orthodontic Services with a $1,000 maximum benefit. Prosthodontics, 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 by the Wellcare Simple Open (PPO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment and Prosthetics/Medical Supplies, is covered under the Wellcare Simple Open (PPO) plan. For Durable Medical Equipment, you will pay 20% coinsurance, while Prosthetic Devices and Medical Supplies also have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, diagnostic procedures/tests, lab services, and radiological services. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $40, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $400, and Therapeutic Radiological Services have a minimum coinsurance of 20%. Outpatient X-Ray Services have a copay of $75.
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 under the Wellcare Simple Open (PPO) plan. However, the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Open (PPO) plan and require prior authorization. For days 1-20 and 61-100, there is no copay, but for days 21-60, the copay is $214. Additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Wellcare Simple Open (PPO) plan covers over-the-counter (OTC) items with no copay, up to $42 every three months. Acupuncture, meal benefits, 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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