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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 NY. This plan received an overall rating of 2.5 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 $13300.00 (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 $13300.00 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 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, you will pay no copay at a preferred pharmacy or through mail order, but a $10 copay at a standard pharmacy. For specialty tier drugs, you will pay no copay regardless of the pharmacy.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays and coinsurance. The plan covers emergency services, primary care, preventive services, and home health services with no copay. Additional benefits include hearing, vision, and dental services, with some services like routine exams and eyewear having no copay. The plan also provides coverage for ambulance, home infusion, dialysis, medical equipment, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $375 for days 1-7 and no copay for days 8-90 for Inpatient Hospital-Acute. Additional days for Inpatient Hospital-Acute have no copay for days 91-100. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered. Inpatient Hospital Psychiatric benefits are covered, with a copay of $275 for days 1-7 and no copay for days 8-90. Additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a 30% coinsurance and a copay between $0 and $500, observation services with a 30% coinsurance and a $110 copay, ambulatory surgical center services with a $475 copay, outpatient substance abuse services with a $35 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Open (PPO) plan, but requires prior authorization. You will pay a copay of $80 for this benefit.
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 $350 copay, with no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Wellcare Simple Open (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $35 copay, and there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay. Chiropractic services have a $15 copay. Occupational Therapy Services have a $35 copay. Physician Specialist Services have a $30 copay. Mental Health Specialty Services, including individual and group sessions, have a $35 copay. Other Health Care Professional services have a copay between $0 and $30. Psychiatric Services, including individual and group sessions, have a $35 copay. Physical Therapy and Speech-Language Pathology Services have a $35 copay. Additional Telehealth Benefits have a copay between $0 and $35. Opioid Treatment Program Services have a $30 copay. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for annual physical exams with no copay, as well as other preventive services including Medicare-covered zero dollar preventive services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, all with no copay. Additional benefits such as health education, in-home safety assessment, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, weight management programs, therapeutic massage, adult day health services, nutritional/dietary benefit, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices, counseling services are not covered.
Hearing Services See details
Hearing Services includes hearing exams with a $30 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum plan benefit coverage of $750 per ear every year, while OTC hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay between $0 and $30, and routine eye exams have no copay. Eyewear has no copay, and a combined maximum benefit of $100 per year for both in-network and out-of-network services.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $30 copay, while 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 are covered with no copay. Orthodontic Services are covered up to a $1,000 maximum benefit per year, while Prosthodontics (removable and fixed), 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 and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while other Medicare Part B drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Open (PPO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
The Wellcare Simple Open (PPO) plan covers medical equipment, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics and Medical Supplies with 20% coinsurance, and Diabetic Equipment with varying copays and coinsurance. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have 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 $50, Lab Services have no copay, Diagnostic Radiological Services have a copay up to $500, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $35 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Open (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Wellcare Simple Open (PPO) plan, but the specific services are not covered. There is a copay for some Cardiac and Pulmonary Rehabilitation Services.
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, but for days 21-60, the copay is $214.
Other Services See details
The Wellcare Simple Open (PPO) plan covers acupuncture with no copay, up to 12 treatments per year, and also covers over-the-counter items and meal benefits with no copay, with a $40 maximum benefit for over-the-counter items every three months. However, the plan does not cover Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and various other services.
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