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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 NY. This plan received an overall rating of 3 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 has a $250.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $13900.00 (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 $13900.00 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) Medicare plan features an annual prescription drug deductible of $615. For generic and select care medications, this plan offers significant savings, including no copay for Tier 1 preferred generics and Tier 2 generics at preferred pharmacies, as well as no copay for Tier 6 select care drugs at all pharmacies. If you use standard pharmacies or standard mail order, Tier 1 and Tier 2 copays range from $5 to $30 depending on the supply. For brand-name and specialty medications, cost-sharing is based on coinsurance rather than flat copays. Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 38% coinsurance. These coinsurance rates remain the same whether you use a preferred pharmacy, standard pharmacy, or mail-order service.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers comprehensive coverage for your primary healthcare needs, featuring no copay and no coinsurance for primary care visits, while specialist visits require a $30 copay. For hospital stays, inpatient acute care has a $600 daily copay for days 1 to 4 and no copay for days 5 to 100, while emergency room visits carry a $115 copay with no coinsurance. Outpatient services feature varying costs, ranging from no copay up to a $500 copay plus 30% coinsurance depending on the service. This plan also includes key supplemental benefits, including no copay for preventive dental cleanings, routine eye exams, and annual hearing exams. Prescription hearing aids are covered up to $750 per ear annually with no copay, and eyewear is covered up to $100 per year with no copay. Additionally, diagnostic labs and home health services are available with no copay, while durable medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple Open (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays require a $600 daily copay for days 1-4 (and no copay for days 5-100), while psychiatric stays require a $500 daily copay for days 1-4 (and no copay for days 5-90), though upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Wellcare Simple Open (PPO), featuring a copay ranging from no copay to $500 plus 30% coinsurance for outpatient hospital services, and a $115 copay per stay plus 30% coinsurance for observation services. Ambulatory surgical center services require a $475 copay with no coinsurance, outpatient substance abuse sessions cost a $35 copay with no coinsurance, and outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Wellcare Simple Open (PPO) covers partial hospitalization services with a $105.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers ground and air ambulance services with a $350 copay and no coinsurance, though prior authorization is required. While transportation services are technically covered, only some services are covered, and transportation to plan-approved health-related locations or any health-related locations is not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $115 copay and urgently needed services with a $35 copay, both with no coinsurance. Worldwide emergency services are partially covered up to a $50,000 maximum with a $115 copay and no coinsurance, but 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 visits require a $30 copay and no coinsurance. Additional services like physical therapy, occupational therapy, and mental health sessions have copays ranging from $0 to $35 with no coinsurance, though podiatry is not covered and chiropractic care is only partially covered as other chiropractic services are excluded.
Preventive Services See details
Wellcare Simple Open (PPO) preventive services are partially covered, offering an annual physical, fitness benefits, alternative therapies, and routine screenings with no copay and no coinsurance, while kidney education has no copay and a 20% coinsurance. Uncovered services include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Wellcare Simple Open (PPO) hearing services are partially covered, featuring a $30 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fitting evaluations. Prescription hearing aids are covered up to $750 per ear annually with no copay or coinsurance, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Wellcare Simple Open (PPO) with no coinsurance or deductibles, though other eye exam services are not covered. Routine eye exams have no copay, other covered eye exams have a copay of $0 to $30, and eyewear options such as contacts and eyeglasses have no copay up to a combined limit of $100 per year.
Dental Services See details
Wellcare Simple Open (PPO) offers partially covered dental services, featuring a $30 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive care like cleanings and exams. However, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay, subject to prior authorization and step therapy guidelines. Under this benefit, Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by Wellcare Simple Open (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Open (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic therapeutic shoes, with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay, and prior authorization is required for these medical equipment benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Wellcare Simple Open (PPO) with prior authorization, featuring no coinsurance for diagnostic services, no copay for lab services, and copays ranging from $0 to $75 for diagnostic tests. Diagnostic radiology services have no copay, outpatient x-rays require a $50 copay, and therapeutic radiological services carry a minimum 20% coinsurance.
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
Cardiac Rehabilitation Services are partially covered under the Wellcare Simple Open (PPO) with no coinsurance. While some services require a copayment, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Wellcare Simple Open (PPO) with no coinsurance, as additional days beyond the Medicare-covered limit are not covered. There is no copay for days 1 to 20 and days 71 to 100, a $218 daily copay for days 21 to 70, and prior authorization is required.
Other Services See details
Wellcare Simple Open (PPO) partially covers other services, providing acupuncture with no copay and no coinsurance for up to 12 treatments per year with prior authorization. Over-the-counter (OTC) items, meal benefits, and other supplemental services are not covered under this plan.
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