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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 All counties in ME. 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 $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 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, in the initial coverage phase, preferred generic drugs have no copay when using a preferred pharmacy or preferred mail order. Standard generic drugs have 25% coinsurance, and preferred brand drugs have 50% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The Wellcare Simple Open (PPO) plan provides comprehensive coverage with a variety of benefits. The plan offers no copay for many services, including primary care, preventive services, vision, and dental services. You'll pay a copay for inpatient hospital stays, with the amount varying by the type of care. This plan also covers outpatient services, emergency services, and hearing services, with copays and coinsurance applying to some services. The plan includes coverage for home health, medical equipment, and skilled nursing facility services, with varying cost-sharing requirements. Additionally, this plan may include additional benefits such as a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For acute care, you pay a \$350 copay for days 1-6, and no copay for days 7-90, and for psychiatric care, you pay a \$300 copay for days 1-6, and no copay for days 7-90; additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a 30% coinsurance and a copay between $0 and $350, and observation services with a 30% coinsurance and a $125 copay. Ambulatory Surgical Center (ASC) services have a $250 copay, and outpatient substance abuse services, including individual and group sessions, have a copay of $35. Outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Open (PPO) plan, but requires prior authorization. You will have a $105 copay 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 $300 copay, with no coinsurance, while 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 $125 copay, while Urgently Needed Services have a $35 copay; all three 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, occupational therapy services with a $35 copay, and physician specialist services with a $30 copay. Mental health specialty services, psychiatric services, and other health care professional services have varying copays. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits have a copay between $0 and $35. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams with no copay, and additional preventive services including fitness benefits, remote access technologies, and alternative therapies with no copay. Kidney Disease Education Services have a 20% coinsurance. Other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
Hearing exams are covered with a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids are covered up to a maximum of $750 per ear per year with no copay, though prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0-$30 and eyewear with no copay. Routine eye exams are covered with no copay for one visit every year, and eyewear has a combined maximum benefit of $100 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered with no copay.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $30 copay. Other covered services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay. Orthodontic services are partially covered, with a maximum plan benefit of $1,500 per year. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. 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, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance, while Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
The Wellcare Simple Open (PPO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a copay of $0 to $20, lab services with no copay, diagnostic radiological services with a copay of up to $350, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $75 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Open (PPO) plan with no copay and no coinsurance, though additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Wellcare Simple Open (PPO) covers Cardiac Rehabilitation Services, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some cardiac and pulmonary rehabilitation services, but the specific amount is not listed.
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 51-100, there is no copay, while days 21-50 have a $214 copay.
Other Services See details
Other Services includes a meal benefit with no copay, but acupuncture, over-the-counter items, 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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