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Wellcare Advantage Simple (PFFS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Advantage Simple (PFFS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Advantage Simple (PFFS) in 2025, please refer to our full plan details page.
Wellcare Advantage Simple (PFFS) is a PFFS 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 3.5 out of 5 stars in 2025.
It's important to know that Wellcare Advantage Simple (PFFS) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellcare Advantage Simple (PFFS).
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 Advantage Simple (PFFS), 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6700.00 (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 $6700.00 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 Advantage Simple (PFFS)
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Drug Coverage
Prescription drugs are not covered by Wellcare Advantage Simple (PFFS).
Additional Benefits
The Wellcare Advantage Simple (PFFS) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays between $0 and $280. Emergency services have a $125 copay, while primary care and preventive services have no copay. The plan provides coverage for hearing, vision, and dental services, with copays for exams and services. Prescription hearing aids are covered up to $350 per year. Additionally, the plan covers ambulance, home health, and skilled nursing facility services.
Inpatient Hospital See details
Inpatient Hospital coverage under the Wellcare Advantage Simple (PFFS) plan includes acute and psychiatric care. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-6, and no copay for days 7-90; for Inpatient Hospital Psychiatric, you pay a $260 copay for days 1-6, and no copay for days 7-90. Additional days, non-Medicare-covered stays, and upgrades for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered with a copay between $0 and $280. Observation Services have a copay between $125 and $280, while Ambulatory Surgical Center (ASC) Services have a $200 copay. Outpatient Substance Abuse Services and Outpatient Blood Services are also covered, with no copay for Individual and Group Sessions for Outpatient Substance Abuse and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Advantage Simple (PFFS) plan. You will have a $105 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including Medicare-covered ground and air ambulance services, each with a $335 copay and 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 under the Wellcare Advantage Simple (PFFS) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $35 copay, and all three have no coinsurance; however, Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Advantage Simple (PFFS) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, but routine care is not covered. Occupational therapy services have a $20 copay, while physician specialist services, physical therapy, and speech-language pathology services have a $20 copay. Mental health and psychiatric individual and group sessions have no copay. Other health care professional services have a copay of $0-$20, and opioid treatment program services have a $20 copay. Additional telehealth benefits have a copay of $0-$35. Podiatry services are not covered.
Preventive Services See details
Preventive services include an annual physical exam with no copay, while additional preventive services have a copay listed in the plan details. Kidney Disease Education Services have a 20% coinsurance, and 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 $20 copay, and routine hearing exams as well as fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered up to $350 per year, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$20, and eyewear with a $0 copay. Eyewear has a combined maximum benefit of $100 per year for both in-network and out-of-network services.
Dental Services See details
The Wellcare Advantage Simple (PFFS) plan covers Medicare Dental Services with a $20 copay, and other dental services including oral exams, dental x-rays, other diagnostic 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 covered up to a maximum of $1000 per year. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are covered with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Advantage Simple (PFFS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, with a 20% coinsurance for Durable Medical Equipment and Prosthetic Devices, while Diabetic Supplies have no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Wellcare Advantage Simple (PFFS) plan. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $280, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Advantage Simple (PFFS) 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 not covered by the Wellcare Advantage Simple (PFFS) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Advantage Simple (PFFS) plan. There is no copay for days 1-20 and days 61-100, but there is a $214 copay for days 21-60.
Other Services See details
Other Services include a meal benefit with no copay, while acupuncture, over-the-counter items, and dual eligible SNPs with highly integrated services are not covered. The meal benefit is for a chronic illness.
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