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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 2026, 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 2026.
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:
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Drug Coverage
Prescription drugs are not covered by Wellcare Advantage Simple (PFFS).
Additional Benefits
The Wellcare Advantage Simple (PFFS) plan provides comprehensive medical coverage featuring no copay for primary care visits, annual physical exams, and routine hearing, dental, and vision assessments. Specialist visits require a $20 copay, while inpatient hospital stays incur a $325 copay for the first six days and no copay for subsequent days up to day 90. Emergency room visits carry a $130 copay, and urgent care is available for a $35 copay, with no coinsurance required for these services. Diagnostic lab work, home health services, and cardiac rehabilitation are covered with no copay and no coinsurance. For specialized needs, durable medical equipment and dialysis services require a 20% coinsurance with no copay. Skilled nursing facility stays are also covered, offering no copay for the first 20 days and a $213 daily copay for days 21 through 50.
Inpatient Hospital See details
Wellcare Advantage Simple (PFFS) covers inpatient hospital services with no coinsurance, although additional days, upgrades, and non-Medicare-covered stays are not covered. For acute hospital stays, there is a $325 copay for days 1 through 6 and no copay for days 7 through 90, while psychiatric stays require a $260 copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Wellcare Advantage Simple (PFFS) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $280 for outpatient hospital services and $130 to $280 per stay for observation services. Ambulatory surgical center services require a $200 copay with no coinsurance, while outpatient substance abuse sessions and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Wellcare Advantage Simple (PFFS) plan with a $140.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Wellcare Advantage Simple (PFFS) covers ground and air ambulance services with a $335 copay and no coinsurance per service. While some transportation services are covered, transportation to plan-approved health-related locations or any other health-related locations is not covered.
Emergency Services See details
Wellcare Advantage Simple (PFFS) covers emergency services with a $130 copay and urgently needed services with a $35 copay, both featuring no coinsurance and waived fees if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered up to a $50,000 lifetime limit with a $130 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Advantage Simple (PFFS) offers primary care physician visits and mental health sessions with no copay and no coinsurance, while specialist visits and physical, occupational, and speech therapies require a $20 copay and no coinsurance. Telehealth benefits are covered with a $0 to $35 copay and no coinsurance, but podiatry is not covered and some chiropractic services are covered though routine and other chiropractic services are not.
Preventive Services See details
Preventive services are partially covered by Wellcare Advantage Simple (PFFS), offering no copay and no coinsurance for annual physical exams, fitness benefits, alternative therapies, and remote access technologies. Kidney disease education is covered with no copay and a 20% coinsurance, while Medicare-covered zero-dollar preventive services, health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Wellcare Advantage Simple (PFFS) covers hearing exams with no deductibles or coinsurance, featuring a $20 copay for Medicare-covered exams and no copay for annual routine exams and fitting evaluations. Prescription and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Wellcare Advantage Simple (PFFS) provides partially covered vision services with no deductibles and no coinsurance, although other eye exam services are not covered. Routine eye exams are covered with no copay (limited to one per year) under a general $0 to $20 exam copay, while eyewear is covered with no copay up to a $100 annual maximum.
Dental Services See details
Dental services are partially covered by Wellcare Advantage Simple (PFFS), featuring a $20 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive and covered comprehensive services up to a $1,000 annual maximum. Implant services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Wellcare Advantage Simple (PFFS) with no copay, though associated Medicare Part B chemotherapy and other drugs require a 0% to 20% coinsurance. Part B insulin is covered with a $35 copay and no coinsurance, exempt from the plan deductible, and step therapy may be required.
Dialysis Services See details
Wellcare Advantage Simple (PFFS) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Wellcare Advantage Simple (PFFS), featuring no copay and a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes or inserts. Diabetic supplies are also covered with no copay, though they are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Wellcare Advantage Simple (PFFS), featuring no copay and no coinsurance for diagnostic tests, lab work, and diagnostic radiology. Outpatient X-rays require a $25 copay, while therapeutic radiological services are covered with a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Wellcare Advantage Simple (PFFS) plan with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Wellcare Advantage Simple (PFFS) with no copay and no coinsurance, though some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Advantage Simple (PFFS) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a three-day prior hospital stay for admission. There is no copay for days 1 to 20 and days 51 to 100, but a $213 daily copay applies for days 21 to 50, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Other Services are not covered under the Wellcare Advantage Simple (PFFS) plan, meaning supplemental benefits such as acupuncture, over-the-counter (OTC) items, and meal benefits are not available.
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