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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 LA. This plan received an overall rating of 3 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:
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Drug Coverage
The Wellcare Simple Open (PPO) plan has a $420.00 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred and mail-order pharmacies, and a $10.00 copay at standard pharmacies. Specialty tier drugs have no copay, regardless of pharmacy. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you will pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers comprehensive coverage with a variety of benefits. This plan includes inpatient hospital stays with a copay, outpatient services with copays ranging from $0 to $325, and partial hospitalization with a $105 copay. Emergency services and primary care visits have copays between $0 and $125. Preventive services, such as annual physical exams, have no copay, while hearing and vision services include hearing exams with a $30 copay and eyewear with no copay. Dental services, including oral exams and cleanings, are covered with no copay, and diagnostic and radiological services have copays up to $325. The plan also includes home health services with no copay and OTC items up to $52 every three months.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric care. For acute inpatient hospital stays, you will pay a $300 copay for days 1-7, and no copay for days 8-90; for inpatient psychiatric stays, the copay is $295 for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services through the Wellcare Simple Open (PPO) plan cover outpatient hospital services with a copay between $0 and $325, observation services with a copay between $125 and $325, and ambulatory surgical center services with a $300 copay. Outpatient substance abuse services are covered with a $40 copay for both individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial hospitalization is covered by the Wellcare Simple Open (PPO) plan, but requires prior authorization. You will have a $105 copay for this service.
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 copay of $275, 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 $40 copay; all have no coinsurance. Worldwide Urgent Coverage has a $125 copay, and 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, and occupational therapy with a $35 copay. The plan also covers physician specialist services with a $30 copay, individual and group mental health and psychiatric sessions with a $40 copay, and physical therapy with a $35 copay. Additionally, the plan has additional telehealth benefits with a copay between $0 and $40, and opioid treatment services with a $30 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services. Additional preventive services include Fitness Benefit, Remote Access Technologies, and Alternative Therapies, which have no copay. Kidney Disease Education Services have a 20% coinsurance. Other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit all 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 have no copay. Prescription hearing aids are covered up to $350 per ear, and prescription hearing aids (all types) have no copay. Prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a copay of $0-$30, and routine eye exams have a copay of $0. Eyewear has a $0 copay, and a combined maximum plan benefit of $100 per year applies to both in-network and out-of-network services.
Dental Services See details
Dental services include a $30 copay for Medicare dental services, no copay for 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 prosthodontics (fixed), and oral and maxillofacial surgery. Orthodontic services have a maximum plan benefit 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, but prior authorization is required. 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. The coinsurance for Dialysis Services is between 20% and 20%.
Medical Equipment See details
The Wellcare Simple Open (PPO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires authorization, while Diabetic Supplies have no copay. Prosthetic Devices and Medical Supplies are covered with a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including all diagnostic services, are covered by the Wellcare Simple Open (PPO) plan. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $40, while Lab Services have no copay. Diagnostic Radiological Services have a maximum copay of $325, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a copay of $75.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Open (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services: Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. The copay for these services is not specified.
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, but for days 21-50, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Wellcare Simple Open (PPO) plan's other services include over-the-counter (OTC) items with no copay, up to $52 every three months, and nicotine replacement therapy and Naloxone coverage. However, acupuncture, meal benefits, 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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