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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 All counties in KY. 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
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 $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) Medicare prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when using a preferred pharmacy or preferred mail-order service. Additionally, Tier 6 select care drugs are highly accessible with no copay across all standard and preferred pharmacy or mail-order options. For higher-tier medications, costs transition to coinsurance, with Tier 3 preferred brands and Tier 5 specialty drugs requiring a 25% coinsurance. Tier 4 non-preferred drugs carry a 34% coinsurance, while standard pharmacy copays for lower-tier generics range from $5 to $30 depending on the supply. This structure helps you estimate your out-of-pocket prescription costs and choose the most budget-friendly pharmacy option.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers robust medical coverage with many services featuring no coinsurance and predictable copays. You will pay no copay and no coinsurance for primary care visits, routine physical exams, and home health services, while specialist visits require a $40 copay. For hospital care, inpatient acute stays have a $375 copay for the first 7 days, and outpatient hospital services range from no copay up to a $500 copay. This plan also includes valuable supplemental benefits to help lower your out-of-pocket healthcare costs. Routine dental, vision, and hearing services are covered with no copay and no coinsurance, including up to $300 annually for eyewear and up to $750 per ear for hearing aids. Additionally, you can access over-the-counter items with no copay or coinsurance, while durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
Wellcare Simple Open (PPO) covers inpatient hospital care with no coinsurance, featuring a $375 copay for days 1 through 7 of acute stays and a $350 copay for days 1 through 5 of psychiatric stays, followed by no copay for subsequent days. This benefit is partially covered, as additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Wellcare Simple Open (PPO) with no coinsurance across all services, featuring copays ranging from no copay to $500 for outpatient hospital services and $115 to $500 per stay for observation services. Additionally, ambulatory surgical center services require a $300 copay with no coinsurance, substance abuse sessions have a $40 copay with no coinsurance, and outpatient blood services are covered 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 access this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) ambulance services are covered with a $350.00 copay and no coinsurance for both ground and air transportation, requiring prior authorization. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $30 copay and no coinsurance, with copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered up to a $50,000 maximum benefit with a $115 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under the Wellcare Simple Open (PPO) include primary care physician visits with no copay and no coinsurance, while specialist, mental health, and psychiatric services require a $40 copay and no coinsurance. Therapy services are covered with a $30 copay and no coinsurance, telehealth ranges from no copay to a $40 copay with no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) preventive services are partially covered, offering an annual physical exam, select screenings, alternative therapies, and fitness benefits with no copay and no coinsurance. Kidney disease education is covered with no copay and a 20% coinsurance, but several additional services such as health education, nutritional therapy, and in-home safety assessments are not covered.
Hearing Services See details
Wellcare Simple Open (PPO) covers Medicare-covered hearing exams with a $40 copay and no coinsurance, plus annual routine exams and fitting evaluations with no copay and no coinsurance. Hearing aids are partially covered with no copay and no coinsurance up to a $750 annual maximum per ear, but OTC hearing aids and prescription inner ear, outer ear, and over-the-ear models are not covered.
Vision Services See details
Wellcare Simple Open (PPO) offers partially covered vision services, which include one annual routine eye exam with no copay and no coinsurance, while other eye exam services are not covered. Covered eyewear options like contacts, eyeglasses, lenses, frames, and upgrades also have no copay or coinsurance, up to a combined maximum benefit of $300 per year for both in-network and out-of-network services.
Dental Services See details
Wellcare Simple Open (PPO) partially covers dental services, with maxillofacial prosthetics, implant services, and orthodontics excluded from coverage. Medicare-covered dental services require a $40 copay and no coinsurance, while other covered preventive and comprehensive dental services are provided with no copay and no coinsurance.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance ranging from no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by the Wellcare Simple Open (PPO) plan 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 medical supplies with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay, while diabetic therapeutic shoes and inserts require a 20% coinsurance, with prior authorization required for these services.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) covers diagnostic and radiological services with prior authorization, offering lab services and diagnostic radiological services with no copay and no coinsurance. Diagnostic procedures and tests have a copay ranging from $0 to $70, outpatient X-rays require a $50 copay, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Wellcare Simple Open (PPO) covers home health services with no copay and no coinsurance. Prior authorization is required before receiving these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Wellcare Simple Open (PPO) with no coinsurance, and some services are covered. However, cardiac rehabilitation (with a $30 copay), intensive cardiac rehabilitation (with a $40 copay), pulmonary rehabilitation (with a $25 copay), and SET for PAD services (with a $20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and days 61 through 100, while days 21 through 60 require a $218 daily copay, and additional days beyond the Medicare-covered 100-day limit are not covered.
Other Services See details
Wellcare Simple Open (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance through reimbursement, which includes nicotine replacement therapy and naloxone. Acupuncture, meal benefits, and other additional services are not covered.
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