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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 KY. This plan received an overall rating of 3.5 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 you meet your deductible, your costs will vary depending on the drug tier and pharmacy you use. For preferred generic drugs, you have no copay when using preferred or mail-order pharmacies, and a $10 copay at standard pharmacies. Standard generic drugs have a 25% coinsurance, while preferred brand drugs have a 39% coinsurance. Non-preferred drugs have a 28% coinsurance, and specialty tier drugs have no copay.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers a wide range of benefits with varying costs. It includes coverage for inpatient hospital stays, outpatient services, and emergency services, with copays ranging from $0 to $350. The plan also covers primary care, preventive services, hearing, vision, and dental services, with a combination of copays and no-cost options. Additional benefits include coverage for ambulance services, home health services with no copay, and skilled nursing facility stays with copays depending on the length of stay. The plan also provides coverage for home infusion services, dialysis services, and medical equipment, with varying cost-sharing. However, it's important to note that certain services like cardiac rehabilitation, private duty nursing, and some other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered by the Wellcare Simple Open (PPO) plan. For days 1-5, there is a $350 copay, and for days 6-90, there is no copay. Additional days and non-Medicare covered stays are not covered.
Outpatient Services See details
The Wellcare Simple Open (PPO) plan covers outpatient services, including outpatient hospital services with a copay of $0-$300, observation services with a copay of $125-$300, and ambulatory surgical center (ASC) services with a copay of $250. Outpatient substance abuse services are covered with a copay of $40 for individual and group sessions, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Open (PPO) plan with a $105 copay, and prior authorization is required.
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, including Urgent and Worldwide Emergency Coverage, are covered by the Wellcare Simple Open (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgent Coverage has a $30 copay. Worldwide Emergency Transportation is not covered, and Worldwide Emergency Services have a maximum benefit coverage of $50,000.
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 $30 copay, physician specialist services with a $30 copay, and physical therapy and speech-language pathology services with a $30 copay. The plan also covers mental health specialty services, psychiatric services, and opioid treatment program services with a copay between $40 and $40, and other health care professional services with a copay between $0 and $30. Additional telehealth benefits are covered with a copay between $0 and $40. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams with no copay, and additional preventive services with a copay for some supplemental benefits. Kidney Disease Education Services have a 20% coinsurance, and other preventive services include services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a welcome visit, all with no copay.
Hearing Services See details
Wellcare Simple Open (PPO) covers hearing exams with a $30 copay, as well as routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to a maximum of $1500 per year. Prescription hearing aids - inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay between $0 and $30, and eyewear with a combined maximum benefit of $300 per year with no copay. Routine eye exams are covered with no copay for one visit every year, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are covered with no copay.
Dental Services See details
The Wellcare Simple Open (PPO) plan covers Medicare Dental Services with a $30 copay and other dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventative 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 $3,000 annual maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple Open (PPO) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while the coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple Open (PPO) plan. The coinsurance for dialysis services is 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 Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, lab services, and outpatient X-ray services, are covered. Diagnostic procedures/tests have a minimum copay of $0 and a maximum copay of $70, lab services have no copay, diagnostic radiological services have a copay of at most $300, and outpatient X-ray services have a copay of $25; therapeutic radiological services have a coinsurance of at least 20%.
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 not covered by the Wellcare Simple Open (PPO) plan. While the plan covers some cardiac and pulmonary rehabilitation services, none of the sub-services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple Open (PPO) plan. For days 1-20 and 61-100, there is no copay, but there is a $214 copay for days 21-60.
Other Services See details
The Wellcare Simple Open (PPO) plan covers over-the-counter items with no copay, up to a maximum of $116 every three months. Acupuncture, Meal Benefit, 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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