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Wellcare Low Premium Open (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Low Premium Open (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Low Premium Open (PPO) in 2025, please refer to our full plan details page.
Wellcare Low Premium Open (PPO) is a PPO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in OR and WA. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Low Premium 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 Low Premium 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 Low Premium Open (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $38.00. 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 has a $225.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $10000.00 (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 $10000.00 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 Low Premium Open (PPO)
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Drug Coverage
The Wellcare Low Premium Open (PPO) plan has a $420 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at preferred pharmacies and a $10 copay at standard pharmacies. For generic drugs, you pay 25% coinsurance. Preferred brand drugs have a 39% coinsurance, and non-preferred drugs have a 28% coinsurance. Specialty tier drugs have no copay. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Wellcare Low Premium Open (PPO) plan offers a range of benefits. This plan has no copay for primary care, annual physical exams, routine hearing exams, routine eye exams, and many dental services. The plan includes coverage for inpatient and outpatient services, ambulance, emergency services, and home health services. The plan also covers hearing, vision, and dental services, along with home infusion services, dialysis services, and medical equipment.
Inpatient Hospital See details
Inpatient Hospital coverage includes both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a copay of $475 for days 1-5 and no copay for days 6-90; for Inpatient Hospital Psychiatric, the copay is $405 for days 1-5 and no copay for days 6-90. Additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services with the Wellcare Low Premium Open (PPO) plan include coverage for outpatient hospital services with a copay between $0 and $500, observation services with a copay between $110 and $500, and ambulatory surgical center services with a $350 copay. Outpatient substance abuse services have a $25 copay for individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellcare Low Premium Open (PPO) plan with an $80 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Low Premium Open (PPO) plan, but Transportation Services to any health-related location are not covered. Ground and Air Ambulance Services have a $325 copay, and there is no coinsurance.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Wellcare Low Premium Open (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, and Urgently Needed Services have a $45 copay, with no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Low Premium Open (PPO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $30 copay, and physician specialist services with a $30 copay. Mental health specialty services, psychiatric services, and opioid treatment program services all have a minimum copay of $25, while physical therapy and speech-language pathology services have a $30 copay. Additional telehealth benefits have a copay between $0 and $45, while routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams with no copay, and additional preventive services with a copay for some services. The plan also covers kidney disease education services with 20% coinsurance and other preventive services, including glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
Wellcare Low Premium Open (PPO) covers hearing exams with a $30 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $500 per ear, and prescription hearing aids of all types have no copay.
Vision Services See details
The Wellcare Low Premium Open (PPO) plan covers vision services, including eye exams and eyewear, with prior authorization required. Eye exams have a copay between $0 and $30, and routine eye exams have no copay, with one exam covered per year. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, have no copay, with a combined maximum benefit of $100 per year.
Dental Services See details
The Wellcare Low Premium Open (PPO) plan covers Medicare Dental Services with a $30 copay, along with Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services, and Adjunctive General Services with no copay. However, Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Low Premium Open (PPO) plan, including Medicare Part B Insulin Drugs with a $35 copay, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Low Premium Open (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, is covered. Durable Medical Equipment (DME) has a 20% coinsurance and requires authorization, while durable medical equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Wellcare Low Premium Open (PPO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20%, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $500, and Outpatient X-Ray Services have a $50 copay, and Therapeutic Radiological Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Wellcare Low Premium 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 Low Premium Open (PPO) 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 Low Premium Open (PPO) plan, but require prior authorization. For days 1-20 and days 61-100, there is no copay, but for days 21-60, there is a $214 copay.
Other Services See details
Other Services are not covered by the Wellcare Low Premium Open (PPO) plan. Specifically, acupuncture, over-the-counter items, 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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