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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.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Wellcare Simple Open (PPO) is a PPO plan offered by Health Net Life Insurance Company available for the 2026 plan year to people living in Select counties in OR. 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 has a $150.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $615.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8500.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8500.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $13200.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $13200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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) Medicare prescription drug plan features an annual drug deductible of $615. You can save on medication costs with no copay for Tier 1 preferred generics and Tier 2 generics when using preferred pharmacies or preferred mail-order services. Additionally, Tier 6 select care drugs are highly affordable with no copay at any standard or preferred pharmacy. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 36% coinsurance at both standard and preferred pharmacies. If you choose to use standard pharmacies, generic copays are still budget-friendly, starting at $5 for Tier 1 and $10 for Tier 2.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers robust coverage with no copay for primary care visits, home health services, and routine preventive care. For specialist visits, physical therapy, and urgent care, members pay low copays with no coinsurance, while emergency room visits require a $115 copay. Inpatient hospital stays feature no coinsurance but require set copays for the first few days of acute or psychiatric stays, after which there is no copay. This plan also includes essential supplemental benefits, including routine dental care, annual vision exams, and hearing tests with no copay or coinsurance. Members receive annual allowances of up to $100 for eyewear and $500 per ear for prescription hearing aids with no copay. Additionally, standard durable medical equipment and dialysis services are covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple Open (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $600 copay for days 1-4 of acute stays (with no copay for days 5 to 95) and a $400 copay for days 1-5 of psychiatric stays (with no copay for days 6 to 90). Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Wellcare Simple Open (PPO) covers outpatient hospital services with a copay ranging from no copay to $500 and 30% coinsurance, and observation services with a $115 copay and 30% coinsurance. Ambulatory surgical center services require a $475 copay with no coinsurance, while outpatient substance abuse sessions carry a $25 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Wellcare Simple Open (PPO) plan with a $105.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers ground and air ambulance services with a $325.00 copay and no coinsurance, though prior authorization is required. While some transportation services are covered under the plan, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Wellcare Simple Open (PPO) emergency services are covered with a $115 copay and no coinsurance, and urgently needed services are covered with a $40 copay and no coinsurance. Worldwide emergency and urgent services are partially covered with a $115 copay, no coinsurance, and a $50,000 maximum benefit, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Open (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $30 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for routine care, whereas podiatry services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) covers annual physical exams, alternative therapies, fitness benefits, remote access, and various screenings with no copay and no coinsurance, while kidney disease education has no copay and 20% coinsurance. Other supplemental benefits are only partially covered, excluding health education, in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, therapeutic massage, adult day health, nutritional/dietary services, home-based palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, home/bathroom safety, and counseling.
Hearing Services See details
Wellcare Simple Open (PPO) hearing services are partially covered with no deductible, featuring a $30 copay and no coinsurance for Medicare-covered exams, and no copay or coinsurance for annual routine exams and fittings. Prescription hearing aids are covered up to $500 per ear annually with no copay and no coinsurance, but OTC hearing aids and inner ear, outer ear, or over the ear prescription models are not covered.
Vision Services See details
Vision Services are partially covered by Wellcare Simple Open (PPO), offering no copay, no coinsurance, and no deductible for one routine eye exam per year, while other eye exam services are not covered. Covered eyewear, including contacts and eyeglasses, also features no copay or coinsurance up to a combined annual maximum benefit of $100.
Dental Services See details
Dental services are partially covered by Wellcare Simple Open (PPO), featuring a $30 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive care. Restorative, endodontic, periodontic, prosthodontic, implant, oral surgery, and orthodontic services are not covered.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs require 0% to 20% coinsurance and no copay, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered by Wellcare Simple Open (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Open (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic supplies are covered with no copay from specified manufacturers, while diabetic therapeutic shoes or inserts require a 20% coinsurance, with prior authorization required.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) diagnostic and radiological services are covered with prior authorization, featuring no copay for diagnostic procedures, lab services, and diagnostic radiological services. Diagnostic procedures and therapeutic radiological services require a 20% coinsurance, while outpatient x-rays have a $50 copay, with coinsurance also applying to lab and x-ray services.
Home Health Services See details
Home health services are covered by Wellcare Simple Open (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Wellcare Simple Open (PPO) plan. Although there is no coinsurance, specific services—including cardiac rehabilitation ($30 copay), intensive cardiac rehabilitation ($40 copay), pulmonary rehabilitation ($25 copay), and supervised exercise therapy for peripheral artery disease ($20 copay)—are all not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers Skilled Nursing Facility (SNF) services 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, a $218 daily copay for days 21 through 60, and additional days beyond the Medicare limit are not covered.
Other Services See details
Wellcare Simple Open (PPO) partially covers other services, offering acupuncture with no copay and no coinsurance for up to 24 treatments per year with prior authorization. Supplemental benefits like over-the-counter (OTC) items and meal benefits are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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