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Wellcare Simple Exclusive (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Exclusive (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Simple Exclusive (HMO) in 2025, please refer to our full plan details page.
Wellcare Simple Exclusive (HMO) is a HMO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in IL. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple Exclusive (HMO) 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 Exclusive (HMO).
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 Exclusive (HMO), 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 Maximum Out-Of-Pocket cost of $2700.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network 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:
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Drug Coverage
The Wellcare Simple Exclusive (HMO) plan has a $420 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For the initial coverage phase, you can expect to pay no copay for preferred generic drugs and specialty tier drugs at preferred and mail-order pharmacies. Standard generic drugs and non-preferred drugs have a 25% and 28% coinsurance, respectively. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellcare Simple Exclusive (HMO) plan offers a variety of benefits with varying costs. For inpatient hospital stays, you'll pay a copay, while outpatient services have copays that vary by service. Emergency services, hearing, vision, dental, and many preventive services have no copay. This plan also includes coverage for ambulance services, with a $300 copay. Other benefits include coverage for home infusion, dialysis, medical equipment, and home health services, which may involve coinsurance or copays. Additionally, this plan provides coverage for OTC items, and a meal benefit, both with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with prior authorization required. For Inpatient Hospital-Acute, you will pay a $225 copay for days 1-9, and no copay for days 10-90; Inpatient Hospital Psychiatric has a $200 copay for days 1-10, and no copay for days 11-90. Additional Days, Non-Medicare-covered Stay, and Upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services, are covered. Outpatient Hospital Services have a copay between $0 and $250, Observation Services have a copay between $140 and $250, Ambulatory Surgical Center (ASC) Services have a $125 copay, and both individual and group sessions for Outpatient Substance Abuse have a $40 copay; there is no copay for Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Exclusive (HMO) plan, but requires prior authorization. You will have a $130 copay for this benefit.
Ambulance and Transportation Services See details
The Wellcare Simple Exclusive (HMO) plan covers ambulance services, including ground and air ambulance services, each with a $300 copay and no coinsurance. 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 under the Wellcare Simple Exclusive (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have no copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Exclusive (HMO) plan covers primary care physician services with a copay between $0 and $35, chiropractic services with a $10 copay, occupational therapy services with a copay between $10 and $40, physician specialist services with a copay between $10 and $40, mental health specialty services with a $40 copay for individual and group sessions, other health care professional services with a copay between $0 and $40, psychiatric services with a $40 copay for individual and group sessions, physical therapy and speech-language pathology services with a copay between $10 and $40, additional telehealth benefits with a 20% coinsurance and a copay between $0 and $40, and opioid treatment program services with a copay between $10 and $40. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Wellcare Simple Exclusive (HMO) plan covers preventive services, including an annual physical exam with no copay. Additional services include Personal Emergency Response System (PERS), Alternative Therapies, In-Home Support Services, and Fitness Benefit, all with no copay, as well as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay. Kidney Disease Education Services have a 20% coinsurance. Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered, with a $10 copay. Routine hearing exams and fitting/evaluation for hearing aids are covered with no copay, and prescription hearing aids are covered up to $1500 per year with no copay, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
The Wellcare Simple Exclusive (HMO) plan covers vision services, including eye exams and eyewear. Eye exams have a copay between $0 and $40, and routine eye exams have no copay. Eyewear has no copay, with a combined maximum of $500 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Wellcare Simple Exclusive (HMO) plan covers Medicare Dental Services with a copay of $10-$40, and other dental services including 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 fixed), and oral and maxillofacial surgery with no copay. Orthodontic services are covered up to a $4000 maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
The Wellcare Simple Exclusive (HMO) plan covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Exclusive (HMO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and prior authorization required, Prosthetics/Medical Supplies with coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with a copay between $0 and $100, and lab services with no copay. Outpatient X-ray services have a $50 copay, and therapeutic radiological services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Exclusive (HMO) plan with a 20% coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Wellcare Simple Exclusive (HMO) 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 Simple Exclusive (HMO) plan, but require prior authorization. You'll pay no copay for days 1-20, a $214 copay for days 21-40, and no copay for days 41-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Wellcare Simple Exclusive (HMO) plan covers Over-the-Counter (OTC) Items with no copay and a maximum benefit of $135 every three months, as well as Meal Benefit with no copay and a doctor referral required. Acupuncture, 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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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.
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