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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 2026, 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 2026.
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 $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 Maximum Out-Of-Pocket cost of $3200.00 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 features an annual prescription drug deductible of $615. Beneficiaries can enjoy significant savings 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 available with no copay at both standard and preferred pharmacies. For higher-tier medications, costs are based on coinsurance rather than flat copayments. Tier 3 preferred brand drugs and Tier 5 specialty drugs carry a 25% coinsurance, while Tier 4 non-preferred drugs require a 47% coinsurance. Choosing preferred pharmacies and mail-order options remains the most cost-effective way to manage prescription expenses under this plan.
Additional Benefits
Wellcare Simple Exclusive (HMO) provides comprehensive medical coverage with predictable out-of-pocket costs, featuring no coinsurance for inpatient hospital stays and outpatient services. Inpatient acute stays require a $225 daily copay for the first nine days, while primary care visits range from no copay up to $35 and specialist visits have a copay of up to $40. Emergency care is available with a $150 copay, and urgent care services are covered with no copay. This plan also includes robust additional benefits, offering routine dental, vision, and hearing exams with no copay. Members can take advantage of a $500 annual eyewear allowance and a $1,500 annual hearing aid allowance per ear with no copay. Standard fitness benefits and diabetic supplies are also covered with no copay, while durable medical equipment requires a 20% coinsurance.
Inpatient Hospital See details
Wellcare Simple Exclusive (HMO) covers inpatient hospital services with no coinsurance, requiring a $225 copay for days 1 to 9 of acute stays (no copay for days 10 to 90) and a $200 copay for days 1 to 10 of psychiatric stays (no copay for days 11 to 90). Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple Exclusive (HMO) covers outpatient hospital services with no coinsurance and copays ranging from no copay up to $250, and ambulatory surgical center services with a $125 copay and no coinsurance. Outpatient substance abuse services require a $40 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Wellcare Simple Exclusive (HMO) covers partial hospitalization services with a $175.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Exclusive (HMO) covers ground and air ambulance services with a $300 copay and no coinsurance per service, though prior authorization is required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Wellcare Simple Exclusive (HMO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with no copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $50,000 benefit limit with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Exclusive (HMO) covers primary care physician services with copays from no copay to $35 and no coinsurance, alongside specialist, therapy, and mental health services that require prior authorization and have copays up to $40 with no coinsurance. Telehealth benefits are offered with copays up to $40 and 20% coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple Exclusive (HMO) partially covers preventive services, offering annual physicals, fitness benefits, and screenings with no copay and no coinsurance, while kidney disease education has no copay and a 20% coinsurance. The plan does not cover health education, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, caregiver support, smoking cessation, disease management, telemonitoring, home safety modifications, and counseling.
Hearing Services See details
Wellcare Simple Exclusive (HMO) covers routine hearing exams and fitting evaluations with no copay and no coinsurance, while Medicare-covered exams require a $10 copay and no coinsurance. Prescription hearing aids are partially covered with no copay or coinsurance up to $1,500 per ear annually, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Wellcare Simple Exclusive (HMO) partially covers vision services with no coinsurance or deductibles, offering no copay for one routine annual eye exam and a $500 annual allowance with no copay for eyewear like contacts and eyeglasses. Other eye exam services are not covered, and prior authorization is required for covered benefits.
Dental Services See details
Wellcare Simple Exclusive (HMO) partially covers dental services, offering key preventive and comprehensive care with no copay and no coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered. Medicare-covered dental services are available with a $10.00 to $40.00 copay and no coinsurance, and prior authorization is required for most services.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Wellcare Simple Exclusive (HMO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry no copay and 0% to 20% coinsurance.
Dialysis Services See details
Wellcare Simple Exclusive (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Exclusive (HMO) covers durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay and no coinsurance, while diabetic therapeutic shoes and inserts have no copay and a 20% coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
Wellcare Simple Exclusive (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic lab services have no copay or coinsurance, other diagnostic tests range from a $0 to $100 copay with no coinsurance, and radiological services involve copays starting at $0, a $50 copay for X-rays with coinsurance, and a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered under the Wellcare Simple Exclusive (HMO) plan with no copay and a 20% coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under Wellcare Simple Exclusive (HMO) feature no coinsurance, and although some services are covered, specific programs like standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Exclusive (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and days 41 through 100, a $218 daily copay for days 21 through 40, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Wellcare Simple Exclusive (HMO), featuring over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this plan, and a referral is required to access the meal benefit.
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