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Wellcare Simple Rx Plus Open (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Simple Rx Plus 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 Rx Plus Open (PPO) in 2025, please refer to our full plan details page.
Wellcare Simple Rx Plus Open (PPO) is a PPO plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in TX. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellcare Simple Rx Plus 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 Rx Plus 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 Rx Plus 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:
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Drug Coverage
The Wellcare Simple Rx Plus Open (PPO) plan has a $420.00 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For the initial coverage phase, preferred generic drugs and specialty tier drugs have no copay, while standard generic drugs have 25% coinsurance. Preferred brand drugs have 38% coinsurance at a preferred pharmacy and 39% coinsurance at a standard pharmacy. Non-preferred drugs have 28% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs.
Additional Benefits
The Wellcare Simple Rx Plus Open (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and coverage for ambulance and emergency services. Primary care physician services, preventive services, and vision services such as eye exams and eyewear, are available with no or low copays. Hearing services, including hearing exams and hearing aids, are also covered, along with dental services like oral exams and cleanings. This plan also covers services like home health, dialysis, and medical equipment, with varying cost-sharing arrangements. Prescription hearing aids are covered up to $1000 per ear, per year. However, some services like cardiac rehabilitation, acupuncture, and private duty nursing are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits for the Wellcare Simple Rx Plus Open (PPO) plan cover acute and psychiatric inpatient hospital stays, with a copay of $350 for days 1-6 and no copay for days 7-90 for acute stays, and a copay of $300 for days 1-6 and no copay for days 7-90 for psychiatric stays; additional days and non-Medicare-covered stays for both are not covered.
Outpatient Services See details
Outpatient Services are covered by the Wellcare Simple Rx Plus Open (PPO) plan, including outpatient hospital services with a copay between $0 and $300, observation services with a copay between $125 and $300, and ambulatory surgical center (ASC) services with a $200 copay. Outpatient substance abuse services have a $25 copay, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. The plan has a $105 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Wellcare Simple Rx Plus Open (PPO) plan. Ground and air ambulance services have a $285 copay, and transportation services to a plan-approved health-related location have no copay for up to 24 one-way trips per year. 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 by the Wellcare Simple Rx Plus Open (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $40 copay; there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Rx Plus Open (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $40 copay. It also covers physician specialist services with a $30 copay, individual and group mental health specialty services with a $25 copay, and physical therapy and speech-language pathology services with a $40 copay. Additional telehealth benefits are covered with a copay between $0 and $40, and opioid treatment program services have a $30 copay. Podiatry services are not covered.
Preventive Services See details
The Wellcare Simple Rx Plus Open (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, including alternative therapies, are covered with no copay, while kidney disease education services have a 20% coinsurance.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams have a $30 copay, while routine hearing exams and fitting/evaluation for hearing aids have no copay. Prescription hearing aids are covered up to $1000 per ear, per year, with no copay for all types except for inner ear, outer ear, and over the ear, which are not covered.
Vision Services See details
The Wellcare Simple Rx Plus Open (PPO) plan covers vision services, including eye exams with a copay of $0-$30. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades, are covered with no copay, with a combined maximum plan benefit coverage of $300 per year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, plus Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services with no copay. Orthodontic services are covered, while 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, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellcare Simple Rx Plus 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 Supplies have no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $40, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $300, while Therapeutic Radiological Services have a 20% coinsurance. Outpatient X-Ray Services have a $63 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Rx Plus Open (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Wellcare Simple Rx Plus Open (PPO) plan. Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are also not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Wellcare Simple Rx Plus Open (PPO) plan, but require prior authorization. For days 1-20 and 61-100, there is no copay, while days 21-60 have a $214 copay. Additional days beyond Medicare coverage and non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered.
Other Services See details
The Wellcare Simple Rx Plus Open (PPO) plan does not cover acupuncture, over-the-counter items, 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, or Self-Directed Personal Assistance Services. However, the plan covers a meal benefit with no copay and requires a doctor's referral.
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