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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 Wellcare National Health Insurance Company available for the 2026 plan year to people living in Select counties in TX. This plan received an overall rating of 3.5 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 does not have a health deductible. Your insurance coverage on covered health services will start immediately.
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 $5000.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $5000.00 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 $10000.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $10000.00 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:
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Drug Coverage
The Wellcare Simple Open (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when filling prescriptions at a preferred pharmacy or through preferred mail-order services. Additionally, Tier 6 select care drugs are covered with no copay across all standard and preferred pharmacy networks. For higher-tier medications, costs are determined by coinsurance rather than flat copayments. Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 36% to 37% coinsurance depending on your pharmacy choice. Standard retail pharmacies and standard mail-order options are also available for generic tiers, with copays ranging from $5 to $30 depending on the supply duration.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. For more intensive medical needs, inpatient hospital stays require a $350 daily copay for the first five days, while outpatient hospital services range from no copay to a $250 copay. Emergency room visits carry a $130 copay, which is waived if you are admitted within 24 hours, and urgent care services require a $45 copay. This plan also includes essential supplemental benefits, providing preventive dental, routine vision, and annual hearing exams with no copay. Diagnostic lab services and diabetic supplies are covered with no copay, though durable medical equipment and dialysis require a 20% coinsurance. Additionally, members benefit from over-the-counter items and up to 24 one-way transportation trips per year to plan-approved locations with no copay.
Inpatient Hospital See details
Wellcare Simple Open (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $350 copay for days 1 through 5 of acute care and a $325 copay for days 1 through 5 of psychiatric care, with no copay for days 6 through 90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Wellcare Simple Open (PPO) covers outpatient services with no coinsurance, featuring outpatient hospital services with a copay ranging from no copay to $250 and ambulatory surgical center services for a $250 copay. Outpatient substance abuse sessions require a $25 copay, observation services carry a $130 to $250 copay per stay, and outpatient blood services have no copay and no deductible.
Partial Hospitalization See details
Partial hospitalization services are covered by Wellcare Simple Open (PPO) with a $140.00 copay and no coinsurance. Prior authorization is required for these services.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers ground and air ambulance services with a $245 copay and no coinsurance per trip. The plan also partially covers transportation services, offering up to 24 one-way trips per year to plan-approved locations with no copay or coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $45 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $50,000 maximum with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Open (PPO) offers primary care physician services with no copay and no coinsurance, while specialist, physical therapy, occupational therapy, and opioid treatment services require a $30 copay and no coinsurance. Mental health and psychiatric sessions have a $25 copay and no coinsurance, telehealth ranges from no copay to a $45 copay with no coinsurance, and podiatry is not covered. Some chiropractic services are covered, though routine and other chiropractic services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) offers partially covered preventive services, featuring no copay and no coinsurance for annual physical exams, alternative therapies, and fitness benefits, while kidney disease education has no copay and a 20% coinsurance. Several supplemental preventive services are not covered under this plan, including health education, in-home safety assessments, personal emergency response systems, and weight management programs.
Hearing Services See details
Wellcare Simple Open (PPO) covers Medicare-covered hearing exams for a $30 copay and no coinsurance, while annual routine exams and fittings have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to $750 per ear annually, though OTC hearing aids and inner-ear, outer-ear, or over-the-ear prescription aids are not covered.
Vision Services See details
Wellcare Simple Open (PPO) partially covers vision services with no coinsurance and no deductibles, although prior authorization is required. One routine eye exam per year and eyewear are covered with no copay up to a $200 annual maximum, but other eye exam services are not covered.
Dental Services See details
Wellcare Simple Open (PPO) partially covers dental services, excluding maxillofacial prosthetics, implant services, and orthodontics. Medicare-covered dental requires a $30 copay and no coinsurance, preventive services are available with no copay and no coinsurance, and comprehensive services require no copay and a 20% coinsurance up to a $1,000 annual maximum.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay and no coinsurance, though prior authorization is required. Under this plan, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Wellcare Simple Open (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Wellcare Simple Open (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and medical supplies, with no copayment and a 20% coinsurance. Diabetic supplies are covered with no copay, while diabetic therapeutic shoes or inserts require a 20% coinsurance, with prior authorization required for these benefits.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) covers diagnostic and radiological services with prior authorization, offering diagnostic lab services with no copay or coinsurance and diagnostic tests with a copay of $0 to $10 and no coinsurance. Diagnostic radiological services carry a minimum $0 copay, outpatient x-rays require a $25 copay and coinsurance, and therapeutic radiological services require a copay and a minimum 20% coinsurance.
Home Health Services See details
Wellcare Simple Open (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services under the Wellcare Simple Open (PPO) feature no coinsurance, meaning some services are covered, though standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 to 20 and 51 to 100, and a $218 daily copay for days 21 to 50. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Wellcare Simple Open (PPO) provides partially covered Other Services, which include over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and other additional services are not covered under this plan benefit.
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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