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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 2025, please refer to our full plan details page.
Wellcare Simple 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 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 $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 $10000.00 (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 $10000.00 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 Open (PPO) plan has a $420 deductible for prescription drugs. After the deductible is met, you will pay the following costs for your prescriptions. For preferred generic drugs and specialty tier drugs, there is no copay. For standard generic drugs, you pay 25% coinsurance. For preferred brand drugs, you pay 39% coinsurance at preferred pharmacies and 40% at standard pharmacies. Non-preferred drugs have 28% coinsurance. 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 Open (PPO) plan provides coverage for a variety of services, including inpatient hospital stays with a copay, outpatient services with copays ranging from $0 to $250, and emergency services with a $125 copay. The plan also covers primary care with no copay, preventive services with no copay for annual exams, and vision services including eye exams and eyewear. Additional benefits include hearing services, dental coverage, home infusion, dialysis services, and medical equipment with varying copays and coinsurance amounts. The plan also offers home health services with no copay, skilled nursing facility services with varying copays, and covers other services like OTC items and a meal benefit with no copay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $350 for days 1-5, and no copay for days 6-90 for Inpatient Hospital-Acute. Inpatient Hospital Psychiatric benefits are also covered, with a copay of $325 for days 1-5, and no copay for days 6-90. Additional days, non-Medicare-covered stays, and upgrades are not covered for either type of inpatient hospital stay.
Outpatient Services See details
The Wellcare Simple Open (PPO) plan covers outpatient services, including all outpatient hospital services, with a copay ranging from $0 to $250. Observation services have a copay of $125 to $250, and ambulatory surgical center services have a $250 copay. Outpatient substance abuse services have a $25 copay for both individual and group sessions, and outpatient blood services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Wellcare Simple Open (PPO) plan, with a $105 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including both ground and air ambulance, are covered by the Wellcare Simple Open (PPO) plan. Ground and air ambulance services have a copay of $245, and transportation services to a plan-approved health-related location are covered with no copay, up to 36 one-way trips per year, using rideshare services, bus/subway, or medical transport. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage all have a $125 copay, with no coinsurance. Worldwide Urgent Coverage also has a $125 copay with no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Simple Open (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $30 copay, and physician specialist services with a $30 copay. Mental health specialty services, psychiatric services, and opioid treatment program services have a copay of $25-$30, and physical therapy and speech-language pathology services have a $30 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services, including Medicare-covered services, annual physical exams, and additional preventive services, are covered. Annual physical exams have no copay, and additional preventive services have a copay for Fitness Benefit, Remote Access Technologies, and Alternative Therapies.
Hearing Services See details
The Wellcare Simple Open (PPO) plan covers hearing exams with a $30 copay, and routine hearing exams and fitting/evaluation for hearing aids with no copay, once per year. Prescription hearing aids are covered up to $750 per ear every year, and prescription hearing aids (all types) are covered with no copay for two visits per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay between $0 and $30, and eyewear with no copay. Routine eye exams are covered with no copay for one visit every year, and eyewear has a combined maximum plan benefit of $200 per year.
Dental Services See details
The Wellcare Simple Open (PPO) plan covers Medicare dental services with a $30 copay, 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 20% coinsurance. Orthodontic services are covered up to a $1,000 yearly maximum. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellcare Simple Open (PPO) plan, with prior authorization required. The plan covers Medicare Part B Insulin Drugs with a $35 copay, and covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Simple Open (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
The Wellcare Simple Open (PPO) plan covers durable medical equipment with a 20% coinsurance, and covers prosthetic devices with a 20% coinsurance as well. The plan also covers medical supplies with a 20% coinsurance, and diabetic supplies with no copay, and diabetic therapeutic shoes/inserts with a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $10, while Lab Services have no copay. Diagnostic Radiological Services have a copay up to $250, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Wellcare Simple Open (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Wellcare Simple Open (PPO) plan, but the specific services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a copay for the covered services, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Simple 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-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Wellcare Simple Open (PPO) plan covers Over-the-Counter (OTC) items with no copay, and a meal benefit with no copay, but requires a doctor's referral. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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