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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.
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 3.5 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. 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 $9000.00 (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 $9000.00 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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs, you will pay no copay when using a preferred pharmacy or preferred mail-order service. Standard pharmacies charge low copays ranging from $5 to $30 for Tier 1 and Tier 2 drugs, while Tier 6 drugs remain at no copay. Brand-name and specialty medications are subject to coinsurance under this plan. Tier 3 preferred brands and Tier 5 specialty drugs require a 25% coinsurance, while Tier 4 non-preferred drugs require a 35% coinsurance. Specialty tier drugs are limited to a 1-month supply at both preferred and standard pharmacies.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers comprehensive coverage for core medical needs, featuring no copay and no coinsurance for primary care visits, specialist consultations, and home health services. For hospital stays, members pay a copay of $320 per day for the first five days of acute inpatient care, while outpatient hospital services range from no copay to a $250 copay. Emergency room visits carry a $130 copay, and urgent care is available with a $30 copay, both of which feature no coinsurance. Routine preventive care, diagnostic dental cleanings, annual vision exams, and basic hearing services are highly accessible with no copay and no coinsurance, though coverage limits apply to eyewear and hearing aids. Skilled nursing facility care is also affordable, requiring no copay for the first 20 days and for days 51 through 100. Additionally, durable medical equipment and dialysis are covered with no copay and a standard 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by the Wellcare Simple Open (PPO) with no coinsurance, though additional days, upgrades, and non-Medicare-covered stays are not covered. Acute stays require a $320 copay for days 1 through 5 and no copay for days 6 through 90, while psychiatric stays require a $225 copay for days 1 through 5 and no copay for days 6 through 90.
Outpatient Services See details
Outpatient services are covered by Wellcare Simple Open (PPO) with no coinsurance, featuring a $0 to $250 copay for outpatient hospital services and a $130 to $250 copay per stay for observation services. Ambulatory surgical center services require a $150 copay, outpatient substance abuse sessions have a $25 copay, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Wellcare Simple Open (PPO) covers partial hospitalization services with a $140.00 copay and no coinsurance. Prior authorization is required to access this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers Medicare-covered ground and air ambulance services with a $300 copay and no coinsurance, though prior authorization is required and the copay is not waived if admitted. While some transportation services are covered, trips to plan-approved or any health-related locations are not covered.
Emergency Services See details
Wellcare Simple Open (PPO) covers emergency services with a $130 copay and no coinsurance, and urgent care with a $30 copay and no coinsurance, with copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are partially covered up to a $50,000 limit with a $130 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Wellcare Simple Open (PPO) primary care benefits are partially covered, offering doctor visits, specialist care, therapies, and opioid treatment with no copay and no coinsurance. Mental health and psychiatric services have a $25 copay and no coinsurance, telehealth ranges from no copay to a $30 copay with no coinsurance, and podiatry is not covered. Some chiropractic services are covered, but routine and other chiropractic services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) provides preventive services with no copay and no coinsurance for annual physical exams, alternative therapies, and select screenings, while kidney disease education requires a 20% coinsurance and no copay. Additional preventive benefits are partially covered, with services such as health education, in-home safety assessments, personal emergency response systems, weight management, and nutritional benefits not covered.
Hearing Services See details
Wellcare Simple Open (PPO) provides partially covered hearing services with no copay and no coinsurance for routine exams, fitting evaluations, and prescription hearing aids up to a $350 annual limit per ear. However, OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Wellcare Simple Open (PPO) partially covers vision services with no copay and no coinsurance, including one routine eye exam per year and eyewear up to a $100 annual limit. Other eye exam services are not covered, and prior authorization is required for covered benefits.
Dental Services See details
Wellcare Simple Open (PPO) dental services are partially covered with no copay and no coinsurance for covered preventive and diagnostic care, though prior authorization is required. However, restorative services, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Wellcare Simple Open (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Wellcare Simple Open (PPO) with no copay and a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, and diabetic therapeutic shoes or inserts. Diabetic supplies are covered with no copay, and prior authorization is required for these medical equipment benefits.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under Wellcare Simple Open (PPO) with prior authorization required. Lab services and diagnostic radiology feature no copay or coinsurance, diagnostic tests have a $0 to $10 copay, outpatient X-rays require a $50 copay, and therapeutic radiology services carry a 20% coinsurance.
Home Health Services See details
Home health services are covered by Wellcare Simple Open (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Wellcare Simple Open (PPO) covers some Cardiac Rehabilitation Services with no coinsurance, but Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Wellcare Simple Open (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 to 20 and days 51 to 100, a $218 copay for days 21 to 50, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Wellcare Simple Open (PPO) partially covers other services, offering a meal benefit for chronic illness with no copay and no coinsurance, although a referral is required. Supplemental services such as acupuncture and over-the-counter (OTC) items are not covered.
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