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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 Sunflower State Health Plan, Inc. available for the 2026 plan year to people living in Select counties in KS. This plan received an overall rating of 2.5 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 $4500.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $4500.00 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 $6800.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6800.00 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:
Sign up for Wellcare Simple Open (PPO)
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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 Generic), Tier 2 (Generic), and Tier 6 (Select Care Drugs), members enjoy no copay for fills at preferred retail pharmacies. Standard pharmacies and standard mail-order options require a copay, starting at $5 for Tier 1 and $10 for Tier 2. Higher-tier medications are subject to coinsurance rather than flat copays. Tier 3 (Preferred Brand) and Tier 5 (Specialty) drugs both require 25% coinsurance at preferred and standard pharmacies. Tier 4 (Non-Preferred) drugs carry a 33% coinsurance at preferred locations and 34% coinsurance at standard locations.
Additional Benefits
The Wellcare Simple Open (PPO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. For specialist visits, physical therapy, and routine hearing exams, members pay a $25 copay or no copay with no coinsurance. Inpatient hospital stays require daily copays for the first eight days with no coinsurance, while emergency care is covered with a $130 copay that is waived if admitted. Additional benefits include preventive dental and routine vision care with no copay and no coinsurance, alongside a $100 annual eyewear allowance and a $500 per ear hearing aid benefit. Durable medical equipment, dialysis, and therapeutic radiology services are covered with no copay and a 20% coinsurance. Over-the-counter items are also available with no copay and no coinsurance, making this plan a highly accessible option for managing your healthcare needs.
Inpatient Hospital See details
Wellcare Simple Open (PPO) partially covers inpatient hospital services with no coinsurance, requiring a daily copay of $375 for days 1 through 8 of an acute stay and $290 for days 1 through 8 of a psychiatric stay, with no copay for days 9 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 a copay of $0 to $375 for outpatient hospital services, $130 to $375 per stay for observation services, and $245 for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Wellcare Simple Open (PPO) with a $140.00 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Wellcare Simple Open (PPO) covers Medicare-approved ground and air ambulance services with a $290 copay per service and no coinsurance, with prior authorization required. Transportation services to 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 urgently needed services with a $50 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 maximum with a $130 copay and no coinsurance, though 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, occupational therapy, and physical therapy visits require a $25 copay and no coinsurance. Mental health and psychiatric sessions have a $30 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Wellcare Simple Open (PPO) covers annual physical exams and other preventive services with no copay and no coinsurance, while kidney disease education is covered with no copay and a 20% coinsurance. Additional preventive benefits are partially covered, offering fitness benefits, alternative therapies, PERS, and remote access with no copay and no coinsurance, while excluding services like health education and nutritional counseling.
Hearing Services See details
Wellcare Simple Open (PPO) covers Medicare-covered hearing exams for a $25 copay and no coinsurance, while routine hearing exams and fitting evaluations have no copay and no coinsurance. Prescription hearing aids are partially covered with no copay, no coinsurance, and a $500 annual limit per ear, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Wellcare Simple Open (PPO) with no deductibles and no coinsurance, though other eye exam services are not covered. Routine eye exams are covered with no copay (other exams have a copay ranging up to $25), and eyewear is covered with no copay up to a combined maximum benefit of $100 per year.
Dental Services See details
Wellcare Simple Open (PPO) provides partially covered dental services, featuring Medicare-covered dental at a $25 copay and no coinsurance, alongside preventive care with no copay and no coinsurance. Comprehensive services are covered with no copay and 40% coinsurance up to a $1,000 annual limit, though implant services, orthodontics, maxillofacial prosthetics, and fixed or removable prosthodontics are not covered.
Home Infusion bundled Services See details
Wellcare Simple Open (PPO) covers home infusion bundled services with no copay and no coinsurance, although prior authorization is required. Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
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 durable medical equipment, prosthetics, and medical supplies with no copay and a 20% coinsurance, subject to prior authorization. Diabetic supplies are covered with no copay, while diabetic therapeutic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Wellcare Simple Open (PPO) covers diagnostic tests, lab work, and diagnostic radiology with no copay and no coinsurance. Outpatient X-rays require a $50 copay with no coinsurance, while therapeutic radiology services require a 20% coinsurance with no copay, and prior authorization is required for these services.
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
Cardiac Rehabilitation Services are covered by Wellcare Simple Open (PPO) with no coinsurance, but some services are covered while cardiac rehabilitation (with a $40 copay), intensive cardiac rehabilitation (with a $50 copay), pulmonary rehabilitation (with a $35 copay), and supervised exercise therapy for symptomatic peripheral artery disease (with a $25 copay) 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 no prior three-day hospital stay. There is no copay for days 1 to 20 and days 51 to 100, a $218 daily 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) provides partial coverage for other services, offering over-the-counter (OTC) items with no copay and no coinsurance, while acupuncture and meal benefits are not covered. Eligible OTC items, including nicotine replacement therapy and naloxone, are available via reimbursement with no maximum plan benefit limit.
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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