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Wellcare Mutual of Omaha Simple Open (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$0.00
Monthly Premium
Wellcare Mutual of Omaha Simple Open (PPO) is a PPO plan offered by WellCare Health Plans, Inc.
Plan ID: H5965-002
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Wellcare Mutual of Omaha Simple Open (PPO) - H5965-002 by WellCare Health Plans, Inc. as well as other Medicare Advantage plans available in your area.
$0.00
Monthly Premium
Washington Counties Served
AdamsAsotinBenewahBentonChelanClallamClarkColumbiaCowlitzDouglasFerryFranklinGarfieldGrantGrays HarborIslandJeffersonKingKitsapKittitasKlickitatKootenaiLewisLincolnMasonOkanoganPacificPend OreillePierceSan JuanSkagitSkamaniaSnohomishSpokaneStevensThurstonUmatillaWahkiakumWalla WallaWhatcomWhitmanYakima
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $420 |
| Out of Pocket Max |
In-Network: $5900 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2000 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Copayment for Medicare Covered Primary Care Office Visit $25 |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $50 |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: 30% per day for days 1 to 90 |
| Urgent Care | Urgent Care: Copayment for Urgent Care $55 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300 Copayment for Medicare Covered Ambulance Services - Air $300 |
Health Care Services and Medical Supplies
Wellcare Mutual of Omaha Simple Open (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Copayment for Routine Care $0
Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Copayment for Routine Care $0
Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The minimum cost share is for spirometry testing and specified testing-related services. The maximum cost share is for all other services. The removal of abnormal tissue and/or polyps during a colonoscopy performed as a preventive screening for colorectal cancer will be covered at a $0 co-payment. |
| Home Health Care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: 30% per day for days 1 to 90 |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $500 Prior Authorization Required for Outpatient Hospital Services Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for outpatient surgical services. The cost share for outpatient non-surgical services, including outpatient palliative care is $300. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $125 to $500 Outpatient Services/Surgery Observation Services: The minimum cost share is charged when a member enters observation status through the ER/ED. The maximum cost share is charged when a member enters observation status through an outpatient facility. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter (OTC) Items | OTC allowance of $91 every quarter is loaded into the Wellcare Spendables card on a quarterly basis. Benefit is designed to allow members the flexibility to purchase OTC items at participating retailers, online, phone order, or catalog order. Benefit expires at end of quarter if unused. |
| Podiatry Services | Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $50 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25 Prior Authorization Required for Podiatry Services Out-of-Network: Medicare Covered Podiatry Services: Copayment for Medicare Covered Podiatry Services $50 In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility Care | Out-of-Network: Skilled Nursing Facility Services: 30% per day for days 1 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $25 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $0
|
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $50 Coinsurance for Medicare Covered Eyewear 40% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Medicare Covered Hearing Exams Services: Copayment for Medicare Covered Hearing Exams $50 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The Wellcare Mutual of Omaha Simple Open (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $420 (excludes Tiers 1, 2 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $420 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $420 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $420 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|