Wellcare Simple Open (PPO)

3 out of 5 stars
$0.00
Monthly Premium

Wellcare Simple Open (PPO) is a PPO plan offered by Centene Corporation

Plan ID: H5439-017

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 Simple Open (PPO) - H5439-017 by Centene Corporation as well as other Medicare Advantage plans available in your area.

$0.00
Monthly Premium

Oregon Counties Served

BentonClackamasDouglasJacksonJosephineLaneLinnMarionMultnomahPolkWashingtonYamhill

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $420
Out of Pocket Max In-Network: $3450
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $2000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty Doctor Visit

Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $60
Inpatient Hospital Care

Out-of-Network:

Acute Hospital Services:
20% per day for days 1 to 90
Urgent Care

Urgent Care:
Copayment for Urgent Care $65
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Maximum Plan Benefit of $50,000
Emergency Room Visit

Emergency Care:
Copayment for Emergency Care $140
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 $140
Maximum Plan Benefit of $50,000
Ambulance Transportation

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325
Copayment for Medicare Covered Ambulance Services - Air $325

Health Care Services and Medical Supplies

Wellcare 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

Out-of-Network:

Medicare Covered Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $0
In-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0
  • Maximum 24 Routine Care every year
Prior Authorization Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Out-of-Network:

Medicare Covered 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)

Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays

Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
20%
Copayment for Medicare Covered Lab Services
$0 to $50
Copayment for Medicare Covered Diagnostic Radiological Services $0 to $400
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $25
Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The co-payment is for spirometry testing and specified testing-related services. The coinsurance 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
In-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental Health Inpatient Care

Out-of-Network:

Psychiatric Hospital Services:
20% per day for days 1 to 90
Mental Health Outpatient Care

Out-of-Network:

Medicare Covered Mental Health Services:
Copayment for Medicare Covered Individual Sessions $25
Copayment for Medicare Covered Group Sessions $25
Outpatient Services / Surgery

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $400
Copayment for Medicare Covered Ambulatory Surgical Center Services $250
Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for all other outpatient services.
Outpatient Substance Abuse Care

Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual Sessions $25
Copayment for Medicare Covered Group Sessions $25
In-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items
OTC allowance of $120 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
In-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30
Prior Authorization Required for Podiatry Services

Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $30
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 40
$0 per day for days 41 to 100
Prior Authorization Required for Skilled Nursing Facility Services

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 $30
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Copayment for Other preventive services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1,500 every year

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 $60
Copayment for Medicare Covered Eyewear $60

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 $60

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
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Wellcare 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
    • Preferred cost-share mail order $0.00
    • Standard retail $5.00
    • Standard mail order $5.00
    • Preferred cost-share retail $0.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $10.00
    • Standard mail order $10.00
    • Preferred cost-share retail $0.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share retail $0.00
    Annual Drug Deductible $420 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $10.00
    • Standard mail order $10.00
    • Preferred cost-share retail $0.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $20.00
    • Standard mail order $20.00
    • Preferred cost-share retail $0.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share retail $0.00
    Annual Drug Deductible $420 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $15.00
    • Standard mail order $15.00
    • Preferred cost-share retail $0.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $30.00
    • Standard mail order $30.00
    • Preferred cost-share retail $0.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share retail $0.00
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