Wellcare Simple Open (PPO) - H3975-001-000

3.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Wellcare Simple Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H3975-001-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Kentucky Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Kentucky Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$420.00
Out-of-pocket maximum	$6,000.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$2,000.00
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 $40
Inpatient hospital care	In-Network: Acute Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services
Urgent care	Urgent Care: Copayment for Urgent Care $30 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	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $300 Air Ambulance: Copayment for Air Ambulance Services $300 Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Wellcare Simple Open (PPO) covers a range of additional benefits. Learn more about Wellcare Simple Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 35%
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 35% Coinsurance for Medicare Covered Lab Services 35% Coinsurance for Medicare Covered Diagnostic Radiological Services 35% Coinsurance for Medicare Covered Therapeutic Radiological Services 35% Coinsurance for Medicare Covered Outpatient X-Ray Services 35% 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 35%
Mental health inpatient care	In-Network: Psychiatric Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services
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	Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 35% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35% 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	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
Over-the-counter items	OTC allowance of $116 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: Coinsurance for Medicare Covered Podiatry Services 35%
Skilled Nursing Facility (SNF) care	In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 60 $0 per day for days 61 to 100 Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	Out-of-Network: Medicare Covered Preventive Dental Services: Copayment for Medicare Covered Preventive Dental $40

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

Coverage	Details
Vision care	Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 to $40 Coinsurance for Medicare Covered Eyewear 35%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing care	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $30 Copayment for Routine Hearing Exams $0 Maximum 1 visit every year Copayment for Fitting/Evaluation for Hearing Aid $0 Maximum 1 visit every year Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0 Maximum 2 Hearing Aids every year Maximum Plan Benefit of $1,500 every year per ear

Coverage

Details

Hearing care

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30
Copayment for Routine Hearing Exams $0

Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0

Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $1,500 every year per ear

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
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

Coverage

Details

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) offers prescription drug coverage, with an annual drug deductible of $420.00 (excludes Tiers 1, 2, and 6)

Coverage & Cost 30 day supply 60 day supply 90 day supply
Coverage	Cost 30 day supply 60 day supply 90 day supply
Annual drug deductible	$420.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Preferred retail $0.00 Standard retail $5.00 Standard retail $5.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $5.00 Standard mail order $5.00
Tier 2	Preferred retail $0.00 Preferred retail $0.00 Standard retail $10.00 Standard retail $10.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $10.00 Standard mail order $10.00
Tier 6	Preferred retail $0.00 Preferred retail $0.00 Standard retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $0.00 Standard mail order $0.00
Annual drug deductible	$420.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Preferred retail $0.00 Standard retail $10.00 Standard retail $10.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $10.00 Standard mail order $10.00
Tier 2	Preferred retail $0.00 Preferred retail $0.00 Standard retail $20.00 Standard retail $20.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $20.00 Standard mail order $20.00
Tier 6	Preferred retail $0.00 Preferred retail $0.00 Standard retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $0.00 Standard mail order $0.00
Annual drug deductible	$420.00 (excludes Tiers 1, 2, and 6)
Tier 1	Preferred retail $0.00 Preferred retail $0.00 Standard retail $15.00 Standard retail $15.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $15.00 Standard mail order $15.00
Tier 2	Preferred retail $0.00 Preferred retail $0.00 Standard retail $30.00 Standard retail $30.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $30.00 Standard mail order $30.00
Tier 6	Preferred retail $0.00 Preferred retail $0.00 Standard retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Preferred mail order $0.00 Standard mail order $0.00 Standard mail order $0.00

When reviewing Kentucky Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Kentucky that offer similar benefits at similar or lower prices than the plan above. Call 1-877-822-4889 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Kentucky Counties Served

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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