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Wellcare Simple Open (PPO) - H1914-007-000
$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: H1914-007-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
North Carolina 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 North Carolina 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 | $4,200.00 |
| 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 | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $20 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: 40% per day for days 1 to 90 |
| 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 $325 Air Ambulance: Copayment for Air Ambulance Services $325 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 45% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 45% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 45% |
| Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
| 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 45% Coinsurance for Medicare Covered Lab Services 45% Coinsurance for Medicare Covered Diagnostic Radiological Services 45% Coinsurance for Medicare Covered Therapeutic Radiological Services 45% Coinsurance for Medicare Covered Outpatient X-Ray Services 45% 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 | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| 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 $25 Copayment for Medicare-covered Group Sessions $25 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $400 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 $280. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $125 to $400 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 45% Coinsurance for Medicare Covered Group Sessions 45% |
| Over-the-counter items | OTC allowance of $107 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 $20 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | Out-of-Network: Skilled Nursing Facility Services: 40% per day for days 1 to 100 |
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 | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $20 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, 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 $45 Coinsurance for Medicare Covered Eyewear 45% |
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 $20 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $0
|
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:
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 | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing North Carolina 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 North Carolina that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
North Carolina Counties Served
- Alexander
- Alleghany
- Anson
- Ashe
- Avery
- Bladen
- Buncombe
- Burke
- Cabarrus
- Caldwell
- Caswell
- Catawba
- Chatham
- Clay
- Cleveland
- Columbus
- Cumberland
- Davidson
- Davie
- Duplin
- Durham
- Forsyth
- Franklin
- Gaston
- Graham
- Granville
- Greene
- Guilford
- Harnett
- Haywood
- Henderson
- Hoke
- Iredell
- Jackson
- Johnston
- Lincoln
- Macon
- Madison
- Mcdowell
- Mecklenburg
- Mitchell
- Montgomery
- Moore
- Orange
- Person
- Polk
- Richmond
- Rowan
- Rutherford
- Sampson
- Scotland
- Stanly
- Stokes
- Swain
- Transylvania
- Union
- Vance
- Wake
- Warren
- Watauga
- Wilkes
- Yadkin
- Yancey
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.