Wellcare Simple Open (PPO)
Available to residents of Franklin County, NY for 2026. Contract H2775, plan 106, segment 0.
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- Browse the Wellcare Simple Open (PPO) formulary
Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| In- and out-of-network out-of-pocket maximum | $13,900.00 |
| Drug deductible | $615.00Tier 1, 2 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | PPO? |
| Contract / plan | H2775-106-0 |
| Offered by | Wellcare |
| Parent organization | Centene Corporation |
| Formulary drugs | 3,309 |
| Formulary exception tier | 4? |
| Pharmacy search | go.wellcare.com/Medicare |
| Member services | (844)480-0680TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 3 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2775 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $25 copay |
| Specialist | $30 copay(authorization required) | $60 copay |
| Other health care professional | $0–$30 copay(authorization required) | $25–$60 copay |
| Additional telehealth services | $0–$35 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | 20% coinsurance | 40% coinsurance |
| Glaucoma screening | $0 copay | 40% coinsurance |
| Diabetes self-management training | $0 copay | 40% coinsurance |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0–$75 copay(authorization required) | 40% coinsurance |
| Lab services | $0–$50 copay(authorization required) | 40% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$500 copay(authorization required) | 40% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization required) | 40% coinsurance |
| Outpatient x-rays | $50 copay(authorization required) | 40% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $115 copay | — |
| Urgent care | $35 copay | — |
| Worldwide emergency coverage | $115 copay · $50,000 plan limit | — |
| Worldwide urgent care | $115 copay · $50,000 plan limit | — |
| Worldwide emergency transportation | Not covered | — |
| Hospital care | ||
| Inpatient hospital stay | $600 per day for days 1–4; $0 per day for days 5–90; $0 per day for days 91–100 (additional days)(authorization required) | 30% coinsurance for days 1–90 |
| Outpatient hospital services | $0–$500 copay; 30% coinsurance(authorization required) | 40% coinsurance |
| Outpatient observation | $115 copay; 30% coinsurance | 40% coinsurance |
| Ambulatory surgical center | $475 copay(authorization required) | 40% coinsurance |
| Outpatient blood services | $0 copay | 40% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per day for days 1–20; $218 per day for days 21–70; $0 per day for days 71–100(authorization required) | 30% coinsurance for days 1–100 |
| Home health care | $0 copay(authorization required) | 40% coinsurance |
| Kidney dialysis | 20% coinsurance | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $35 copay(authorization required) | 40% coinsurance |
| Physical therapy and speech-language therapy | $35 copay(authorization required) | 40% coinsurance |
| Cardiac rehabilitation | $30 copay | 40% coinsurance |
| Pulmonary rehabilitation | $25 copay | 40% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $500 per day for days 1–4; $0 per day for days 5–90(authorization required) | 30% coinsurance for days 1–90 |
| Outpatient mental health, individual session | $35 copay(authorization required) | 40% coinsurance |
| Outpatient mental health, group session | $35 copay(authorization required) | 40% coinsurance |
| Psychiatrist, individual session | $35 copay(authorization required) | 40% coinsurance |
| Psychiatrist, group session | $35 copay(authorization required) | 40% coinsurance |
| Partial hospitalization | $105 copay(authorization required) | 40% coinsurance |
| Intensive outpatient program | $105 copay(authorization required) | 40% coinsurance |
| Outpatient substance use, individual session | $35 copay(authorization required) | 40% coinsurance |
| Outpatient substance use, group session | $35 copay(authorization required) | 40% coinsurance |
| Opioid treatment program | $30 copay(authorization required) | $60 copay |
| Ambulance and transportation | ||
| Ground ambulance | $350 copay(authorization required) | $350 copay |
| Air ambulance | $350 copay(authorization required) | $350 copay |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 40% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 40% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 40% coinsurance |
| Diabetes supplies | $0 copay(authorization required) | 40% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 40% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay(authorization required) | 40% coinsurance |
| Routine chiropractic care | $15 copay(authorization required) | 40% coinsurance |
| Acupuncture | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Foot exams and treatment (Medicare-covered) | $30 copay(authorization required) | 40% coinsurance |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $30 copay(authorization required) | $60 copay |
| Oral exams | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Cleanings | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Fluoride treatment | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Dental x-rays | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Other diagnostic dental services | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Other preventive dental services | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Restorative services (fillings, crowns) | Not covered | — |
| Endodontics (root canals) | Not covered | — |
| Periodontics (gum disease) | Not covered | — |
| Dentures and other removable prosthodontics | Not covered | — |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | Not covered | — |
| Oral and maxillofacial surgery | Not covered | — |
| Orthodontics | Not covered | — |
| Adjunctive general services | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$30 copay(authorization required) | $0–$60 copay |
| Routine eye exam | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyewear plan limit | $100 plan limit every year | — |
| Contact lenses | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyeglasses (frames and lenses) | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyeglass lenses | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyeglass frames | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Eyewear upgrades | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $30 copay(authorization required) | $60 copay |
| Routine hearing exam | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Hearing aid fitting and evaluation | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Hearing aid plan limit | $750 plan limit every year | — |
| Hearing aids (all types) | $0 copay(authorization required, limits apply) | 40% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | $35 copay(authorization required, step therapy may apply) | $35 copay |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–40% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–40% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Not covered | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | $0 copay |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | $0 copay | $0 copay |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | $0 copay | $0 copay |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | 25% |
| Tier 4 | 38% |
| Tier 5 | 25% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | n/a | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | n/a | $0.00 | $30.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | n/a | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | n/a | $0.00 | $30.00 | $0.00 |
| Tier 3: Preferred Brand | 25% | 25% | n/a | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 38% | 38% | n/a | 38% | 38% | 38% |
| Tier 5: Specialty Tier | 25% | 25% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 51 other NY counties
- Albany
- Allegany
- Bronx
- Broome
- Cattaraugus
- Cayuga
- Chautauqua
- Chemung
- Chenango
- Clinton
- Columbia
- Cortland
- Dutchess
- Erie
- Essex
- Fulton
- Genesee
- Greene
- Hamilton
- Herkimer
- Jefferson
- Kings
- Madison
- Montgomery
- Nassau
- New York
- Niagara
- Oneida
- Onondaga
- Ontario
- Orange
- Oswego
- Putnam
- Queens
- Rensselaer
- Rockland
- St. Lawrence
- Saratoga
- Schenectady
- Schoharie
- Seneca
- Steuben
- Suffolk
- Sullivan
- Tioga
- Tompkins
- Ulster
- Warren
- Washington
- Westchester
- Wyoming
Benefits in plain text
Wellcare Simple Open (PPO) (H2775-106-0) is a 2026 PPO Medicare Advantage plan offered by Wellcare, available to residents of Franklin County, NY.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The combined in- and out-of-network out-of-pocket maximum is $13,900.00.
The drug deductible is $615.00. Tier 1, 2 and 6 exempt.
The plan's formulary lists 3,309 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: 25%; tier 4: 38%; tier 5: 25%; tier 6: $0.00.
CMS gives the plan's contract (H2775) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.