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Wellcare Mutual of Omaha Simple Open (PPO)

H0111 - 001 - 0
3 out of 5 stars (3 / 5)

wellcare medicare provider logo

Wellcare Mutual of Omaha Simple Open (PPO) is a Medicare Advantage Plan by Wellcare.

This page features plan details for 2025 Wellcare Mutual of Omaha Simple Open (PPO) H0111 – 001 – 0 available in Select counties in GA.

Locations

Wellcare Mutual of Omaha Simple Open (PPO) is offered in the following locations.

Appling County, Georgia
Atkinson County, Georgia
Bacon County, Georgia

Click to see more locations

Plan Overview

Wellcare Mutual of Omaha Simple Open (PPO) offers the following coverage and cost-sharing.

Insurer:Wellcare
Health Plan Deductible:$0
MOOP:$10,000 In and Out-of-network
$5,900 In-network
Drugs Covered:Yes

Ready to sign up for Wellcare Mutual of Omaha Simple Open (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Wellcare Mutual of Omaha Simple Open (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Wellcare Mutual of Omaha Simple Open (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $420.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $420.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Wellcare Mutual of Omaha Simple Open (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Endodontics
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Periodontics
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Restorative Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-400 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-75 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $75 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: $0-50 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 50% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $30 copay per visit
    • In-Network: $0 copay
  • Specialist
    • In-Network: $40 copay per visit (Authorization Required)
    • Out-of-Network: $55 copay per visit (Authorization Required)

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $30 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $290 copay
    • In-Network: $290 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Fitting/evaluation
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Hearing aids
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: $55 copay (Authorization Required)

Inpatient hospital coverage

    • In-Network: $375 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
    • Out-of-Network: 50% per day for days 1 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $10,000 In and Out-of-network
      $5,900 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 45% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-50% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-50% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $1,590 per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 50% per day for days 1 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: $40 copay (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-400 copay per visit (Authorization Required)
    • Out-of-Network: 50% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: $40 copay (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 50% per day for days 1 through 100 (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 60
      $0 per day for days 61 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Upgrades
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglass lenses
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglass frames
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Upgrades
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply, Authorization Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Wellcare Mutual of Omaha Simple Open (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

SMID: MULTIPLAN_HCIHNDOGMED01PY25_M

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This is a promotional communication.

Every year, Medicare evaluates plans based on a 5-star rating system.

Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period.

We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

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