Plan H0111-001-0: Wellcare Mutual of Omaha Simple Open (PPO) – 2025 Coverage Details
This page provides coverage, cost, and availability details for Wellcare’s H0111-001-0 Medicare Advantage plan for 2025.
*CMS rated this Wellcare plan (H0111-001-0) 3 (Average) out of 5 stars.
Wellcare Mutual of Omaha Simple Open Basic Plan Details
- Plan ID
- H0111-001-0
- Plan Type
- PPO
- Plan Year
- 2025
- Premium
- $0.00/mo
Plus your Medicare Part B premium. - Health Plan Deductible
- $0.00
- Out-of-Pocket Maximum
- 5,900.00 /yr (in-network)
- Part B Reduction
- $0.00/mo
- Drug Plan Benefit
- Enhanced, $420.00 deductible
- Supplemental Benefits
- Vision, Hearing
- Availability
- See List
- Insured By
- Wellcare
| Summary of Benefits |
|---|
Health Plan Out-of-Pocket Costs
This Wellcare Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H0111-001-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
- Primary
- $0 Copay
- Specialist
- $40 Copay
Prior Authorization Required
Emergency, Urgent, and Inpatient Hospital Coverage
- Emergency room care
- $125 Copay
- Urgent care
- $30 Copay
- Ground ambulance
- $290 Copay
- Inpatient hospital care
- $375.00 per day for days 1 through 7
$0.00 per day for days 8 and beyond - Skilled Nursing Facility
- $0.00 per day for days 1 through 20
$214.00 per day for days 21 through 60
$0.00 per day for days 61 and beyond
Foot Care
- Foot Exams and Treatments (Medicare-covered)
- $40 Copay
Prior Authorization Required - Routine Foot Care
- Not Covered
Chiropractic Care
- Medicare-covered chiropractic
- $20 Copay
Prior Authorization Required - Routine chiropractic
- Not Covered
Mental Health Services
- Outpatient individual therapy
- $40 Copay
- Outpatient group therapy
- $40 Copay
- Inpatient psychiatric hospital care
- $1,590.00 per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- $40 Copay
Prior Authorization Required - Occupational therapy
- $40 Copay
Prior Authorization Required
Medical Equipment and Supplies
- Diabetes supplies
- $0 Copay
Prior Authorization Required - Durable medical equipment
- 20% Coinsurance
Prior Authorization Required - Prosthetics
- 20% Coinsurance
Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services
- $400 Copay
Prior Authorization Required - Lab services
- $50 Copay
Prior Authorization Required - Outpatient x-rays
- $75 Copay
Prior Authorization Required - Diagnostic tests and procedures
- $75 Copay
Prior Authorization Required
Medicare Part B Drugs
- Chemotherapy
- 20% Coinsurance
- Other Part B drugs (Medicare-covered)
- 20% Coinsurance
Dental Services
- Medicare Covered Preventive Dental
- $40 Copay
Prior Authorization Required - Oral exam
- $0 Copay
Prior Authorization Required - Dental x-rays
- $0 Copay
Prior Authorization Required - Cleaning
- $0 Copay
Prior Authorization Required - Periodontics
- Not Covered
- Endodontics
- Not Covered
- Restorative Services
- Not Covered
Hearing Aids and Services
- Fitting/evaluation
- Covered
Limits may apply - Hearing aids
- Covered
Limits may apply - Hearing exam
- Covered
Limits may apply
Vision Services
- Medicare-covered eye exam
- $ to $40 Copay
- Routine eye exam
- $0 Copay
1 Every year - Eyewear benefits
- Eyeglasses: No
Contact Lenses: No
Eyeglass Lenses: No
Eyeglass Frames: No
Eyewear Upgrades: No - Maximum eyewear benefit:
- $2.00
Every three years
Prescription Drug Costs & Benefits
Wellcare Mutual of Omaha Simple Open includes enhanced benefit Medicare Part D. Enhanced benefits offer greater coverage than basic, typically providing lower cost-sharing, broader drug coverage, and additional benefits, such as covering drugs not included in the standard formulary. These plans usually have higher premiums due to the extra coverage and flexibility they provide, but they cover a larger percentage of overall drug costs.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Premium with Extra Help
Extra Help is a Social Security program that helps people with limited income and resources lower or cut Part D costs. The following table outlines premium assistance details with Extra Help.
| Low Income Premium Subsidy: | ${part_d_lips_amount} |
|---|---|
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Deductible
The Medicare Part D annual deductible with this plan is $420.00. You must pay this amount at the pharmacy before Wellcare begins paying its share.
Prescription Drug Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Wellcare Mutual of Omaha Simple Open has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic* | $0.00 | $5.00 |
| Generic* | $0.00 | $10.00 |
| Preferred Brand | 25.00% | 25.00% |
| Non-Preferred Drug | 46.00% | 46.00% |
| Specialty Tier | 28.00% | 28.00% |
| Select Care Drugs* | $0.00 | $0.00 |
| *The Part D deductible does not apply. | ||
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) and drug plans (Part D) in several major categories using a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join Wellcare Mutual of Omaha Simple Open .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |