Wellcare Mutual of Omaha Simple Open (PPO) – H0111-001-0
This page outlines coverage, cost, and availability for Wellcare’s H0111-001-0 Medicare Advantage plan for 2025.
Health Plan Costs
💰 Monthly Premium, Deductible, Max Out-of-Pocket & Giveback
Monthly Premium: The total monthly premium is $0.00, including drug coverage. You must also pay your standard Medicare Part B premium.
Health Plan Deductible: Some health plans have a deductible (amount you pay before cost-sharing begins). This plan's deductible is $0.00.
Maximum Out-of-Pocket: All Medicare Advantage plans have an annual maximum out-of-pocket (MOOP) limit. This is the most you will pay for standard health services in a year before that plan begins paying all costs. This plan's MOOP is $5,900.00 for in-network services, excluding the cost of your Part D medications.
Part B Giveback: This plan offers a Part B premium giveback of $0.00.
Health Plan Out-of-Pocket Costs
🩺 Doctor’s Office Visits
- Primary: $0 Copay
- Specialist: $40 Copay
Prior Authorization Required - NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
🏥 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
Supplemental Benefits
🦷 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 Costs & Benefits
📦 This plan’s prescription drug deductible is $420.00.
You’ll need to pay this amount before Wellcare begins helping with drug costs.
📊 See what you’ll pay for covered prescriptions by tier and pharmacy type.
| Drug Tier | Retail Pharmacy | 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 |
| * Not all tiers apply to the deductible. See the formulary for full details. | ||
Drug tiers group medications by type and cost. Tier 1 has the lowest-cost generics, and Tier 5 includes specialty drugs.
View the plan’s complete formulary drug list (opens in a new browser tab).
💡 Learn how Extra Help could lower your drug costs.
If you qualify for the Social Security Extra Help program, your Part D premium may be reduced.
| Low Income Premium Subsidy: | ${part_d_lips_amount} |
|---|---|
| Amount Paid by CMS: | $0.00 |
| Your Adjusted Premium: | $0.00 |
Learn more at the Social Security Extra Help program .
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 .
Plan Availability
Wellcare Mutual of Omaha Simple Open (H0111-001-0) is available in the following locations (click to open):
Need Help Enrolling?
Call 1-855-728-0510 (TTY 711) to speak with a licensed insurance agent and learn more about this plan and others on this site.
Or enroll online through our trusted and secure platform:
🚀 Enroll Online NowClicking this button will open MedicareEnrollment.com (powered by HealthCompare Insurance Services) and the official Wellcare plan page.
📄 View Wellcare Contact Information
| Website: | Wellcare Plan Page (opens in new tab) |
|---|---|
| Providers: | Wellcare Providers Page (opens in new tab) |
| Formulary: | Wellcare Formulary Page (opens in new tab) |
| Pharmacy: | Wellcare Pharmacy Page (opens in new tab) |
| New Member Health Plan Help: | (800)225-8017 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)270-5320 |
| New Member Part D TTY Users: | 711 |
🔍 Why This Information Matters
Many Medicare websites only show you their own phone numbers and redirect you to their sales team. We believe you deserve full access to your plan resources — including direct links to the official Wellcare site, provider directories, and support contacts.
That’s why we include this information here, clearly and transparently — so you can research and enroll with confidence.
🛡️ Official Medicare Enrollment Resources
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Frequently Asked Questions
📘 What does Medicare plan code H0111 001 mean?
Wellcare Mutual of Omaha Simple Open is a Medicare Advantage plan by Wellcare. The code H0111 is the CMS contract ID, whereas 001 is its plan ID.
- Plan Name: Wellcare Mutual of Omaha Simple Open
- Plan Type: PPO
- Premium: $0.00/mo + your monthly Part B premium
- Out-of-Pocket Max: $5,900.00 (in-network)
- Drug Coverage: Includes Medicare Part D prescription drug coverage with tiered cost sharing.
- CMS Star Rating: 3 out of 5
- Contract Year: 2025
This information is based on official CMS data and is provided for educational purposes. Always review your plan’s official documents or contact the provider directly before making enrollment decisions.
📋 What type of plan is H0111 001?
This plan is a PPO — specifically, it's an PPO plan with a Medicare Advantage contract that's offered by Wellcare. It comes with defined provider network rules you should be aware of.
- Plan Marketing Name: Wellcare Mutual of Omaha Simple Open
- Network Type: Preferred Provider Organization with in- and out-of-network coverage.
- Referral Requirement: Referrals are generally not required, though some services may be exceptions. Refer to the plan’s coverage tables above.
- Prescription Coverage: Includes Medicare Part D prescription drug coverage with tiered cost sharing.
Plan types like HMOs and PPOs determine whether you can go out-of-network or need referrals to see specialists.
📦 What benefits are included in H0111 001?
This plan covers all Medicare Part A and Part B services. Depending on the plan, it may also include valuable extras like dental, vision, and hearing benefits.
- Medical Services: Hospital, doctor visits, preventive care
- Prescription Drugs: Enhanced, $420.00 deductible
- Dental: No — this plan does not include dental benefits.
- Vision: Yes — vision benefits are included. Review the vision section above for copay and limit details.
- Hearing: Yes — hearing benefits are included. See the coverage details above to learn what services are covered.
Benefit availability may vary by location and plan version. Confirm specific details in your plan's Evidence of Coverage (EOC).