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The Health Plan SecureChoice Optimum (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for The Health Plan SecureChoice Optimum (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on The Health Plan SecureChoice Optimum (PPO) in 2025, please refer to our full plan details page.
The Health Plan SecureChoice Optimum (PPO) is a PPO plan offered by The Health Plan of West Virginia, Inc. available for enrollment in 2025 to people living in OHIO/WEST VIRGINIA. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that The Health Plan SecureChoice Optimum (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about The Health Plan SecureChoice Optimum (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For The Health Plan SecureChoice Optimum (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9550.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9550.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Health Plan SecureChoice Optimum (PPO) has an "Enhanced Alternative" drug benefit. This plan has no deductible. In the initial coverage phase, you will pay no copay for preferred generic drugs at preferred pharmacies or mail order pharmacies. For standard generic drugs, you will pay 20% coinsurance.
Additional Benefits
The Health Plan SecureChoice Optimum (PPO) offers comprehensive coverage, including inpatient hospital stays with a $350 copay for the first five days, and no copay for days 6-90. Outpatient services have varying copays, and emergency services have copays ranging from $40-$125. Primary care visits have no copay, with specialist and other services at a $40 copay. Preventive services are covered, including annual exams, with no copay. The plan also covers hearing services like routine exams and prescription hearing aids, and vision services, including routine eye exams and eyewear. Dental services and home infusion services are covered, while skilled nursing facilities have a copay after 20 days. Other benefits include ambulance services, and various therapies, with some services requiring prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a $350 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will also pay a $350 copay for days 1-5, and no copay for days 6-90. Additional days and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include outpatient hospital services with a copay between $0 and $500, observation services with a $500 copay, and ambulatory surgical center services with a $500 copay. Outpatient substance abuse services, including individual and group sessions, have a copay of $40. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by The Health Plan SecureChoice Optimum (PPO) and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by The Health Plan SecureChoice Optimum (PPO). Ground Ambulance Services have a $250 copay, while Air Ambulance Services have a $500 copay, and there is no coinsurance for either. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under The Health Plan SecureChoice Optimum (PPO), with copays of $125, $40, and $125, respectively, and no coinsurance. Worldwide Emergency Transportation is also covered, with a copay between $250 and $500, and no coinsurance. Worldwide Urgent Coverage is not covered.
Primary Care See details
The Health Plan SecureChoice Optimum (PPO) covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $40 copay. Also covered are physician specialist services with a $40 copay, mental health specialty services with a $40 copay, podiatry services with a $40 copay, and other health care professional services with a $40 copay. Psychiatric services, physical therapy and speech-language pathology services, opioid treatment program services, and additional telehealth benefits are also covered, each with a $40 copay.
Preventive Services See details
The Health Plan SecureChoice Optimum (PPO) covers preventive services, including annual physical exams, health education, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, EKG following Welcome Visit, and additional sessions of smoking and tobacco cessation counseling, with up to 8 visits. Some services, such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, and others, are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $40 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and the plan does not cover OTC hearing aids. Prescription hearing aids have a copay between $599 and $899, and are covered for 2 visits every two years.
Vision Services See details
The Health Plan SecureChoice Optimum (PPO) plan covers vision services, including routine eye exams once per year. Eyewear is covered with a combined maximum benefit of $200 per year, and contact lenses are covered with a variable number of pairs based on annual use. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
The Health Plan SecureChoice Optimum (PPO) plan covers Medicare Dental Services with a $40 copay, and other dental services including oral exams, dental x-rays, prophylaxis (cleaning), prosthodontics, removable, prosthodontics, fixed, and oral and maxillofacial surgery. Fluoride treatment, maxillofacial prosthetics, implant services, and orthodontics are not covered. Orthodontic services have a maximum benefit of $1,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by The Health Plan SecureChoice Optimum (PPO) with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered, with Durable Medical Equipment covered with 20% coinsurance and no copay. Prosthetics, medical supplies, and diabetic equipment are also covered, with 20% coinsurance. Diabetic Supplies have a 0-20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a $50 copay, and Diagnostic Radiological Services with a copay up to $150.00. Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $50 copay; however, Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance, though authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services for The Health Plan SecureChoice Optimum (PPO) include Over-the-Counter (OTC) Items with a maximum benefit coverage amount of $200 every three months, while acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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