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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 2026, 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 3.5 out of 5 stars in 2026.
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 a $150.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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) features an annual drug deductible of $150. For Tier 1 preferred generic drugs, members pay no copay when using preferred pharmacies or preferred mail order services, compared to a $13 monthly copay at standard pharmacies. Tier 2 generic drugs are also highly affordable, costing a $2 copay for a one-month supply at preferred locations and a $20 copay at standard pharmacies. For higher-tier medications, cost sharing transitions to a percentage of the drug cost across all network pharmacies and mail order options. Tier 3 preferred brand drugs require a 25% coinsurance, while Tier 4 non-preferred drugs carry a 40% coinsurance. Specialty drugs in Tier 5 are limited to a one-month supply and require a 31% coinsurance.
Additional Benefits
The Health Plan SecureChoice Optimum (PPO) offers robust medical coverage with no copay for primary care, preventive services, and home health care. For inpatient hospital stays, members pay a $375 daily copay for the first five days and no copay for days six through 90, while specialist visits require a $40 copay. Emergency services are covered with a $125 copay and urgent care visits require a $40 copay, both with no coinsurance. Ancillary benefits include dental services and routine vision exams with no copay, plus up to a $200 annual allowance for eyewear and a $1,500 annual limit for dental care. Routine hearing exams carry a $20 copay, and members receive up to $105 every three months for over-the-counter items with no copay. For durable medical equipment and dialysis, a 20% coinsurance applies, while Medicare Part B insulin is covered with a $35 copay.
Inpatient Hospital See details
The Health Plan SecureChoice Optimum (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days are covered with no copay for acute care, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by The Health Plan SecureChoice Optimum (PPO) with no coinsurance, featuring copays ranging from $0 to $500 for outpatient hospital services and a $500 copay for ambulatory surgical center and observation services. Outpatient substance abuse services require a $40 copay per session with no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
The Health Plan SecureChoice Optimum (PPO) covers partial hospitalization services with no copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
The Health Plan SecureChoice Optimum (PPO) covers ground ambulance services with a $250 copay and air ambulance services with a $500 copay, both requiring prior authorization and carrying no coinsurance. Transportation services, including trips to plan-approved or any health-related locations, are not covered.
Emergency Services See details
The Health Plan SecureChoice Optimum (PPO) covers emergency services with a $125 copay and urgently needed services with a $40 copay, both with no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency services are partially covered up to a $25,000 maximum with no coinsurance, featuring a $125 copay for emergency care and a $250 to $500 copay for emergency transportation, while worldwide urgent coverage is not covered.
Primary Care See details
The Health Plan SecureChoice Optimum (PPO) offers primary care and telehealth services with no copay and no coinsurance, while specialist visits, therapy, mental health, and podiatry services require a $40 copay and no coinsurance. Chiropractic services are technically covered, but routine and other chiropractic sub-services are not covered in practice.
Preventive Services See details
Preventive services are partially covered by The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance for covered services like annual physical exams, kidney disease education, and diabetes self-management. However, several supplemental benefits are not covered, including in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Hearing services are partially covered by The Health Plan SecureChoice Optimum (PPO), featuring a $20 copay and no coinsurance for routine exams, and a $399 to $899 copay with no coinsurance for up to two prescription hearing aids every two years. OTC hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by The Health Plan SecureChoice Optimum (PPO) with no copay, no coinsurance, and no deductible for covered care. This benefit includes one routine eye exam per year and up to a $200 annual allowance for contact lenses, eyeglass lenses, and eyeglass frames, while upgrades and other eye exam services are not covered.
Dental Services See details
The Health Plan SecureChoice Optimum (PPO) offers partially covered dental services with a $40 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $1,500 annual maximum. Specific services such as other diagnostic services, fluoride treatment, other preventive services, adjunctive general services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by The Health Plan SecureChoice Optimum (PPO) with no copay, while associated Medicare Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance. Additionally, Medicare Part B insulin is covered with a $35 copay and no coinsurance, and prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by The Health Plan SecureChoice Optimum (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment benefits under The Health Plan SecureChoice Optimum (PPO) are covered with no copays, though prior authorization is required for these services. Members will pay a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
The Health Plan SecureChoice Optimum (PPO) partially covers diagnostic and radiological services, with lab services being excluded and prior authorization required. Diagnostic procedures require a $50 copay with no coinsurance, diagnostic radiological services have no copay, outpatient X-rays require a $50 copay, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance. However, some services are covered but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by The Health Plan SecureChoice Optimum (PPO) with no coinsurance, requiring prior authorization and no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by The Health Plan SecureChoice Optimum (PPO), with acupuncture and meal benefits not covered under the plan. Over-the-Counter (OTC) items are covered with no copay and no coinsurance, providing up to $105 every three months for select items like naloxone, while nicotine replacement therapy is excluded.
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