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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 a preferred pharmacy or preferred mail order service, while standard pharmacy and mail order options require a $13 copay for a one-month supply. Tier 2 generic drugs cost as little as a $2 copay for a one-month supply at preferred locations, compared to a $20 copay at standard pharmacies. For higher-tier medications, the plan transitions from flat copays to coinsurance percentages. Tier 3 preferred brand drugs carry a 25% coinsurance across all pharmacy and mail order channels, while Tier 4 non-preferred drugs require a 40% coinsurance. Tier 5 specialty drugs are covered with a 31% coinsurance for a one-month supply at both preferred and standard locations.
Additional Benefits
The Health Plan SecureChoice Optimum (PPO) offers comprehensive medical coverage featuring no copay for primary care visits and a $45 copay for specialist consultations, all with no coinsurance. For inpatient hospital stays, members pay a $375 copay per day for the first five days and no copay for days six through 90. Emergency care is available with a $125 copay, while urgent care services require a $40 copay, with both fees waived if you are admitted. This plan also includes valuable supplemental benefits, such as a $200 annual eyewear allowance and up to $1,500 in dental coverage with no copay for preventive and comprehensive services. Additionally, members receive a $105 quarterly allowance for over-the-counter items with no copay, alongside covered home health services. Durable medical equipment is covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
The Health Plan SecureChoice Optimum (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $375 copay for days 1 through 5 and no copay for days 6 through 90. Unlimited additional days for acute stays are covered with no copay, while 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 of $0 to $500 for outpatient hospital visits, $500 for observation and ambulatory surgical center services, and $45 for substance abuse sessions. Outpatient blood services are covered 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, although 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 featuring no coinsurance. Transportation services are not covered under this plan.
Emergency Services See details
The Health Plan SecureChoice Optimum (PPO) covers emergency services with a $125 copay and no coinsurance, and urgently needed services with a $40 copay and no coinsurance, with both copays waived if admitted within 24 hours. Worldwide emergency services are partially covered up to a $25,000 maximum benefit 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
Primary care and telehealth services under The Health Plan SecureChoice Optimum (PPO) feature no copay and no coinsurance, while specialist, mental health, and podiatry visits require a $45 copay with no coinsurance. Physical, occupational, and speech therapy services carry a $40 copay with no coinsurance, and though some chiropractic services are covered, routine and other chiropractic services are not covered.
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 physicals, kidney disease education, and glaucoma screenings. While select benefits like health education, smoking cessation, and memory fitness are included, other services such as weight management, alternative therapies, and personal emergency response systems are not covered.
Hearing Services See details
The Health Plan SecureChoice Optimum (PPO) partially covers hearing services, offering routine hearing exams for a $20 copay and no coinsurance, with no deductible. Prescription hearing aids are covered with no coinsurance and a copay ranging from $399 to $899, but OTC hearing aids as well as inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance for covered services, which include one routine eye exam per year and a $200 annual eyewear allowance. While contact lenses, eyeglass lenses, and frames are covered under this allowance, other eye exam services, upgrades, and combined eyeglasses are not covered.
Dental Services See details
The Health Plan SecureChoice Optimum (PPO) partially covers dental services with a $45 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for other covered preventive and comprehensive services up to a $1,500 annual maximum. Sub-services that are not covered under this plan include fluoride treatment, implants, orthodontics, maxillofacial prosthetics, adjunctive general services, and other diagnostic or preventive dental services.
Home Infusion bundled Services See details
The Health Plan SecureChoice Optimum (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy, radiation, and other drugs have a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
The Health Plan SecureChoice Optimum (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by The Health Plan SecureChoice Optimum (PPO) with no copays, though prior authorization is required. You will pay a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic 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 services, which exclude lab services, offering diagnostic procedures and tests for a $50 copay and no coinsurance. Radiological services require prior authorization and feature no copay for diagnostic radiological services, a $50 copay for outpatient X-rays, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered under The Health Plan SecureChoice Optimum (PPO) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
The Health Plan SecureChoice Optimum (PPO) indicates some services are covered with no copay and no coinsurance, but Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
The Health Plan SecureChoice Optimum (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not required, additional days beyond the standard 100 days are not covered.
Other Services See details
The Health Plan SecureChoice Optimum (PPO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $105 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered.
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