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2021 Medicare Advantage Plan Benefit Details for the The Health Plan SecureChoice - Option II (PPO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2021 Medicare Advantage Plan Details
Medicare Plan Name:The Health Plan SecureChoice - Option II (PPO)
Location:Trumbull, Ohio     Click to see other locations
Plan ID:H8604 - 010 - 0     Click to see other plans
Member Services:1-877-847-7907 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the The Health Plan SecureChoice - Option II (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$79.00 (see Plan Premium Details below)
Annual Deductible:$100 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,452 drugsBrowse the The Health Plan SecureChoice - Option II (PPO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$3.00$10.00$47.00$100.0031%
• Number of Drugs per
  Tier:		3881726278309751
Plan's Pharmacy Search:http://www.healthplan.org
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Trumbull, Ohio:14 members
Number of Members enrolled in this plan in (H8604 - 010):314 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$79.00$49.20$29.80$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$7.40$14.90$22.30
Total Monthly Premium with LIS (Parts C & D):$49.20$56.60$64.10$71.50
— Plan Health Benefits —
** Base Plan **
Premium
• Total monthly premium: $79.00
• Health plan premium: $49.20
• Drug plan premium: $29.80
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $1,500 annual deductible
• Other health plan deductibles: In-network: No
• Drug plan deductible: $100.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $10,000 In and Out-of-network
$6,700 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $5 copay per visit
• Primary Out-of-network: $25 copay per visit
• Specialist In-network: $45 copay per visit (authorization and referral required)
• Specialist Out-of-network: $60 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $50 copay
• Diagnostic tests and procedures Out-of-network: 30% coinsurance
• Lab services In-network: $0 copay
• Lab services Out-of-network: 30% coinsurance
• Diagnostic radiology services (e.g., MRI) In-network: $0-150 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization and referral required)
• Outpatient x-rays In-network: $50 copay (authorization and referral required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $45 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $250 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization and referral required)
• Out-of-network: 30% per stay (authorization and referral required)
Outpatient hospital coverage
• In-network: $0-250 copay per visit (authorization and referral required)
• Out-of-network: 30% coinsurance per visit (authorization and referral required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20
$160 per day for days 21 through 100 (authorization and referral required)
• Out-of-network: 20% per stay (authorization and referral required)
Preventive care
• In-network: $0 copay (authorization required)
• Out-of-network: 30% coinsurance (authorization required)
Ground ambulance
• In-network: $200 copay
• Out-of-network: $200-500 copay
Rehabilitation services
• Occupational therapy visit In-network: $40 copay (authorization and referral required)
• Occupational therapy visit Out-of-network: $60 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit In-network: $40 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit Out-of-network: $60 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric In-network: $250 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization and referral required)
• Inpatient hospital - psychiatric Out-of-network: 30% per stay (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: $60 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: $60 copay (authorization and referral required)
• Outpatient group therapy visit In-network: $40 copay (authorization and referral required)
• Outpatient group therapy visit Out-of-network: $60 copay (authorization and referral required)
• Outpatient individual therapy visit In-network: $40 copay (authorization and referral required)
• Outpatient individual therapy visit Out-of-network: $60 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 40% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 40% coinsurance per item (authorization required)
• Diabetes supplies In-network: $7.50 copay or 0-20% coinsurance per item (authorization required)
• Diabetes supplies Out-of-network: 40% coinsurance per item (authorization required)
Hearing
• Hearing exam In-network: $45 copay
• Hearing exam Out-of-network: $60 copay
• Fitting/evaluation: Not covered
• Hearing aids - inner ear: Not covered
• Hearing aids - outer ear: Not covered
• Hearing aids - over the ear: Not covered
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: 30% coinsurance (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: 30% coinsurance (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: 30% coinsurance (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $60 copay (limits apply)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $15 copay (limits apply)
• Eyeglasses (frames and lenses): Not covered
• Eyeglass frames In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $15 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $15 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $45 copay (authorization and referral required)
• Foot exams and treatment Out-of-network: $60 copay (authorization and referral required)
• Routine foot care In-network: $45 copay (limits apply, authorization and referral required)
• Routine foot care Out-of-network: $60 copay (limits apply, authorization and referral required)
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required)
Package #1
• Monthly Premium: $28.90
• Deductible:




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