The Health Plan SecureChoice - Option II (PPO)

Available to residents of Madison County, OH for 2026. Contract H8604, plan 011, segment 0.

Renewed, service area reduced for 2026. CMS carries this plan forward from 2025.

Plan details

Monthly premium (Part C + D)	$109.00
— medical (Part C) part	$21.40
— drug (Part D) part	$87.60?
Monthly premium with full Extra Help (LIS)	$76.90?drug (Part D) part $55.50; Extra Help does not cover the medical (Part C) premium
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$6,700.00?
In- and out-of-network out-of-pocket maximum	$10,000.00
Drug deductible	$275.00Tier 1 and 2 exempt
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO?
Contract / plan	H8604-011-0
Offered by	The Health Plan
Parent organization	The Health Plan of West Virginia, Inc.
Formulary drugs	3,508
Formulary exception tier	4?
Pharmacy search	www.healthplan.org
Member services	(877)847-7915TTY 711

CMS star ratings

Overall: 3.5 out of 5 stars for Overall
Health plan (Part C): 3.5 out of 5 stars for Health plan (Part C)
Drug plan (Part D): 3.5 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H8604 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$10 copay	$25 copay
Specialist	$45 copay	$60 copay
Other health care professional	$45 copay(authorization required)	$60 copay
Additional telehealth services	$0 copay	—
Preventive care
Medicare-covered preventive services	$0 copay	30% coinsurance
Annual physical exam	$0 copay	$25 copay
Kidney disease education	$0 copay	30% coinsurance
Glaucoma screening	$0 copay	30% coinsurance
Diabetes self-management training	$0 copay	30% coinsurance
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$50 copay(authorization required)	30% coinsurance
Lab services	$0 copay(authorization required)	30% coinsurance
Diagnostic radiology (e.g. MRI, CT)	$0–$150 copay(authorization required)	30% coinsurance
Therapeutic radiology	20% coinsurance(authorization required)	30% coinsurance
Outpatient x-rays	$50 copay(authorization required)	30% coinsurance
Emergency and urgent care
Emergency room	$125 copay	—
Urgent care	$45 copay	—
Worldwide emergency coverage	$125 copay · $25,000 plan limit	—
Worldwide urgent care	Not covered	—
Worldwide emergency transportation	$200–$500 copay	—
Hospital care
Inpatient hospital stay	$295 per day for days 1–6; $0 per day for days 7–90(authorization required)	30% coinsurance per stay
Outpatient hospital services	$0–$295 copay(authorization required)	30% coinsurance
Outpatient observation	$150 copay(authorization required)	30% coinsurance
Ambulatory surgical center	$295 copay(authorization required)	30% coinsurance
Outpatient blood services	$0 copay	30% coinsurance
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $218 per day for days 21–100(authorization required)	20% coinsurance per stay
Home health care	$0 copay	30% coinsurance
Kidney dialysis	20% coinsurance	20% coinsurance
Rehabilitation
Occupational therapy	$40 copay(authorization required)	$60 copay
Physical therapy and speech-language therapy	$40 copay(authorization required)	$60 copay
Cardiac rehabilitation	$0 copay	30% coinsurance
Pulmonary rehabilitation	$0 copay	30% coinsurance
Mental health and substance use
Inpatient psychiatric hospital stay	$250 per day for days 1–5; $0 per day for days 6–90(authorization required)	30% coinsurance per stay
Outpatient mental health, individual session	$40 copay	$60 copay
Outpatient mental health, group session	$40 copay	$60 copay
Psychiatrist, individual session	$40 copay	$60 copay
Psychiatrist, group session	$40 copay	$60 copay
Partial hospitalization	$0 copay(authorization required)	30% coinsurance
Intensive outpatient program	$0 copay(authorization required)	30% coinsurance
Outpatient substance use, individual session	$45 copay(authorization required)	$60 copay
Outpatient substance use, group session	$45 copay(authorization required)	$60 copay
Opioid treatment program	$45 copay(authorization required)	$60 copay
Ambulance and transportation
Ground ambulance	$200 copay(authorization required)	$200 copay
Air ambulance	$500 copay(authorization required)	$500 copay
Transportation to plan-approved locations	Not covered	—
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	20% coinsurance(authorization required)	40% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	40% coinsurance
Medical supplies	20% coinsurance(authorization required)	40% coinsurance
Diabetes supplies	0%–20% coinsurance(authorization required)	40% coinsurance
Diabetic therapeutic shoes or inserts	20% coinsurance(authorization required)	40% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay(authorization required)	$60 copay
Routine chiropractic care	Not covered	—
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$45 copay	$60 copay
Routine foot care	$45 copay(limits apply)	$60 copay
Dental?
Medicare-covered dental services	$45 copay(authorization required)	$60 copay
Oral exams	$0 copay(limits apply)	0%–30% coinsurance
Cleanings	$0 copay(limits apply)	30% coinsurance
Fluoride treatment	Not covered	—
Dental x-rays	$0 copay(limits apply)	30% coinsurance
Other diagnostic dental services	Not covered	—
Other preventive dental services	Not covered	—
Restorative services (fillings, crowns)	Not covered	—
Endodontics (root canals)	Not covered	—
Periodontics (gum disease)	Not covered	—
Dentures and other removable prosthodontics	Not covered	—
Maxillofacial prosthetics	Not covered	—
Implants	Not covered	—
Bridges and other fixed prosthodontics	Not covered	—
Oral and maxillofacial surgery	Not covered	—
Orthodontics	Not covered	—
Adjunctive general services	Not covered	—
Vision?
Eye exam (Medicare-covered)	$0 copay	$25–$60 copay
Routine eye exam	$0 copay(limits apply)	$60 copay
Eyewear after cataract surgery (Medicare-covered)	$0 copay(limits apply)	30% coinsurance
Eyewear plan limit	$150 plan limit every year	—
Contact lenses	$0 copay(limits apply)	$15 copay
Eyeglasses (frames and lenses)	Not covered	—
Eyeglass lenses	$0 copay(limits apply)	$15 copay
Eyeglass frames	$0 copay(limits apply)	$15 copay
Eyewear upgrades	Not covered	—
Hearing?
Hearing exam (Medicare-covered)	$20 copay	$20 copay
Routine hearing exam	Not covered	—
Hearing aid fitting and evaluation	Not covered	—
Hearing aids (all types)	Not covered	—
Hearing aids, inner ear	Not covered	—
Hearing aids, outer ear	Not covered	—
Hearing aids, over the ear	Not covered	—
Medicare Part B drugs
Part B insulin	$35 copay(authorization required, step therapy may apply)	$35 copay
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	30% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	30% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	$55 allowance every three months	—
Meals after a hospital stay or for a chronic condition	Not covered	—
Fitness benefit	$0 copay	$0 copay
Health education	$0 copay	30% coinsurance
Nutritional / dietary benefit	Not covered	—
Extra smoking and tobacco cessation counseling	$0 copay	30% coinsurance
Enhanced disease management	Not covered	—
Telemonitoring	Not covered	—
Remote access technologies (web/phone, nurse line)	Not covered	—
Home and bathroom safety devices	Not covered	—
Counseling services	Not covered	—
In-home safety assessment	Not covered	—
Personal emergency response system (PERS)	Not covered	—
Medical nutrition therapy	Not covered	—
Post-discharge in-home medication reconciliation	Not covered	—
Re-admission prevention	Not covered	—
Wigs for hair loss from chemotherapy	Not covered	—
Weight management programs	Not covered	—
Alternative therapies	Not covered	—
Therapeutic massage	Not covered	—
Adult day health services	Not covered	—
Home-based palliative care	Not covered	—
In-home support services	Not covered	—
Support for caregivers	Not covered	—

In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$3.00
Tier 2	$10.00
Tier 3	$47.00
Tier 4	$100.00
Tier 5	29%

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	Preferred	Standard	Mail Order	Preferred	Standard	Mail Order
Initial deductible phase
Tier 1: Preferred Generic	$3.00	$13.00	$3.00	$9.00	$39.00	$9.00
Tier 2: Generic	$10.00	$20.00	$10.00	$30.00	$60.00	$30.00
Initial coverage phase
Tier 1: Preferred Generic	$3.00	$13.00	$3.00	$9.00	$39.00	$9.00
Tier 2: Generic	$10.00	$20.00	$10.00	$30.00	$60.00	$30.00
Tier 3: Preferred Brand	$47.00	$47.00	$47.00	$141.00	$141.00	$141.00
Tier 4: Non-Preferred Drug	$100.00	$100.00	$100.00	$300.00	$300.00	$300.00
Tier 5: Specialty Tier	29%	29%	29%	n/a	n/a	n/a
Catastrophic coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 3: Preferred Brand	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 4: Non-Preferred Drug	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 5: Specialty Tier	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

Benefits in plain text

The Health Plan SecureChoice - Option II (PPO) (H8604-011-0) is a 2026 PPO Medicare Advantage plan offered by The Health Plan, available to residents of Madison County, OH.

The monthly premium is $109.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $76.90.

Its in-network out-of-pocket maximum is $6,700.00.

The combined in- and out-of-network out-of-pocket maximum is $10,000.00.

The drug deductible is $275.00. Tier 1 and 2 exempt.

The plan's formulary lists 3,508 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $3.00; tier 2: $10.00; tier 3: $47.00; tier 4: $100.00; tier 5: 29%.

CMS gives the plan's contract (H8604) an overall rating of 3.5 out of 5 stars.

Email a copy of the plan benefit details

Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.