Introducing Optima Health Plan for COVA and TLC Employees

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Thanks for checking out our video to learn more about Optima Health. We’ve put together this short video to give you a quick overview of the Optima Health plan option.

My name is Amy Burgoyne and I work for Optima Health. We’re a local plan – with dedicated customer service representatives here in Virginia. Our headquarters are in Virginia Beach, but we have offices in Richmond and in the western part of the state.

So – what are the reasons you should consider choosing Optima Health? Probably the most important reason is VALUE! The monthly cost for the Optima Health plan - which includes medical, prescription drug, dental and vision - is one of the lowest cost COMPREHENSIVE plans offered to you. It’s one plan for one price!

Another great reason to choose Optima Health is: savings. You can …. Save time and hassle. With all your benefits all in one plan for one price, it’s an easy-to-use benefits package. You can … Save on copayments. Most of the frequently used benefits are at low, affordable copayments. Some copayments are as low as $5 or $10. And finally, You can save on additional benefits - There’s no need to “buy up” for dental, vision or hearing benefits because these are all included.

Finally, it’s easy to choose Optima Health. The Optima Health network includes all the major hospital systems in the area and over 35,000 providers. There are no referrals to see a specialist. And we can cover you when you’re traveling outside of Virginia. Our plan also includes coverage for out of area dependents and also includes many tools and resources to support your health and well being.

First, you’ll want to know if you’re eligible to join the Optima Health plan through your employer. The plan is available to “state” employees who live or work in the Greater Hampton Roads Area. The plan is also available to The Local Choice groups – as long as your employer has selected Optima Health as an offering – and like the state employees, you’ll need to live or work in the Greater Hampton Roads area. Enrollment opportunities are available at your annual election period or during a special enrollment period following a qualifying life event – such as a birth, marriage or adoption.

You might live or work in the greater Hampton Roads area, but maybe you have a dependent who doesn’t. Not to worry - The Optima Health plan includes coverage for out of area dependents – such as those away at college or out of the state. The plan is structured so that dependents residing out of the area will have in-network benefits when seeking care from a provider who participates with our national network partner called PHCS. Families with an out of area dependent can fill out a simple form to make sure their family member is covered under PHCS.

The plan also includes coverage for emergencies when you are out of the area. If you’re traveling and have an emergency, the plan will cover you at the in-network level.

We’ve also included a special Emergency Travel Assistance benefit to help cover you when you are traveling more than 100 miles away from home.

Let’s learn a little bit more about the plan preventive care is covered at no charge when you go to an in-network provider. Tier 1 providers copayment is $5 for Primary care office visits and $10 for Specialist office visits. Tier 1 providers include the Sentara Quality Care Network, and in-network providers at Tidewater Physicians Multispecialty Group or Riverside. Sentara Quality Care network includes not only Sentara doctors, but many other independent providers in the region. You can check out the website at under “Find Doctors” to get the latest listing of Tier 1 providers. Scroll down to the section that says “Getting the Most out of your plan – Save with Tier 1 Providers”.

If your provider is not on Tier 1 – don’t worry. We still have many others to choose from and you’ll have a copayment of $25 for primary care and $40 for specialist. The plan includes Virtual Visits through MDLive and these are at no cost to you. There are some services where the deductible of $150 per individual and $300 for families as well as a coinsurance amount come into play – for example diagnostic lab services.

The Maximum Out of Pocket – is $1500 for individuals and $3000 for families. This feature is a financial protection for YOU - if all of the copayments and coinsurance you pay in a given plan year hit this amount, the plan begins paying 100% and you do not pay any more. The plan year deductible and out of pocket maximum re-set each plan year.

Next, let’s cover dental. Remember – the dental plan is included in one plan, one price. Dental is covered through our partner – Dominion National. Preventive Care is covered at 100%, Basic care such as fillings or extractions is covered with your cost share being 20% after the deductible and major work – such as crowns or dentures is covered at 50%. Orthodontics are covered for adults and children.

Your benefits are the same if you seek care in or out of the Dominion National Choice PPO network - however if you see a non-network dentist, there may be member charges over the allowed amount. Finally, the plan has a maximum benefit which is $2000 – this is the most that the plan will pay for a covered member’s dental benefits in a year.

Now, let’s cover prescription drugs. Depending on which tier your drug is on, you’ll pay a different amount according to your plan. The copayments for your plan are $15, $30, $45, and $55.

If the cost of the drug is less than the copayment, you would only pay the cost of the drug. Sometimes, there are drugs that have lower tier (or lower cost) alternatives. Always check with your doctor to find the right prescription for your condition.

A mail order benefit is included for you to obtain 90 day supplies of your maintenance medications. Note that the specialty medications are not available in a 90 day supply and this is because these medications often require special storage or handling and usually require more frequent monitoring by your physician.

You can visit to check which tiers your drugs are on. When using the drug search tool, you would select the Open Formulary.

As we mentioned earlier, with the one plan for one price, you do not need to ‘buy up’ for the extras. The plan already includes a vision benefit through EyeMed and a hearing aid benefit through Epic Hearing Healthcare.

Again, many of the services are included at flat, affordable copayments. You pay for your health benefits through a premium that typically comes out of your paycheck. For those who work for an agency under the Commonwealth of Virginia, you can find these cost shares in the annual publication called the Spotlight. We’ve included a link to that publication on our dedicated website.

For those who work for a group that’s under The Local Choice program, check with your employer to find out how much would come out of your paycheck for the Optima Health option.

Your plan also includes great extras like wellness programs, gym discounts, virtual visits, an Employee Assistance Program and discounts other wellness products and services.

After you become a new member, you’ll want to register online at You’ll be able to check on all aspects of your plan. You’ll also want to take us on the go by downloading the Optima Health mobile app. Your online access and the mobile app can help you access all the features of your Optima Health plan.

The Optima Health plan includes a special incentive program to help those with certain chronic conditions. This program is designed for those with Asthma/COPD, Diabetes or Hypertension. Once you’re enrolled in this special program, you’ll have a waived annual deductible and waived copayments for drugs on Tier 1 and Tier 2 medications for your condition.

Along the way, you’ll be asked to engage with our care management team to check in and see what we can do to help you stay healthy. This is another great way to help you save money and stay healthy! More on this program is on the dedicated website’s home page under “Incentive Programs”.

Here at Optima Health, you can contact us – even before you’re a member – and we will help you understand your plan and answer your questions. There’s a team of dedicated customer service representatives waiting to help you.

If you like, you can email us at If you decide to send an email, be sure to mention the name of your employer so we can help you with your specific benefits information. You can enroll at your regularly scheduled open enrollment period, or if you have a qualifying event such as a birth, marriage or adoption, you can make a mid-year change in your health plan election. Most of you have a July 1 – June 30 plan year and the enrollment period is in early May. Some of the TLC groups have an October 1 – September 30 plan year and the enrollment period is in the late summer.

After you’re enrolled, you and every covered member in your household will get a new Optima Health ID card. Your employer and Optima Health can help take care of all the details. Thanks for stopping by to learn more about Optima Health!