Basic (HMO)

Who is eligible for this plan?

Basic (HMO) is a plan that does not include prescription drug coverage and is designed for Medicare beneficiaries with Parts A and B, who live in one of Puerto Rico’s 78 municipalities, who have not been diagnosed with end-stage renal disease (ESRD) and who already have Part D Prescription Drug coverage, such as private sector retirees or veterans.

For additional information about copayments, coinsurances and details about the benefits and restrictions that apply, please refer to the Evidence of Coverage and Summary of Benefits.

Some benefits of this plan:

  • $0 Monthly Premium
  • $0 copay for each Hospital Stay *
  • $0 copay for each visit to Primary Care Physicians (PCP)
  • $10 copay for each visit to Specialists*
  • 0% coinsurance for Laboratory*
  • 0% coinsurance for X-Rays
  • 0% coinsurance for Durable Medical Equipment*
  • $5 copay for Preventive Dental Benefit and $550 annual limit for Comprehensive Dental Benefit
  • Up to one pair of eyewear (frame and lenses) or up to one pair of contact lenses every 2 years.
  • $300 every 3 years for Hearing Aid Benefit
  • $0 copay for each Acupuncture Benefit visit, up to 12 visits per year.
  • Shower Chair
  • Health and Wellness Program and $50 per month for Gym
  • Teleconsulta Program

*Copay/coinsurance applies for services in the Preferred Provider Network or preferred brands/manufacturers.

This is a brief summary for informational purposes and it does not replace or modify your Evidence of Coverage (EOC).

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits gives you a general idea of your coverage, highlighting important features. It doesn’t list every service that we cover or every limitation or exclusion. To get a complete list of benefits, please refer to the Evidence of Coverage.

Download .PDF Document

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare and prescription drug coverage for the calendar year. It explains how to get coverage for the services and prescription drugs you need. This is an important legal document

Download .PDF Document

Annual Notice of Change (ANOC)

This document, sent every fall to members, informs you about all the changes to benefits, costs, providers, and prescription drugs for the next year. The ANOC helps you compare your current health and prescription drugs benefits and costs with next year’s.

Download .PDF Document

Provider Directory 2017

Preferred Provider Directory

A preferred network provider has agreed to offer your health care coverage at a lower cost-sharing level than other network providers.

Download .PDF Document

Provider Directory

Find doctors, other health care professionals, medical groups, hospitals, and health care facilities available to you through our network in our Provider Directory.

Download .PDF Document

List of Durable Medical Equipment (DME)

The list of Durable Medical Equipment (DME), tells you the brands and manufacturers of equipment and medical supplies that we will cover in this plan as described in your Evidence of Coverage.

Download .PDF Document

Star Rating Medicare

One of the Centers for Medicare & Medicaid Services (CMS) most important goals is to make the quality of Medicare Advantage plans for their beneficiaries transparent. In this effort, Medicare Advantage plans are each year rated on a scale ranging from 1 to 5 stars. The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing illness, ratings from patients, patient safety, drug pricing and customer service). The score provides an overall measure of a plan’s quality, and is a cumulative indicator of the quality of care, access to care, responsiveness, and beneficiary satisfaction provided by the plan. One star represents poor performance, while a five-star rating is considered excellent. The plans’ ratings are posted on the Medicare website to provide beneficiaries with additional information to help them choose among the Medicare Advantage plans offered in their area. You can go to www.medicare.gov for more information.

If you would like to get additional information on our plan’s performance please contact us at 1-888-620-1919 (toll-free) from Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY users should call 1-866-620-2520.

Download .PDF Document

ID Cards

While you are a member of our plan, you must use the Triple-S Advantage membership card whenever you get any services and for prescription drugs you get at network pharmacies. You must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. If you get covered services using your red, white, and blue Medicare card instead of using the Triple-S Advantage membership card while you are a plan member, you may have to pay the full cost yourself.

If your plan membership card is damaged, lost, or stolen, call Customer Services right away and we will send you a new card.

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Last update: 11/02/2016