Óptimo Plus (PPO)

Who is eligible for this plan?

Óptimo Plus (PPO) plan is designed for Medicare beneficiaries with Parts A and B, who live in one of Puerto Rico’s 78 municipalities, and who have not been diagnosed with end-stage renal disease (ESRD) in which the beneficiary has the freedom to access all the physicians and hospitals within the Triple-S Advantage provider network as well as the nationwide Blue Cross and Blue Shield network without having to obtain a referral or an authorization.

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

  • $109 Monthly Premium
  • $35 copay for each Hospital Stay
  • $0 copay for each visit to Primary Care Physicians (PCP)
  • $15 copay for each visit to Specialists
  • Erectile Dysfunction Treatment Drugs
  • Preventive and Comprehensive Dental Benefit
  • One pair of eyewear (frame and lenses) or one pair of contact lenses every year or $200 for eyewear or contact lenses every year.
  • Hearing Aid Benefit
  • Acupuncture and Alternative Therapies Benefit
  • Non-Emergency Transportation
  • Blood Pressure Monitor
  • Health and Wellness Program and $25 per month for Gym
  • Teleconsulta Program
  • Prescription Drug Coverage

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

Annual Notice of Change (ANOC) Óptimo Advance to Óptimo Plus

The information in this document tells you about the differences between your current benefits in Óptimo Advance and the benefits you will have on January 1, 2017 as a member of Óptimo Plus.

If you do nothing to change your Medicare coverage by December 7, 2016, we will automatically enroll you in our Óptimo Plus. This means starting January 1, 2017, you will be getting your medical coverage through Óptimo Plus. If you want to, you can change to a different Medicare health plan. You can also switch to Original Medicare. If you want to change, you must do so between October 15 and December 7.

Download .PDF Document

Provider and Pharmacy Directory 2017

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

Pharmacy Directory

The Pharmacy Directory gives you a complete list of the pharmacies in our network. These pharmacies have agreed to fill covered prescriptions for our plan members.

Download .PDF Document

Drugs

Comprehensive Formulary

The Comprehensive Formulary lists all the drugs covered by our plan. These drugs were selected in consultation with a team of health care providers and represent the prescription therapies believed to be necessary for a quality treatment program.

Download .PDF Document

Notice of Change to Formulary

Our plan is required to provide notice regarding the removal or change in the preferred or tiered cost sharing status of any Part D drugs included in the formulary.

* Changes Effective at 7/1/2017

Prior Authorization Criteria

Our plan requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from us before filling your prescription. If you don’t get approval, we may not cover the drug.

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Step Therapy Criteria

In some cases, Triple-S Advantage requires that you first try certain medications to treat your medical condition, before other medications for the same medical conditions are covered. For example, if medication A and medication B both treat your medical condition, Triple-S Advantage may not cover medication B unless you have used medication A first. If medication A does not work for you, then Triple-S Advantage will cover medication B.

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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: 06/07/2017