Óptimo ELA–Plata (PPO) is a Medicare Advantage plan for the Commonwealth of Puerto Rico retirees (also known as ELA) and their dependents, which provides Original Medicare Part A and Part B Benefits with a Part D prescription drug coverage without the need for referrals. In this plan the member has the freedom to access physicians and hospitals within the Triple-S Advantage provider network and Blue Cross and Blue Shield network nationwide. The prescription drug coverage provides a wide variety of brand-name drugs, including drugs for erectile dysfunction management. It also offers supplemental benefits such as coverage for eyeglasses and hearing aids.
The Annual Enrollment Period for 2016 ELA Plans will begin on October 3 and end on December 2, 2016.
Who is eligible for this plan?
Óptimo ELA–Plata (PPO) is a plan for beneficiaries with Medicare Parts A and B who are retired from the Commonwealth of Puerto Rico (also known as ELA), or an eligible dependent. The ELA retiree should receive an employer contribution from the ELA Central Retirement System or from the Teachers’ Retirement System. Also, beneficiary should reside in one of the 78 municipalities of Puerto Rico.
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 after a $100 employer contribution. You must continue to pay your Medicare Part B premium
- Services available without referral
- 25 Emergency Care
- $0 Hospitalization
- $0 Primary Physician Visit
- $5 Specialist Physician Visit
- 0% Laboratory
- 0% X Rays
- 10% Durable Medical Equipment
- $1,000 coverage for Preventive and Comprehensive Dental Benefit
- One pair of eyewear or up to one pair of contact lenses or $200 every 2 years
- $400 every 2 years for Hearing Aids
- Prescription Drug Coverage
- Drugs for Erectile Dysfunction
- Health and Wellness Program
- Chronic Disease Management
- Teleconsulta Program
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 documentDownload .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 and Pharmacy 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
Preferred Pharmacy Directory
A preferred network pharmacy offers covered drugs to plan members that may have lower cost-sharing level than other network pharmacies.Download .PDF Document
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
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
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.
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.Download .PDF Document
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.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
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.
Authorized by Comisión Estatal de Elecciones CEE-SA- 16-12281
Last update: 08/08/2017