Óptimo Plus (PPO)

Compare this plan

A health plan with coverage in Puerto Rico and the United States, including Part D Prescription Drug coverage.

Óptimo Plus (PPO) offers you an alternative for coverage in the United States. This coverage will give you 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 authorization. It also includes prescription drug coverage.

Who is eligible for this plan?

  • Beneficiaries with Medicare Parts A and B
  • Residents living in one of Puerto Rico’s 78 municipalities
  • Patients who have not been diagnosed with end-stage renal disease (ESRD)
  • United States citizens or legal residents

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

Some benefits of this plan

  • $109 Monthly Premium (You must continue to pay your Medicare Part B premium).
  • $35 copay for each Hospital Stay
  • $0 copay for each visit to Primary Care Physicians (PCP)
  • $15 copay for each visit to Specialists / $0 Salus Clinic
  • Prescription Drug Coverage
  • Preventive and Comprehensive Dental Benefit
  • One pair of eyewear (frame and lenses) or one pair of contact lenses every year or up to $200 for eyewear or contact lenses every year.
  • Hearing Aid Benefit
  • Erectile Dysfunction Treatment Drugs
  • Acupuncture and Alternative Therapies Benefit, up to 12 visits per year
  • Blood Pressure Monitor
  • Non-Emergency Transportation
  • Health and Wellness Program
  • $25 per month for Gym
  • Teleconsulta Service

*Copay/Coinsurance applies for services in the Preferred Provider Network, preferred collections, 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 read the Evidence of Coverage.

Download PDF Document

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare health care and prescription drug coverage for the calendar year. It also 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 is sent to members every fall to inform 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 drug benefits and costs with those for next year.

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 as of January 1, 2017 as a member of Óptimo Plus.

Download PDF Document
Provider and Pharmacy Directory 2017

Provider Directory

Find doctors, medical groups, hospitals, health care facilities, and other health care professionals 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

Drug 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 Changes to Formulary

Our plan is required to provide notice about removals or changes in the preferred or tiered cost-sharing status of any Part D drugs included in the formulary.

* Changes Effective at 7/1/2017
* Changes Effective at 11/1/2017

Prior Authorization Criteria

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

If you need the information contained in this document in Spanish, you may contact Member Services at 1-888-620-1919, from Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

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 covering other medications for the same medical condition. For example, if medication A and medication B both treat your medical condition, Triple-S Advantage may not cover medication B unless you have tried medication A first. If medication A does not work for you, then Triple-S Advantage will cover medication B.

If you need the information contained in this document in Spanish, you may contact Member Services at 1-888-620-1919, from Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

Download PDF Document

Star Rating Medicare

One of the most important goals for the Centers for Medicare & Medicaid Services (CMS) is to make the quality of Medicare Advantage plans transparent for their beneficiaries. To achieve this goal, Medicare Advantage plans are rated every year on a one- to five-star scale. The Medicare Program rates how well Medicare health and drug plans perform in different categories (for example, detecting and preventing illness, ratings provided by patients, patient safety, drug pricing, and customer service). This 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 plan beneficiary satisfaction. One star represents poor performance, while a five-star rating is considered excellent. The plan 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 visit www.medicare.gov for more information.

If you would like to get additional information on our plan’s performance please call 1-888-620-1919, from Monday through Sunday, from 8:00 a.m. to 8:00 p.m. TTY/TDD 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 covered services and for prescription drugs obtained at network pharmacies. You must not use your red, white, and blue Medicare card to get covered medical services (except for routine clinical research studies and hospice services). Keep your Medicare card in a safe place in case you need it later. If you obtain 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 out of pocket.

If your plan membership card is damaged, lost, or stolen, call our Customer Service Center immediately, and we will send you a new card.

Frente
Atás

Last update: 10/11/2017

Get in touch with our experts:

Sales Representative

1-877-207-8777

TTY/TDD Users

Monday through Friday
from 8:00 a.m. to 8:00 p.m.

I want to know more about this product.

By completing this form, you as a beneficiary or authorized representative agree to have one of our sales representatives contact you to discuss the products Triple-S Advantage offers under Part C. Please be aware that the person calling you is a Medicare employee or subcontractor. They do not work directly with the federal government. This person could receive compensation based on your plan enrollment.

This selection does NOT obligate you to enroll in a plan, it does not affect your current membership, and it will not enroll you in another Medicare plan.

Get to Know Medicare

Member Service

1-888-620-1919

TTY/TDD users

1-866-620-2520

Monday thru Sunday, from 8:00 am to 8:00 pm

Service for Providers

1-855-886-7474

Monday thru Friday, from 8:00 am to 5:00 pm

Teleconsulta

1-800-255-4375

Teleconsejo

1-877-879-5964

Your opinion is important to us

We want to improve and provide you with a better service, so we would like to learn more about your experience on our website and get your feedback.

How was your overall experience in the website?

How would you rate the look (appearance) of this website?

How clear was the information provided?

How easy to use was the website?

Suggestions/Feedback:

loader