Platino Ultra (HMO-SNP)

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If you want a plan that offers a wide variety of additional benefits, the Platino Ultra (HMO-SNP) plan is for you. Platino Ultra (HMO-SNP) offers maximum coverage in vision, dental, and hearing aid benefits, and it has no deductible. Platino Ultra (HMO-SNP) is a coordinated service plan that also allows you to select your preferred primary care physician among the hundreds of providers in our network.

Who is eligible for this plan?

  • Beneficiaries with Medicare Parts A and B, who are also eligible for Medicaid coverage
  • 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. You may enroll in this plan at any time of the year.

Some benefits of this plan

  • $0 Monthly Premium (You must continue to pay your Medicare Part B premium).
  • $0 copay for each Hospital Stay
  • $0 copay for each visit to Primary Care Physicians (PCP)
  • $0 copay for each visit to Specialists
  • $0 copay for Laboratory Tests
  • $0 copay for X-Rays
  • 0% coinsurance Durable Medical Equipment
  • $0 copay for covered prescription drugs
  • Preventive Dental Benefit and $1,000 every year for Comprehensive Dental Benefit.
  • Up to one pair of eyewear (frame and lenses) or up to one pair of contact lenses per year from the preferred collection of our contracted provider, or $200 per year for one pair of eyewear (frame and lenses) or one pair of contact lenses from the non-preferred collection of our contracted provider.
  • $500 every 3 years for Hearing Aid Benefit
  • $0 copay for each Acupuncture Benefit visit. Up to 12 visits per year.
  • Teleconsulta Service

*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 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
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 prescription drugs for our plan members at a lower cost-sharing level than other network pharmacies.

Download PDF Document

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.

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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.

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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.

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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

List of Durable Medical Equipment (DME)

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

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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.

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Last update: 10/11/2017

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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

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