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1-866-620-2520

Monday through Sunday, from 8:00 a.m. to 8.00 p.m.

Basic (HMO)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

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

DOWNLOAD EVIDENCE OF COVERAGE

Annual Notice of Change (ANOC)

This document is sent to members every fall to inform you about all the changes to benefits, costs, and providers for the next year. The ANOC helps you compare your current health benefits and costs with those for next year.

DOWNLOAD ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Drugs

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs but does not include all the drugs covered by the plan and some items that assist in your health. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Contigo Plus (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Platino Alcance (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Platino Advance (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Platino Blindao (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Platino Plus (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Platino Ultra (HMO-SNP)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Brillante (HMO-POS)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Magno (HMO-POS)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

Real (HMO)

Important documents for you

Summary of Benefits (SB)

The Summary of Benefits tells you about some of the characteristics of the plan. It does not include all covered services or all limitations or exclusions. For a complete list of benefits, refer to the Evidence of Coverage.

DOWNLOAD SUMMARY OF BENEFITS DOWNLOAD PRE-ENROLLMENT CHECKLIST

Evidence of Coverage (EOC)

The EOC gives you details about your Medicare healthcare 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 EVIDENCE OF COVERAGE

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 ANNUAL NOTICE OF CHANGE FOR REAL (HMO)

 

DOWNLOAD ANNUAL NOTICE OF CHANGE FOR ENLACE (HMO) TO REAL (HMO)

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists information about brands, equipment manufacturers and medical providers in this plan, as described in your Evidence of Coverage.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

Provider and Pharmacy Directory 2022

Provider Directory

This document provides you with a list of all our contracted healthcare providers such as primary care physicians, specialists, hospitals, outpatient facilities among other health professionals. This directory contains contracted providers and preferred network providers.

DOWNLOAD PROVIDER DIRECTORY

Pharmacy Directory

The Pharmacy Directory gives you a complete list of pharmacies in our network, which means that all of these pharmacies have agreed to fill covered prescriptions for members of our plan. This directory contains contracted pharmacies and preferred network pharmacies.

DOWNLOAD PHARMACY DIRECTORY

Drugs

Drug Formulary

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

DOWNLOAD DRUG FORMULARY

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.

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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, Monday through Sunday from 8:00 a.m. to 8:00 p.m. TTY/TDD users should call 1-866-620-2520.

DOWNLOAD STEP THERAPY CRITERIA

Guide for Over-the-Counter (OTC) Drugs and items

This guide includes over-the-counter (OTC) medications and health-related items that do not require a prescription to help treat injuries or illnesses. It contains a list of some commonly used drugs, but does not include all the drugs covered by the plan and some items that assist in your healthcare. This list was selected by a team of health professionals and represents the therapies of medications and non-prescription items that we understand are important to complement your treatment program with prescription drugs.

DOWNLOAD GUIDE FOR OVER-THE-COUNTER (OTC) DRUGS AND ITEMS

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

Dedicated Teleconsulta for TTY/TDD Callers: 711 | 1-855-209-2639

Teleconsejo

1-877-879-5964
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