When the President, Governor or Secretary of Health and Human Services declares an emergency, disaster or a public health emergency Triple-S Advantage takes the following actions to ensure members can get health care needed. a) Medical Benefits (Part C) i. Allow Part A/B and supplemental Part C plan benefits to be furnished at specified non-contracted facilities (note that Part A/B benefits must, per 42 CFR § 422.204(b) (3), be furnished at Medicare certified facilities). ii. Waive in full, requirements for referrals and prior authorizations where applicable. iii. Temporarily reduce plan-approved out-of-network cost sharing to in-network cost-sharing amounts. b) Pharmacy Benefits (Part D): i. Triple-S Advantage has a process through its Pharmacy Benefit Manger (PBM), to lift “refill-too-soon” edits during a disaster or emergency as long as access to Part D drugs is provided at the point-of-sale and allows an affected enrollee to obtains the maximum extended day supply, if requested and available at the time of refill. Triple-S Advantage may lift other edits as a protection to our members for access to drugs. ii. Triple S Advantage lifts these edits, until the termination of a public health emergency or the end of a declared disaster or emergency. In the case of a public health emergency, it terminates when it no longer exists or upon the expiration of the 90-day period beginning from the initial declaration, whichever occurs first. iii. In the absence of a Presidential major disaster or emergency declaration or a public health emergency, Triple– S Advantage lifts the edits — for instance, in advance of an impending disaster — if they determine it is appropriate to do so to ensure pharmacy access. However, at all times, and especially in disaster and/or public health emergency situations, Triple – S Advantage ensures, that their enrollees have adequate access to covered Part D drugs dispensed at out-of-network pharmacies when those enrollees cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy, and when such access is not routine. c) These actions remains in effect until: i. Triple – S Advantage pay particular attention to the closure of disaster incident periods listed in the Disaster Federal Register Notice section on Federal Emergency Management Agency’s (FEMA’s Web site http://www.fema.gov/news/disasters.fema) noting that in circumstances in which the incident period has not officially closed 30 days from the initial Presidential declaration. ii. If, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, Triple-S Advantage should resume normal operations 30 days from the initial declaration. Triple-S Advantage not being able to resume normal operations after 30 days should notify CMS and ASES. d) Contact Information: i. Members may contact Triple-S Advantage at: Call Center: 1-888-620-1919 (Monday to Sunday de 8:00 a.m. – 8:00 pm) TTY : 1-866-620-2520 Teleconsulta (Health helpline available 24 hours a day, 7 days a week). Your calls to Teleconsulta are toll-free, and you may call from anywhere in Puerto Rico or the United States. The number appears on the back of your Triple-S Advantage plan membership card. Remember to always have your plan membership card at hand when you call Teleconsulta. Teleconsulta nursing professionals will be happy to answer all your health-related questions. If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
