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ELA Royal Plus (HMO-POS)

Are you a retiree from the Commonwealth of Puerto Rico (also known as ELA)?

This plan is designed for ELA retirees and their dependents. It provides Original Medicare Part A and Part B Benefits with a Part D prescription drug coverage without the need for referrals.

With this plan, you are free to visit all doctors and hospitals in the Triple-S Advantage provider network and the BlueCross BlueShield Network in the United States. You have access to the complete Triple-S Advantage network of doctors, hospitals, pharmacies without referrals. Also as part of your benefits, it offers you a Point of Service (POS) option – which allows you to visit out-of-network providers, as well as a reduction in the monthly Medicare Part B premium. In addition, it offers a drug coverage with co-payments accessible to you.
Our drug coverage provides a wide variety of brand-name and generic drugs. It also offers supplemental benefits such as coverage for eyeglasses and hearing aids.

Who is eligible for this plan?

  • Beneficiaries with Medicare Parts A and B
  • ELA retirees or an eligible dependent. The ELA retiree should receive an employer contribution from the ELA Central Retirement System or from the Teachers’ Retirement System.
  • 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:

  • $0 Monthly Premium (after a $100 employer contribution) (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
  • Prescription Drug Coverage
  • $1,500 Comprehensive Dental Benefit
  • $500 annually for a pair of prescription eyeglasses (frame and lenses) or contact lenses
  • $1,500 for Hearing Aids
  • Acupuncture and Alternative Therapies Benefit, up to 12 visits per year
  • Blood Pressure Monitor
  • Non-Emergency Transportation
  • Health and Wellness Program
  • $25 monthly for Gym
  • Teleconsulta and Teleconsejo Service

This information is not a complete description of benefits. Call: 1-888-620-1919 (TTY 1-866-620-2520) for more information. 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 SUMMARY OF BENEFITS

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 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

ELA Royal (HMO) to ELA Royal Plus (HMO-POS)

The information in this document tells you about the differences between your current benefits in ELA Royal (HMO) and the benefits you will have on January 1, 2019 as a member of ELA Royal Plus (HMO-POS).

If you do nothing to change your Medicare coverage, we will automatically enroll you in our ELA Royal Plus (HMO-POS). This means starting January 1, 2019, you will be getting your medical and prescription drug coverage through ELA Royal Plus (HMO-POS). If you want to, you can change to a different Medicare health plan. You can also switch to Original Medicare.

DOWNLOAD ELA Royal (HMO) to ELA Royal Plus (HMO-POS)
Provider and Pharmacy Directory 2019

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 PROVIDER DIRECTORY

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

DOWNLOAD PRIOR AUTORIZATION 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, from 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

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.

DOWNLOAD LIST OF DURABLE MEDICAL EQUIPMENT

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 STAR RATING MEDICARE

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: 07/17/2019



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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