Home > Our 2019 health plans > Platino Ultra (HMO-SNP) 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 during the Annual Enrollment Period or once every Special Enrollment Period** 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. $50 every 3 months for Over the Counter Drugs and Items (OTC) $375 annually for a pair of prescription eyeglasses (frame and lenses) or contact lenses $500 every 3 years for Hearing Aid Benefit $0 copay for each Acupuncture Benefit visit. Up to 12 visits per year. Teleconsulta and Teleconsejo Service *Copay/coinsurance applies for services in the Preferred Provider Network or preferred brands/manufacturers. **Each Special Enrollment Period occurs from January to March, April to June and From July to September. If you’re in a drug management program, you may not be able to change plans. Some Specialists may require a referral from your primary physician. 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 EVIDENCE OF COVERAGE Provider and Pharmacy Directory 2019 Preferred Provider DirectoryA preferred network provider has agreed to offer your health care coverage at a lower cost-sharing level than other network providers. DOWNLOAD PREFERRED PROVIDER DIRECTORY Preferred Pharmacy DirectoryA preferred network pharmacy offers covered prescription drugs for our plan members at a lower cost-sharing level than other network pharmacies. DOWNLOAD PREFERRED PHARMACY DIRECTORY Provider DirectoryFind 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 DirectoryThe 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 FormularyThe 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 FormularyOur 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. Effective Changes at 2/20/2019 Effective Changes at 3/1/2019 Effective Changes at 10/1/2019 Prior Authorization CriteriaOur 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 AUTHORIZATION CRITERIA Step Therapy CriteriaIn 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 Guide for Over the Counter (OTC) DrugsThis guide includes OTC drugs and health-related items that help treat injuries or illnesses for you. It contains a list of some common-use drugs, but it does not include all drugs covered by the plan. This list has been chosen by a team of health care professionals, and represents the non-prescription therapies believed to be important in supplementing your treatment program with prescription drugs. DOWNLOAD GUIDE FOR OVER THE COUNTER (OTC) DRUGS 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. Front Back I want this Plan Platino Ultra (HMO-SNP) Compare this Plan Platino Ultra (HMO-SNP) Last update: 10/31/2019
