Are you looking for a more complete health plan with prescription drug coverage?
Royal (HMO) gives you access to the full Triple-S Advantage network for doctors, hospitals, pharmacies, and other providers. If you take prescription drugs on a monthly basis, Royal (HMO) offers you drug coverage with affordable copayments.
Who is eligible for this plan?
- Beneficiaries with Medicare Parts A and B
- 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.
- $0 Monthly Premium (You must continue to pay your Medicare Part B premium).
- $30 monthly reduction to Medicare Part B premium
- $0 copay for each Hospital Stay *
- $0 copay for each visit to Primary Care Physicians (PCP)
- $5 copay for each visit to Specialists* / $0 Salus Clinic
- 0% coinsurance for Laboratory Tests*
- 0% coinsurance for X-Rays
- 0% coinsurance Durable Medical Equipment*
- $30 every 3 months for Over the Counter Drugs and Items (OTC)
- $0 copay for Preventive Dental Benefit
- $150 annually for a pair of prescription eyeglasses (frame and lenses) or contact lenses
- $0 copay for each Acupuncture Benefit visit, up to 12 visits per year
- Teleconsulta and Teleconsejo Service
- Comprehensive Dental
- $300 every 3 years for Hearing Aid Benefit
*Copay/coinsurance applies for services in the Preferred Provider Network, or preferred brands/manufacturers.
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
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
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
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
PROVIDER AND PHARMACY DIRECTORY 2019
A 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
A 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
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
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
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
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 AUTHORIZATION 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
This 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
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 Customer Service Center immediately, and we will send you a new card.
Last update: 07/17/2019