Some benefits of this plan: $10 monthly reduction to Medicare Part B premium $0 Hospital Stay $0 Primary Care Physicians (PCP) $0 Specialists $0 Laboratory Tests and X-Rays $0 Covered Prescription Drugs Preventive Dental Benefit $1,000 every year for Comprehensive Dental Benefit $350 every 3 months for OTC WITHOUT PRESCRIPTION $200 annually for prescription eyeglasses or contact lenses $1,000 every year for Hearing Aids 18 one-way trips to plan approved locations 4 supplemental nutritionist visits 48 hours of In-home support ** Extended Care Package (“La Ñapa”) – a flexible benefit with $0 additional cost in which you can extend your comprehensive dental coverage, or your OTC cover, or eyeglasses / contact lenses, hearing or transportation in accordance with your needs. *** *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. **Benefit eligibility will be based on medical recommendation and meet certain conditions. See Summary of Benefits or Evidence of Coverage for details. ***The Ñapa benefit that you select will be effective from the first day of effectiveness of your enrollment and as long as you are a member of Platino Enlace (HMO-SNP) or until December 31, 2021 and your benefit selection in the enrollment form is final and cannot be changed during the year. 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). Now you can benefit from La Ñapa What is La Ñapa? It is a flexible option with no extra cost that allows you to expand 1 of these 5 benefits in your plan: eyewear, transportation, comprehensive dental, hearing aids or OTC medications. Increase whichever you want, to have a more personalized health plan. Eyewear Option 1 Coverage Amount $200 per year “TU Ñapa” $150 per year Your Benefit can Reach $350 per year Transportation Option 2 Coverage Amount 18 trips per year “TU Ñapa” 18 trips per year Your Benefit can Reach 36 trips per year Comprehensive Dental Option 3 Coverage Amount $1,000 per year “TU Ñapa” $1,500 per year Your Benefit can Reach $2,500 per year Hearing aids Option 4 Coverage Amount $1,000 per year “TU Ñapa” $1,500 per year Your Benefit can Reach $2,500 per year OTC Option 5 Coverage Amount $350 every 3 months “TU Ñapa” $25 every 3 months Your Benefit can Reach $375 every 3 months Your Benefit Coverage Amount “Tu Ñapa” Pick One * Your Benefit can Reach Eyewear Option 1 $200 per year $150 per year $350 per year Transportation Option 2 18 trips per year 18 trips per year 36 trips per year Comprehensive Dental Option 3 $1,000 per year $1,500 per year $2,500 per year Hearing aids Option 4 $1,000 per year $1,500 per year $2,500 per year OTC Option 5 $350 every 3 months $25 every 3 months $375 every 3 months 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 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 List of Durable Medical Equipment (DME)The Durable Medical Equipment (DME) list 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 2021 Provider DirectoryThis document provides you with a list of all our contracted health care 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 DirectoryThe 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 HospiceDOWNLOAD HOSPICE DOCUMENT 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. 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) Drugs and itemsThis 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 care. 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 Compare this Plan Platino Enlace (HMO-SNP) Find the right plan for you! Tell us more about yourself to help us find the best option for you I am undecided. Please call me to provide some guidance. Please fill the required fields: Yes, I wish to receive information about the Medicare Advantage (Part C) coverage products and services offered by Triple-S Advantage. First Name Last Name Mailing Address Personal E-mail Home Phone Cell Phone Current Plan (if apply) Message Medicare Part A Medicare Part B Government Health Plan of Puerto Rico (GHP) ELA * May we contact you? Yes No By completing this form, you as a beneficiary or authorized representative agree to have one of our sales representatives contact you to discuss the products Triple-S Advantage offers under Part C. Please be aware that the person calling you is a Medicare employee or subcontractor. They do not work directly with the federal government. This person could receive compensation based on your plan enrollment. This selection does NOT obligate you to enroll in a plan, it does not affect your current membership, and it will not enroll you in another Medicare plan. CONTACT ME Last update: 15/10/2020