Basic (HMO)

Why choose Basic (HMO)?

For people that have a prescription drugs coverage and look for an additional coverage for your medical care with $0 monthly premium. Basic (HMO), offers special benefits for the chronically ill, with savings and attractive supplemental benefits for dental procedures, eyeglasses, transportation, and OTC.

  • $0 copay in Specialists**, Hospitalization**, laboratories** and X-Rays
  • $1,200 per year in Medicare Part B Premium giveback benefit (BuyDown)
  • $300 per year in the ComboCard®
  • $200 per year in OTC items
  • $2,500 per year in comprehensive dental (including individual implants)
  • $500 per year in eyeglasses and contact lenses

To compare this and other plans click here

Who is elegible for this plan?

  • Beneficiaries with Medicare Parts A and B
  • Residents living in one of Puerto Rico’s 78 municipalities
  • 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. 

*Restrictions apply.

**Copay/coinsurance applies to services in the Preferred Provider Network or services rendered at SALUS facilities. Other providers are available in our network.

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 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 healthcare for the calendar year. It also explains how to get coverage for the services 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, and providers for the next year. The ANOC helps you compare your current health benefits and costs with those for next year.

DOWNLOAD ANNUAL NOTICE OF CHANGE

List of Durable Medical Equipment (DME)

The Durable Medical Equipment (DME) lists 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 Directory 2023

Provider Directory

This document provides you with a list of all our contracted healthcare 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

DRUGS

Guide for Over-the-Counter (OTC) Drugs and items

This 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 healthcare. 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

The benefits you want, the savings you need.

Discover in simple steps, the best option for you

I need more information to choose my plan. Call me!

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.

Last update: 15/10/2022