Óptimo Plus (PPO)

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.

The EOC gives you details about your Medicare healthcare 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.

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.

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.

The 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.

The Comprehensive Formulary lists all the drugs covered by our plan. These drugs were selected in consultation with a team of healthcare providers and represent the prescription therapies believed to be necessary for a quality treatment program.

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.

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

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