Óptimo Xtra (PPO)

Why choose Óptimo Xtra (PPO)?

A new coverage with free access to visit providers inside and outside of network in Puerto Rico and United States, without referrals. Optimo Xtra (PPO) offers low copays to take care of your health, savings and supplemental benefits like eyeglasses, dental procedures, among others.

  • $40 monthly premium
  • $0 copay in: Specialists*, Prescription drugs**
  • $300 per year in OTC items
  • $3,250 per year (includes individual implants)
  • $400 per year
  • 24 trips to medical destinations

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. 

Some benefits of this plan:

  • $40 Monthly Premium
  • $0 Hospital Stay
  • $0 Primary Care Physicians (PCP)
  • $0 Specialists*
  • $0 Laboratory 
  • $0 Covered Prescription Drugs**
  • Preventive Dental Benefit 
  • $3,000 annually for Comprehensive Dental Benefit
  • $75 every 3 months for OTC WITHOUT MEDICAL ORDER
  • $400 annually for prescription eyeglasses or contact lenses
  • $1,000 annually for hearing aids
  • 24 one-way trips to plan approved locations
  • 12 supplemental nutritionist visits
  • Erectile dysfunction drugs

*Copay/coinsurance applies to services rendered at SALUS facilities. Other providers are available in our network.

**Applies to the Preferred Pharmacy Network in Tiers 1, 2 & 6.

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.


Evidence of Coverage (EOC)

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.


Provider and Pharmacy 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.


Pharmacy Directory

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.



Drug Formulary

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.


Notice of Changes to Formulary

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.

Effective Changes at 2/1/2023
Effective Changes at 4/1/2023
Effective Changes at 5/1/2023
Effective Changes at 7/1/2023

Prior Authorization Criteria

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.


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


Notice of Medicare Part B Prescription Drugs, Inflation Reduction Act (IRA)

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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