Óptimo Xtra (PPO)

Why choose Óptimo Xtra (PPO)?

A 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.

  • $30 monthly premium
  • $0 copay in: Specialists*, Prescription drugs**
  • $300 per year in OTC items and drugs
  • $3,250 per year (includes individual implants)
  • $400 per year
  • 24 trips per year to medical destinations
  • Erectile dysfunction drugs

To compare this and other plans click here

Who is eligible 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. 

*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.

DOWNLOAD SUMMARY OF BENEFITS

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.

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 and Pharmacy Directory 2024

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

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.

DOWNLOAD PHARMACY DIRECTORY

Drugs and OTC

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.

DOWNLOAD DRUG FORMULARY

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 2/1/2024

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.

DOWNLOAD PRIOR AUTHORIZATION CRITERIA

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.

DOWNLOAD STEP THERAPY CRITERIA

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

I wish to receive information about the coverage products and services offered by Triple-S Advantage

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By completing this form, you agree to a meeting with a sales agent to discuss the types of products you check above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

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.

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Last update: 10/15/2024