2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Triple-S Medicare Optimo Select (HMO) (HMO) | ||||
Location: | Villalba, Puerto Rico Click to see other locations | ||||
Plan ID: | H4012 - 008 - 0 Click to see other plans | ||||
Member Services: | 1-800-510-0722 TTY users 1-800-383-4457 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Triple-S Medicare Optimo Select (HMO) (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 2,115 drugs | Browse the Triple-S Medicare Optimo Select (HMO) (HMO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | 0% | $5.00 | $15.00 | 25% | |
• Number of Drugs per Tier: | 1209 | 176 | 508 | 222 | |
Plan's Pharmacy Search: | http://www.ssspr.com | ||||
Number of Members enrolled in this plan in (H4012 - 008): | 3,239 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
Referral required for network specialists (for certain benefits). | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
$0 copay for Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.ssspr.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Triple-S Medicare Optimo Select (HMO) (HMO) for certain drugs. | |||||
The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and Triple-S Medicare Optimo Select (HMO) (HMO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
Supplemental drugs don't count toward your out-of-pocket drug costs. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers many formulary generics (65%-99% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Generic Drugs | |||||
Tier 1: Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Triple-S Medicare Optimo Select (HMO) (HMO). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye wear every two years. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
Plan offers additional comprehensive dental benefits. | |||||
$500 plan coverage limit for comprehensive dental benefits every year. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
Referral required for network specialists (for certain benefits). | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
$0 copay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Inpatient Mental Health Care | |||||
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. | |||||
$0 copay | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 120 days each benefit period. | |||||
No prior hospital stay is required. | |||||
$0 copay for SNF services | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$0 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. | |||||
$0 copay for each specialist doctor visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$0 copay for Medicare-covered chiropractic visits. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
$0 copay for Medicare-covered podiatry visits | |||||
routine visits | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
$0 copay for Medicare-covered Mental Health visits. | |||||
Outpatient Substance Abuse Care | |||||
$0 copay for Medicare-covered visits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$0 copay for Medicare-covered emergency room visits. | |||||
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. | |||||
$0 copay for Medicare-covered Occupational Therapy visits. | |||||
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
0% to 20% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
** Additional Benefits ** | |||||
Dialysis | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
Prescription Drugs | |||||
$0 copay for Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.ssspr.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Triple-S Medicare Optimo Select (HMO) (HMO) for certain drugs. | |||||
The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and Triple-S Medicare Optimo Select (HMO) (HMO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
Supplemental drugs don't count toward your out-of-pocket drug costs. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers many formulary generics (65%-99% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Generic Drugs | |||||
Tier 1: Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Triple-S Medicare Optimo Select (HMO) (HMO). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
Plan offers additional comprehensive dental benefits. | |||||
$500 plan coverage limit for comprehensive dental benefits every year. | |||||
Hearing Services | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$0 copay for up to 1 hearing aid(s) every three years. | |||||
$250 plan coverage limit for hearing aids every three years. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye wear every two years. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Health/Wellness Education | |||||
Authorization rules may apply. | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |