** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
Triple-S Salud Inc. will reduce your monthly Medicare Part B premium by up to $ 35.00. |
$6 700 out-of-pocket limit for 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 ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |
** Important Information ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
Triple-S Salud Inc. will reduce your monthly Medicare Part B premium by up to $ 35.00. |
$6 700 out-of-pocket limit for 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 |
No limit to the number of days covered by the plan each hospital stay. |
$0 or $3 copay for each Medicare-covered hospital stay* |
$0 copay for additional hospital days |
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 or $3 copay for each Medicare-covered hospital stay* |
$0 copay for additional hospital days |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 120 days each benefit period |
No prior hospital stay is required. |
$0 or $3 copay for each Medicare-covered SNF stay.* |
$0 copay for additional SNF days |
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. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
Authorization rules may apply. |
$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 or $0 to $1 copay for each specialist visit for Medicare-covered benefits.* |
Chiropractic Services |
$0 or $1 copay for each Medicare-covered visit* |
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 benefits.* |
supplemental routine visits |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 or $1 copay for each Medicare-covered individual therapy visit* |
$0 or $1 copay for each Medicare-covered group therapy visit* |
$0 or $1 copay for each Medicare-covered individual therapy visit with a psychiatrist* |
$0 or $1 copay for each Medicare-covered group therapy visit with a psychiatrist* |
$0 or $1 copay for Medicare-covered partial hospitalization program services* |
Outpatient Substance Abuse Care |
$0 or $1 copay forMedicare-covered individual therapy visits* |
$0 or $1 copay forMedicare-covered group visits* |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 or $1 copay for each Medicare-covered ambulatory surgical center visit* |
$0 or $1 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
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. |
Urgently Needed Care |
$0 copay for Medicare-covered urgently-needed-care visits* |
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 or $1 copay for Medicare-covered Occupational Therapy visits* |
$0 or $1 for Medicare-covered Physical and/or Speech and Language Therapy visits* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 0% to 15% of the cost for Medicare-covered items* |
Prosthetic Devices |
Authorization rules may apply. |
0% or 10% of the cost for Medicare-covered items* |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-management training* |
0% or 0% to 20% of the cost for Diabetes monitoring supplies* |
0% or 0% to 20% of the cost for Therapeutic shoes or inserts* |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered lab services* |
$0 or $3 copay for Medicare-covered diagnostic procedures and tests* |
$0 or $3 copay for Medicare-covered X-rays* |
$0 or $3 copay for Medicare-covered diagnostic radiology services(not including X-rays)* |
$0 or $3 copay for Medicare-covered therapeutic radiology services* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$0 or $1 copay for Medicare-covered Cardiac Rehabilitation Services* |
$0 or $1 copay for Medicare-covered Intensive Cardiac Rehabilitation Services* |
$0 or $1 copay for Medicare-covered Pulmonary Rehabilitation Services* |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
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. Please contact plan for details. |
Authorization rules may apply. |
The plan covers the following supplemental education/wellness programs: |
Written health education materials including Newsletters |
Additional Smoking Cessation |
Nursing Hotline |
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for renal dialysis* |
$0 copay for kidney disease education services* |
Outpatient Prescription Drugs |
$0 copay for Part B-covered drugs. |
$0 annual deductible for Part B-covered drugs.* |
$0 copay for Part B covered chemotherapy drugs and other 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 have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers. |
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 you the plan and Medicare. |
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 Selecto with Medicare Platino 2 (HMO SNP) 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. |
In 2012 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) $0 for prescription drugs Deductible Level 1 (Low Income Threshold 51% - 100%) $0.50 for prescription drugs |
You can get drugs the following way(s): |
one-month (30-day) supply |
three-month (90-day) supply |
15-day supply |
Not all drugs are available at this extended day supply. Please contact the plan for more information. |
You can get drugs the following way(s): |
one-month (31-day) supply |
You can get drugs the following way(s): |
three-month (90-day) supply |
Not all drugs are available at this extended day supply. Please contact the plan for more information. |
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 Selecto with Medicare Platino 2 (HMO SNP). |
You can get drugs the following way: |
one-month (30-day) supply |
Dental Services |
Authorization rules may apply. |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 fluoride treatment(s) every six months |
up to 1 dental x-ray(s) every year |
$0 or $1 copay for Medicare-covered dental benefits* |
Plan offers additional comprehensive dental benefits. |
$500 plan coverage limit for comprehensive dental benefits every year |
Hearing Services |
Hearing aids not covered. |
$0 copay for Medicare-covered diagnostic hearing exams* |
$1 copay for up to 1 supplemental routine hearing exam(s) every year |
** Additional Benefits ** |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery * |
up to 1 pair(s) of glasses every two years |
up to 1 pair(s) of contacts every two years |
$0 copay for exams to diagnose and treat diseases and conditions of the eye.* |
$1 copay for up to 1 supplemental routine eye exam(s) every year |
$50 plan coverage limit for eye wear every two years. |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
No limit to the number of days covered by the plan each hospital stay. |
$0 or $3 copay for each Medicare-covered hospital stay* |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
** Outpatient Care ** |
Doctor Office Visits |
Authorization rules may apply. |
$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 or $0 to $1 copay for each specialist visit for Medicare-covered benefits.* |
Outpatient Services/Surgery |
Authorization rules may apply. |
$0 or $1 copay for each Medicare-covered ambulatory surgical center visit* |
$0 or $1 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 0% to 15% of the cost for Medicare-covered items* |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
$0 copay for Medicare-covered lab services* |
$0 or $3 copay for Medicare-covered diagnostic procedures and tests* |
$0 or $3 copay for Medicare-covered X-rays* |
$0 or $3 copay for Medicare-covered diagnostic radiology services(not including X-rays)* |
$0 or $3 copay for Medicare-covered therapeutic radiology services* |
** Additional Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |