** 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. |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$6 700 out-of-pocket limit for Medicare-covered services. |
$10 000 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Extra Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |
$0 copay for transportation. |
** 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. |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$6 700 out-of-pocket limit for Medicare-covered services. |
$10 000 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
$55 copay for each Medicare-covered hospital stay |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
20% of the cost for each hospital stay. |
Inpatient Mental Health Care |
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
$55 copay for each Medicare-covered hospital stay. |
20% of the cost for each hospital stay. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
$0 copay for SNF services |
20% of the cost for each SNF stay. |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits |
20% of the cost 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 |
$7 copay for each Medicare-covered primary care doctor visit. |
$12 to $17 copay for each Medicare-covered specialist visit. |
20% of the cost for each Medicare-covered primary care doctor visit |
20% of the cost for each Medicare-covered specialist visit |
Chiropractic Services |
$12 copay for each Medicare-covered chiropractic 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. |
25% of the cost for Medicare-covered chiropractic visits. |
Podiatry Services |
$12 copay for each Medicare-covered podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
25% of the cost for Medicare-covered podiatry visits |
Outpatient Mental Health Care |
$12 copay for each Medicare-covered individual therapy visit |
$12 copay for each Medicare-covered group therapy visit |
$12 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$12 copay for each Medicare-covered group therapy visit with a psychiatrist |
$0 copay for Medicare-covered partial hospitalization program services |
20% of the cost for Medicare-covered Mental Health visits with a psychiatrist |
25% of the cost for Medicare-covered Mental Health visits |
20% of the cost for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
$15 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$15 copay for Medicare-covered group substance abuse outpatient treatment visits |
25% of the cost Medicare-covered substance abuse outpatient treatment visits |
Outpatient Services |
Authorization rules may apply. |
$55 copay for each Medicare-covered ambulatory surgical center visit |
$55 copay for each Medicare-covered outpatient hospital facility visit |
20% of the cost for Medicare-covered outpatient hospital facility visits |
20% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
20% of the cost for Medicare-covered ambulance benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits |
Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit. |
Urgently Needed Care |
$50 copay for Medicare-covered urgently-needed-care visits |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
15% of the cost for Medicare-covered Occupational Therapy visits |
15% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
25% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits |
25% of the cost for Medicare-covered Occupational Therapy visits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
15% of the cost for Medicare-covered durable medical equipment |
20% of the cost for Medicare-covered durable medical equipment |
Prosthetic Devices |
Authorization rules may apply. |
15% of the cost for Medicare-covered prosthetic devices |
20% of the cost for Medicare-covered prosthetic devices. |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Medicare-covered Diabetes self-management training |
$0 copay for Medicare-covered: |
- Diabetes monitoring supplies
|
Therapeutic shoes or inserts |
25% of the cost for Medicare-covered Diabetes self-management training |
20% of the cost for Medicare-covered Diabetes monitoring supplies |
20% of the cost for Medicare-covered Therapeutic shoes or inserts |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
15% of the cost for Medicare-covered lab services |
15% of the cost for Medicare-covered diagnostic procedures and tests |
15% of the cost for Medicare-covered X-rays |
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
15% of the cost for Medicare-covered therapeutic radiology services |
20% of the cost for Medicare-covered therapeutic radiology services |
20% of the cost for Medicare-covered outpatient X-rays |
20% of the cost for Medicare-covered diagnostic radiology services |
20% of the cost for Medicare-covered diagnostic procedures tests and lab services |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$25 copay for Medicare-covered Cardiac Rehabilitation Services |
$25 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$5 to $25 copay for Medicare-covered Pulmonary Rehabilitation Services |
25% of the cost for Medicare-covered Cardiac Rehabilitation Services |
25% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services |
25% of the cost 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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. |
The plan covers the following supplemental education/wellness programs: |
|
Nutritional Education |
Additional Smoking and Tobacco Use Cessation Visits |
Nursing Hotline |
$0 copay for Telemonitoring (including cuff coverage). Contact plan for details. |
$0 copay for Enhanced Disease Management. Contact plan for details. |
20% of the cost for Medicare-covered preventive services |
$0 copay for supplemental education/wellness programs |
25% of the cost for Telemonitoring (including cuff coverage) |
25% of the cost for Enhanced Disease Management |
Kidney Disease and Conditions |
$0 copay for Medicare-covered renal dialysis |
$0 copay for Medicare-covered kidney disease education services |
$0 copay for Medicare-covered kidney disease education services |
$0 copay for Medicare-covered renal dialysis |
Outpatient Prescription Drugs |
$25 copay for Medicare Part B chemotherapy drugs and other Part B drugs. |
20% of the cost for Medicare Part B drugs out-of-network. |
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.
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and a Part D 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 Basic (PPO) 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. |
$325 annual deductible. |
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 970. |
You can get drugs the following way(s): |
- one-month (30-day) supply
|
three-month (90-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 of generic drugs
|
31-day supply of brand drugs. |
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. |
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. |
After your total yearly drug costs reach $2 970 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 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750. |
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of: - 5% coinsurance or
- $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
|
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 Basic (PPO). |
You can get out-of-network drugs the following way: |
- one-month (30-day) supply
|
After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 970. |
You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). |
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share which is the greater of: - 5% coinsurance or
- $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
|
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits |
In general preventive dental benefits (such as cleaning) not covered. |
25% of the cost for Medicare-covered comprehensive dental benefits |
Hearing Services |
In general supplemental routine hearing exams and hearing aids not covered. |
$0 copay for Medicare-covered diagnostic hearing exams |
20% of the cost for Medicare-covered diagnostic hearing exams. |
** Additional Benefits ** |
Vision Services |
This plan offers only Medicare-covered eye care and eye wear |
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
|
20% of the cost for Medicare-covered eye exams |
$0 copay for Medicare-covered eye wear |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |
$0 copay for transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
$55 copay for each Medicare-covered hospital stay |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
20% of the cost for each hospital stay. |
** Outpatient Care ** |
Doctor Office Visits |
$7 copay for each Medicare-covered primary care doctor visit. |
$12 to $17 copay for each Medicare-covered specialist visit. |
20% of the cost for each Medicare-covered primary care doctor visit |
20% of the cost for each Medicare-covered specialist visit |
Outpatient Services |
Authorization rules may apply. |
$55 copay for each Medicare-covered ambulatory surgical center visit |
$55 copay for each Medicare-covered outpatient hospital facility visit |
20% of the cost for Medicare-covered outpatient hospital facility visits |
20% of the cost for Medicare-covered ambulatory surgical center visits |
Ambulance Services |
20% of the cost for Medicare-covered ambulance benefits. |
20% of the cost for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
15% of the cost for Medicare-covered durable medical equipment |
20% of the cost for Medicare-covered durable medical equipment |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
15% of the cost for Medicare-covered lab services |
15% of the cost for Medicare-covered diagnostic procedures and tests |
15% of the cost for Medicare-covered X-rays |
15% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) |
15% of the cost for Medicare-covered therapeutic radiology services |
20% of the cost for Medicare-covered therapeutic radiology services |
20% of the cost for Medicare-covered outpatient X-rays |
20% of the cost for Medicare-covered diagnostic radiology services |
20% of the cost for Medicare-covered diagnostic procedures tests and lab services |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
Transportation benefit available. Contact plan for details. |
$0 copay for transportation. |