2011 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Adjuntas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Aguada | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Aguadilla | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Aguas Buenas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Aibonito | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Anasco | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Arecibo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Arroyo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Barceloneta | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Barranquitas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Bayamon | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Cabo Rojo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Caguas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Camuy | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Canovanas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Carolina | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Catano | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Cayey | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Ceiba | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Ciales | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Cidra | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Coamo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Comerio | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Corozal | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Culebra | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Dorado | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Fajardo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Florida | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Guanica | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Guayama | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Guayanilla | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Guaynabo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Gurabo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Hatillo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Hormigueros | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Humacao | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Isabela | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Jayuya | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Juana Diaz | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Juncos | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Lajas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Lares | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Las Marias | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Las Piedras | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Loiza | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Luquillo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Manati | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Maricao | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Maunabo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Mayaguez | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Moca | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Morovis | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Naguabo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Naranjito | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Orocovis | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Patillas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Penuelas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Ponce | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Quebradillas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Rincon | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Rio Grande | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Sabana Grande | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Salinas | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
San German | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
San Juan | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
San Lorenzo | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
San Sebastian | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Santa Isabel | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Toa Alta | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Toa Baja | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Trujillo Alto | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Utuado | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Vega Alta | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Vega Baja | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Vieques | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Villalba | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Yabucoa | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) in PR - H4005-004-0 Benefit Details |
Yauco | $24.00 | $0 | Many Generics | Generic Drugs: $5.00 Preferred Brand Drugs: $25.00 Brand Drugs: $45.00 Non-Preferred Brand Drugs: 25% Specialty Tier Drugs: 25% | $6,700 Browse Formulary | |||||
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