Óptimo Plus (PPO)
Available to residents of Salinas County, PR for 2027. Contract H4005, plan 004, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Salinas County
- Plan website
- Browse the Óptimo Plus (PPO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every PR plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $7,151.00? |
| In- and out-of-network out-of-pocket maximum | $10,000.00 |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | PPO? |
| Contract / plan | H4005-004-0 |
| Offered by | Triple-S Advantage |
| Parent organization | Guidewell Mutual Holding Corporation |
| Formulary tiers | 6 |
| Formulary exception tier | 4? |
| Pharmacy search | www.sssadvantage.com |
| Member services | (833)221-2234TTY (866)620-2520 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H4005 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | 50% coinsurance |
| Specialist | $0–$5 copay(authorization required) | 50% coinsurance |
| Other health care professional | $0–$5 copay(authorization required) | 50% coinsurance |
| Additional telehealth services | $0–$5 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | Not covered | — |
| Kidney disease education | $0 copay | 50% coinsurance |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | 50% coinsurance |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | 0%–10% coinsurance(authorization required) | 50% coinsurance |
| Lab services | 0%–10% coinsurance(authorization required) | 50% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$100 copay(authorization required) | 50% coinsurance |
| Therapeutic radiology | 0%–10% coinsurance(authorization required) | 50% coinsurance |
| Outpatient x-rays | 0%–10% coinsurance(authorization required) | 50% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $50 copay | — |
| Urgent care | $0 copay | — |
| Worldwide emergency coverage | $0 copay · $75 plan limit | — |
| Worldwide urgent care | $0 copay · $75 plan limit | — |
| Worldwide emergency transportation | Not covered | — |
| Hospital care | ||
| Inpatient hospital stay | $0 per stay; varies by hospital tier(authorization required) | 50% coinsurance per stay |
| Outpatient hospital services | $35 copay(authorization required) | 50% coinsurance |
| Outpatient observation | $35 copay(authorization required) | 50% coinsurance |
| Ambulatory surgical center | $35 copay(authorization required) | 50% coinsurance |
| Outpatient blood services | $0 copay | 50% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | $0 per stay(authorization required) | 50% coinsurance per stay |
| Home health care | $0 copay(authorization required) | 50% coinsurance |
| Kidney dialysis | 20% coinsurance | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $5 copay(authorization required) | 50% coinsurance |
| Physical therapy and speech-language therapy | $5 copay(authorization required) | 50% coinsurance |
| Cardiac rehabilitation | $0 copay(authorization required) | 50% coinsurance |
| Pulmonary rehabilitation | $0 copay(authorization required) | 50% coinsurance |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $25 per stay | 50% coinsurance per stay |
| Outpatient mental health, individual session | $0 copay | 50% coinsurance |
| Outpatient mental health, group session | $0 copay | 50% coinsurance |
| Psychiatrist, individual session | $0 copay | 50% coinsurance |
| Psychiatrist, group session | $0 copay | 50% coinsurance |
| Partial hospitalization | $0 copay(authorization required) | 50% coinsurance |
| Intensive outpatient program | $0 copay(authorization required) | 50% coinsurance |
| Outpatient substance use, individual session | $0 copay | 50% coinsurance |
| Outpatient substance use, group session | $0 copay | 50% coinsurance |
| Opioid treatment program | $0 copay | 50% coinsurance |
| Ambulance and transportation | ||
| Ground ambulance | $0 copay(authorization required) | 20% coinsurance |
| Air ambulance | $0 copay(authorization required) | 20% coinsurance |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 10% coinsurance(authorization required) | 50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 0%–10% coinsurance(authorization required) | 50% coinsurance |
| Medical supplies | 10% coinsurance(authorization required) | 50% coinsurance |
| Diabetes supplies | $0 copay(authorization required) | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) | 50% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $0–$5 copay | 50% coinsurance |
| Routine chiropractic care | $0–$5 copay(limits apply) | 50% coinsurance |
| Acupuncture | $5 copay | 50% coinsurance |
| Foot exams and treatment (Medicare-covered) | $0–$5 copay | 50% coinsurance |
| Routine foot care | $0–$5 copay(limits apply) | 50% coinsurance |
| Dental? | ||
| Medicare-covered dental services | $0 copay(authorization required) | 50% coinsurance |
| Oral exams | $0 copay(limits apply) | 50% coinsurance |
| Cleanings | $0 copay(limits apply) | 50% coinsurance |
| Fluoride treatment | $0 copay(limits apply) | 50% coinsurance |
| Dental x-rays | $0 copay(limits apply) | 50% coinsurance |
| Other diagnostic dental services | $0 copay(limits apply) | 50% coinsurance |
| Other preventive dental services | $0 copay(limits apply) | 50% coinsurance |
| Comprehensive dental plan limit | $1,000 plan limit every year | — |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | $0 copay(authorization required, limits apply) | 50% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0 copay | 50% coinsurance |
| Routine eye exam | $0 copay(limits apply) | 50% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | 50% coinsurance |
| Eyewear plan limit | $200 plan limit every year | — |
| Contact lenses | $0 copay(limits apply) | 50% coinsurance |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | 50% coinsurance |
| Eyeglass lenses | $0 copay(limits apply) | 50% coinsurance |
| Eyeglass frames | $0 copay(limits apply) | 50% coinsurance |
| Eyewear upgrades | $0 copay(limits apply) | 50% coinsurance |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $0 copay | 50% coinsurance |
| Routine hearing exam | $0 copay(limits apply) | 50% coinsurance |
| Hearing aid fitting and evaluation | $0 copay(limits apply) | 50% coinsurance |
| Hearing aid plan limit | $200 plan limit every three years | — |
| Hearing aids (all types) | $0 copay(limits apply) | 50% coinsurance |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | $0 copay(authorization required, step therapy may apply) | 50% coinsurance |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 50% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | Covered (allowance not stated) | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay(limits apply) | $0 copay |
| Health education | $0 copay(limits apply) | $0 copay |
| Nutritional / dietary benefit | $0 copay(limits apply) | $0 copay |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | $0 copay(limits apply) | $0 copay |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | $0 copay(limits apply) | $0 copay |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | $0 copay(limits apply) | $0 copay |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | Not covered | — |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | $5 copay(limits apply) | 50% coinsurance |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $0.00 |
| Tier 3 · Preferred Brand | $30.00 |
| Tier 4 · Non-Preferred Brand | $50.00 |
| Tier 5 · Specialty Tier | 33% |
| Tier 6 · Select Care Drugs | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $30.00 | $30.00 | n/a | $60.00 | $60.00 | $60.00 |
| Tier 4: Non-Preferred Brand | $50.00 | $50.00 | n/a | $100.00 | $100.00 | $100.00 |
| Tier 5: Specialty Tier | 33% | 33% | n/a | 33% | 33% | 33% |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 4 out of 5 stars for Breast Cancer Screening | 4 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 4 out of 5 stars for Colorectal Cancer Screening | 4 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 3 out of 5 stars for Annual Flu Vaccine | 1 out of 5 stars for Annual Flu Vaccine |
| Improving or Maintaining Physical Health · C04 | 3 out of 5 stars for Improving or Maintaining Physical Health | 4 out of 5 stars for Improving or Maintaining Physical Health |
| Improving or Maintaining Mental Health · C05 | 5 out of 5 stars for Improving or Maintaining Mental Health | 3 out of 5 stars for Improving or Maintaining Mental Health |
| Monitoring Physical Activity · C06 | 5 out of 5 stars for Monitoring Physical Activity | 4 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Diabetes Care – Eye Exam · C11 | 5 out of 5 stars for Diabetes Care – Eye Exam | 5 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 4 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 4 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 3 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 5 out of 5 stars for Controlling High Blood Pressure | 5 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 3 out of 5 stars for Reducing the Risk of Falling | 4 out of 5 stars for Reducing the Risk of Falling |
| Improving Bladder Control · C16 | 5 out of 5 stars for Improving Bladder Control | 3 out of 5 stars for Improving Bladder Control |
| Plan All-Cause Readmissions · C17 | 2 out of 5 stars for Plan All-Cause Readmissions | 2 out of 5 stars for Plan All-Cause Readmissions |
| Statin Therapy for Patients with Cardiovascular Disease · C18 | 3 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease | 3 out of 5 stars for Statin Therapy for Patients with Cardiovascular Disease |
| Transitions of Care · C19 | 3 out of 5 stars for Transitions of Care | 2 out of 5 stars for Transitions of Care |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 2 out of 5 stars for Getting Needed Care | 2 out of 5 stars for Getting Needed Care |
| Getting Appointments and Care Quickly · C22 | 2 out of 5 stars for Getting Appointments and Care Quickly | 1 out of 5 stars for Getting Appointments and Care Quickly |
| Customer Service · C23 | 4 out of 5 stars for Customer Service | 3 out of 5 stars for Customer Service |
| Rating of Health Care Quality · C24 | 5 out of 5 stars for Rating of Health Care Quality | 5 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 5 out of 5 stars for Rating of Health Plan | 5 out of 5 stars for Rating of Health Plan |
| Care Coordination · C26 | 3 out of 5 stars for Care Coordination | 2 out of 5 stars for Care Coordination |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 5 out of 5 stars for Complaints about the Health Plan | 5 out of 5 stars for Complaints about the Health Plan |
| Members Choosing to Leave the Plan · C28 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | 5 out of 5 stars for Health Plan Quality Improvement | 3 out of 5 stars for Health Plan Quality Improvement |
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 5 out of 5 stars for Complaints about the Drug Plan | 5 out of 5 stars for Complaints about the Drug Plan |
| Members Choosing to Leave the Plan · D03 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | 4 out of 5 stars for Drug Plan Quality Improvement | 3 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 5 out of 5 stars for Rating of Drug Plan | 5 out of 5 stars for Rating of Drug Plan |
| Getting Needed Prescription Drugs · D06 | 4 out of 5 stars for Getting Needed Prescription Drugs | 5 out of 5 stars for Getting Needed Prescription Drugs |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 5 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 3 out of 5 stars for Medication Adherence for Diabetes Medications | 3 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 3 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 3 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 4 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4005 shares it.
Also available in 77 other PR counties
- Adjuntas
- Aguada
- Aguadilla
- Aguas Buenas
- Aibonito
- Anasco
- Arecibo
- Arroyo
- Barceloneta
- Barranquitas
- Bayamon
- Cabo Rojo
- Caguas
- Camuy
- Canovanas
- Carolina
- Catano
- Cayey
- Ceiba
- Ciales
- Cidra
- Coamo
- Comerio
- Corozal
- Culebra
- Dorado
- Fajardo
- Florida
- Guanica
- Guayama
- Guayanilla
- Guaynabo
- Gurabo
- Hatillo
- Hormigueros
- Humacao
- Isabela
- Jayuya
- Juana Diaz
- Juncos
- Lajas
- Lares
- Las Marias
- Las Piedras
- Loiza
- Luquillo
- Manati
- Maricao
- Maunabo
- Mayaguez
- Moca
- Morovis
- Naguabo
- Naranjito
- Orocovis
- Patillas
- Penuelas
- Ponce
- Quebradillas
- Rincon
Benefits in plain text
Óptimo Plus (PPO) (H4005-004-0) is a 2027 PPO Medicare Advantage plan offered by Triple-S Advantage, available to residents of Salinas County, PR.
The monthly premium is $0.00.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $7,151.00.
The combined in- and out-of-network out-of-pocket maximum is $10,000.00.
The drug deductible is $0.00.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $0.00; tier 3 (Preferred Brand): $30.00; tier 4 (Non-Preferred Brand): $50.00; tier 5 (Specialty Tier): 33%; tier 6 (Select Care Drugs): $0.00.
CMS gives the plan's contract (H4005) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.