Contigo Plus (HMO C-SNP)
H5774 - 022 - 0
(4.5 / 5)
Contigo Plus (HMO C-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Triple S Advantage.
This page features plan details for 2024 Contigo Plus (HMO C-SNP) H5774 – 022 – 0 available in Puerto Rico.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Contigo Plus (HMO C-SNP) is offered in the following locations.
Plan Overview
Contigo Plus (HMO C-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Chronic or Disabling Condition |
| Conditions Covered: | Cardiovascular Disorders, Chronic Heart Failure and Diabetes |
| Insurer: | Triple S Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,650 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Contigo Plus (HMO C-SNP) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Contigo Plus (HMO C-SNP) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Contigo Plus (HMO C-SNP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $100.00 | $74.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Contigo Plus (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $0.00 | $0.00 |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $5.00 copay | ||
| 2 (Generic) | $0.00 copay | $8.00 copay | ||
| 3 (Preferred Brand) | $0.00 copay | $20.00 copay | ||
| 4 (Non-Preferred Brand) | $10.00 copay | $55.00 copay | ||
| 5 (Specialty Tier) | 33% | 33% | ||
| 6 (Select Care Drugs) | $0.00 copay | $3.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Brand) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay | $0.00 copay | |
| 2 (Generic) | $0.00 copay | $16.00 copay | $0.00 copay | |
| 3 (Preferred Brand) | $0.00 copay | $40.00 copay | $0.00 copay | |
| 4 (Non-Preferred Brand) | $20.00 copay | $110.00 copay | $20.00 copay | |
| 5 (Specialty Tier) | 33% | 33% | 33% | |
| 6 (Select Care Drugs) | $0.00 copay | $6.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $5.00 copay | ||
| 2 (Generic) | $0.00 copay | $8.00 copay | ||
| 6 (Select Care Drugs) | $0.00 copay | $3.00 copay | ||
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay | $0.00 copay | |
| 2 (Generic) | $0.00 copay | $16.00 copay | $0.00 copay | |
| 6 (Select Care Drugs) | $0.00 copay | $6.00 copay | $0.00 copay | |
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced benefit type.
Additional Benefits
Contigo Plus (HMO C-SNP) also provides the following benefits.
| $0 |
| In-network | No |
| $3,650 In-network |
| No |
| In-network | Yes, contact plan for further details |
| $25 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0-3 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 0-15% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | 0-15% coinsurance (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $0-20 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0-20 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| $0 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 0-10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-10% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| Tier 1 $0 copay per stay Tier 2 $50 per stay (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Contigo Plus (HMO C-SNP) ?
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