Contigo Plus (HMO C-SNP)

H5774 - 022 - 0
4.5 out of 5 stars (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) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

8am – 11pm EST. 7 days a week

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
Please Note:
  • 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 DLIS 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.

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.

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.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$3,650 In-network

Optional supplemental benefits

No

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network Yes, contact plan for further details

Outpatient hospital coverage

$25 copay per visit (Authorization is required.) (Referral is not required.)

Doctor visits

Primary$0 copay (Not applicable.) (Not applicable.)
Specialist$0-3 copay per visit (Authorization is required.) (Referral is not required.)

Preventive care

$0 copay (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$50 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$0 copay (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures0-15% coinsurance (Authorization is required.) (Referral is not required.)
Lab services0-15% 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

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.)

Preventive dental

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.)

Comprehensive dental

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.)

Vision

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.)

Rehabilitation services

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.)

Ground ambulance

$0 copay (Not applicable.) (Not applicable.)

Transportation

$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Foot care (podiatry services)

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.)

Medical equipment/supplies

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.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

Chemotherapy0-10% coinsurance (Authorization is required.) (Not applicable.)
Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

Tier 1
$0 copay per stay
Tier 2
$50 per stay (Authorization is not required.) (Referral is not required.)

Mental health services

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.)

Skilled Nursing Facility

$0 copay (Authorization is required.) (Referral is not required.)

Ready to sign up for Contigo Plus (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

8am – 11pm EST. 7 days a week

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