Óptimo Plus (PPO)

H4005 - 004 - 0
4 out of 5 stars (4 / 5)

Óptimo Plus (PPO) is a Medicare Advantage (Part C) Plan by Triple S Advantage.

This page features plan details for 2024 Óptimo Plus (PPO) H4005 – 004 – 0 available in Puerto Rico.

IMPORTANT: This page has been updated with plan and premium data for 2024.

Locations

Óptimo Plus (PPO) is offered in the following locations.

Plan Overview

Óptimo Plus (PPO) offers the following coverage and cost-sharing.

Insurer:Triple S Advantage
Health Plan Deductible:$0.00
MOOP:$10,000 In and Out-of-network
$6,700 In-network
Drugs Covered:Yes
Please Note:
  • Available to current members only.

Ready to sign up for Óptimo Plus (PPO) ?

Get help from a licensed insurance agent.

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

8am – 11pm EST. 7 days a week

Premium Breakdown

Óptimo Plus (PPO) 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 $0.00 $174.70
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

Óptimo Plus (PPO) 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 Alternative
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
$0.00$

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 Alternative benefit type.

Additional Benefits

Óptimo Plus (PPO) 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)

$10,000 In and Out-of-network
$6,700 In-network

Optional supplemental benefits

No

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

In-network No

Outpatient hospital coverage

In-network $35 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network 20% coinsurance per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary20% coinsurance per visit (Not applicable.) (Not applicable.)
In-network Specialist$0-5 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network Specialist20% coinsurance per visit (Authorization is required.) (Referral is not required.)

Preventive care

In-network $0 copay (Authorization is not required.) (Referral is not required.)
out-of-network $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

In-network Diagnostic tests and procedures0-10% coinsurance (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures20% coinsurance (Authorization is required.) (Referral is not required.)
In-network Lab services0-10% coinsurance (Authorization is required.) (Referral is not required.)
out-of-network Lab services20% coinsurance (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$0-25 copay or 0-10% coinsurance (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)20% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays0-10% coinsurance (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays20% coinsurance (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$0 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam20% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fitting/evaluation20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Hearing aids$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Hearing aids$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Oral exam20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Cleaning20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Fluoride treatment$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Fluoride treatment20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Dental x-ray(s)20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Non-routine services25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Diagnostic services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic services25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Restorative services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Restorative services25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Endodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Endodontics25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Periodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Periodontics25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Extractions$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Extractions25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Vision

In-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Routine eye exam20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Other$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Other20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Upgrades$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Upgrades$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Rehabilitation services

In-network Occupational therapy visit$5 copay (Authorization is required.) (Referral is not required.)
out-of-network Occupational therapy visit25% coinsurance (Authorization is required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$5 copay (Authorization is required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit25% coinsurance (Authorization is required.) (Referral is not required.)

Ground ambulance

In-network $0 copay (Not applicable.) (Not applicable.)
out-of-network 20% coinsurance (Not applicable.) (Not applicable.)

Transportation

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

Foot care (podiatry services)

In-network Foot exams and treatment$0-5 copay (Authorization is not required.) (Referral is not required.)
out-of-network Foot exams and treatment25% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Routine foot care$0-5 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)10% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)30% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)0-10% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)30% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies$0 copay (Authorization is not required.) (Not applicable.)
out-of-network Diabetes supplies20% coinsurance per item (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

In-network Chemotherapy0-10% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy20% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs20% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs20% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network Tier 1
$0 copay per stay
Tier 2
$50 per stay (Authorization is not required.) (Referral is not required.)
out-of-network 20% per stay (Authorization is not required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$25 per stay (Authorization is not required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric20% per stay (Authorization is not required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$5 copay (Authorization is not required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist20% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$5 copay (Authorization is not required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist20% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Outpatient group therapy visit$5 copay (Authorization is not required.) (Referral is not required.)
out-of-network Outpatient group therapy visit20% coinsurance (Authorization is not required.) (Referral is not required.)
In-network Outpatient individual therapy visit$5 copay (Authorization is not required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit20% coinsurance (Authorization is not required.) (Referral is not required.)

Skilled Nursing Facility

In-network $0 copay (Authorization is required.) (Referral is not required.)
out-of-network 20% per stay (Authorization is required.) (Referral is not required.)

Ready to sign up for Óptimo Plus (PPO) ?

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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