Óptimo (PPO) is a Medicare Advantage Plan by Triple S Advantage.
This page features plan details for 2024 Óptimo (PPO) H4005 – 001 – 0 available in Puerto Rico.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Óptimo (PPO) is offered in the following locations.
Óptimo (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: | No |
Ready to sign up for Óptimo (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Óptimo (PPO) qualifies for a monthly Medicare Give Back Benefit of $75.00.
Premium Reduction: | $75.00 |
Part B | Part C | Part B Give Back | Total |
---|---|---|---|
$174.70 | $0.00 | $75.00 | $ |
Óptimo (PPO) also provides the following benefits.
$0 |
In-network | No |
$10,000 In and Out-of-network $6,700 In-network |
No |
In-network | No |
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.) |
In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
out-of-network Primary | 20% coinsurance per visit (Not applicable.) (Not applicable.) |
In-network Specialist | $0-10 copay per visit (Authorization is required.) (Referral is not required.) |
out-of-network Specialist | 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
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 | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
Urgent care | $10 copay per visit (always covered) (Not applicable.) (Not applicable.) |
In-network Diagnostic tests and procedures | $0-5 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
In-network Lab services | $0-5 copay (Authorization is required.) (Referral is not required.) |
out-of-network Lab services | 20% coinsurance (Authorization is required.) (Referral is not required.) |
In-network Diagnostic radiology services (e.g., MRI) | $0-25 copay (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-rays | $0-5 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is not required.) |
In-network Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing exam | 20% 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/evaluation | 20% 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 | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Oral exam | 20% 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 Cleaning | 20% 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 treatment | 20% 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.) |
In-network Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
out-of-network Non-routine services | 25% 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 services | 25% 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 services | 25% 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 Endodontics | 25% 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 Periodontics | 25% 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 Extractions | 25% 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 services | 25% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
out-of-network Routine eye exam | 20% 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 Other | 20% 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 | 20% coinsurance (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) | 20% coinsurance (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 | 20% coinsurance (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 | 20% coinsurance (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 | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Occupational therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
out-of-network Occupational therapy visit | 25% 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 visit | 25% coinsurance (Authorization is required.) (Referral is not required.) |
In-network | $0 copay (Not applicable.) (Not applicable.) |
out-of-network | 20% coinsurance (Not applicable.) (Not applicable.) |
In-network | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
In-network Foot exams and treatment | $0-2 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Foot exams and treatment | 25% coinsurance (Authorization is not required.) (Referral is not required.) |
In-network Routine foot care | $0-2 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
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 supplies | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
Covered (Authorization is not required.) (Referral is not required.) |
In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
out-of-network Chemotherapy | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
out-of-network Other Part B drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
out-of-network Part B Insulin drugs | 20% coinsurance (Authorization is required.) (Not applicable.) |
In-network | $35 per stay (Authorization is not required.) (Referral is not required.) |
out-of-network | 20% per stay (Authorization is not required.) (Referral is not required.) |
In-network Inpatient hospital – psychiatric | $35 per stay (Authorization is not required.) (Referral is not required.) |
out-of-network Inpatient hospital – psychiatric | 20% per stay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient group therapy visit with a psychiatrist | $12 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
In-network Outpatient individual therapy visit with a psychiatrist | $12 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit with a psychiatrist | 20% coinsurance (Authorization is not required.) (Referral is not required.) |
In-network Outpatient group therapy visit | $12 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit | 25% coinsurance (Authorization is not required.) (Referral is not required.) |
In-network Outpatient individual therapy visit | $12 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit | 25% coinsurance (Authorization is not required.) (Referral is not required.) |
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 (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Need more information on Óptimo (PPO)? See 2025 Óptimo (PPO) at MedicareAdvantageRX.com.
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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