Óptimo Plus (PPO)
H4005 - 004 - 0
(4 / 5)
Óptimo Plus (PPO) is a Medicare Advantage 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 features the 2024 version of this plan. See the 2025 version using the link below:
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.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
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 | $ |
- 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 D | LIS Full |
|---|---|
| $0.00 | $ |
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) | $25.00 copay | $40.00 copay | ||
| 4 (Non-Preferred Brand) | $40.00 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) | $50.00 copay | $80.00 copay | $50.00 copay | |
| 4 (Non-Preferred Brand) | $80.00 copay | $110.00 copay | $80.00 copay | |
| 5 (Specialty Tier) | 33% | 33% | 33% | |
| 6 (Select Care Drugs) | $0.00 copay | $6.00 copay | $0.00 copay |
Gap Coverage Phase
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 Alternative benefit type.
Additional Benefits
Óptimo Plus (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 | $0-5 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 | $50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | 0-10% coinsurance (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 | 0-10% coinsurance (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 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-rays | 0-10% coinsurance (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 | $0 copay (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 | $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.) |
| 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 | $0-5 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 | $0-5 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 | 0-10% 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 | 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.) |
| In-network Inpatient hospital – psychiatric | $25 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 | $5 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 | $5 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 | $5 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 20% 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 visit | 20% 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 Plus (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
Table of Contents
Need more information on Óptimo Plus (PPO)? See 2025 Óptimo Plus (PPO) at MedicareAdvantageRX.com.
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SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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