Optimo Xtra (PPO)
H4005 - 007 - 0
(4 / 5)
Optimo Xtra (PPO) is a Medicare Advantage Plan by Triple S Advantage.
This page features plan details for 2024 Optimo Xtra (PPO) H4005 – 007 – 0 available in Puerto Rico.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Optimo Xtra (PPO) is offered in the following locations.
Plan Overview
Optimo Xtra (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 |
Ready to sign up for Optimo Xtra (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
Optimo Xtra (PPO) has a monthly premium of $30.00. 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 | $6.50 | $23.50 | $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
Optimo Xtra (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 |
|---|---|
| $23.50 | $ |
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) | $15.00 copay | $40.00 copay | ||
| 4 (Non-Preferred Brand) | $30.00 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) | $30.00 copay | $80.00 copay | $30.00 copay | |
| 4 (Non-Preferred Brand) | $60.00 copay | $110.00 copay | $60.00 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
Optimo Xtra (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 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 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 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 | 0-20% 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 | $0 copay (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 Optimo Xtra (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 Optimo Xtra (PPO)? See 2025 Optimo Xtra (PPO) at MedicareAdvantageRX.com.
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