Download platino optimum (hmo snp) - Triple

PLATINO OPTIMUM (HMO SNP)
(a Medicare Advantage Health Maintenance Organization (HMO) offered by Triple-S
Advantage, Inc. with a Medicare contract)
Summary of Benefits
January 1, 2015 - December 31, 2015
This booklet gives you a summary of what we cover and what you pay. It doesn't list every
service that we cover or list every limitation or exclusion. To get a complete list of services we
cover, call us and ask for the "Evidence of Coverage."
You have choices about how to get your Medicare benefits

One choice is to get your Medicare benefits through Original Medicare (fee-for-service
Medicare). Original Medicare is run directly by the Federal government.

Another choice is to get your Medicare benefits by joining a Medicare health plan (such
as Platino Optimum (HMO SNP)).
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what Platino Optimum (HMOSNP) covers and what you pay.

If you want to compare our plan with other Medicare health plans, ask the other plans for
their Summary of Benefits booklets. Or, use the Medicare Plan Finder on
http://www.medicare.gov.

If you want to know more about the coverage and costs of Original Medicare, look in
your current "Medicare & You" handbook. View it online at http://www.medicare.gov
or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.
Sections in this booklet

Things to Know About Platino Optimum (HMO-SNP)

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Service
Y0082_1061_15_08_E File & Use 9/29/2014

Covered Medical and Hospital Benefits

Prescription Drug Benefits
This document is available in other formats such as Braille and large print.
This document may be available in a non-English language. For additional information, call us at
1-888-620-1919 TTY/TDD 1-866-620-2520.
Este documento está disponible en otros formatos tales como Braille y letra grande.
Este documento puede estar disponible en otros idiomas que no son inglés. Para información
adicional, llámenos al 1-888-620-1919 TTY/TDD 1-866-620-2520.
Things to Know About Platino Optimum (HMO SNP)
Hours of Operation
You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Atlantic time.
Platino Optimum (HMO SNP) Phone Numbers and Website

If you are a member of this plan, call toll-free 1-888-620-1919 TTY/TDD 1-866-6202520.

If you are not a member of this plan, call toll-free 1-877-207-8777 TTY/TDD 787-7494059.

Our website: http://www.sssadvantage.com
Who can join?
To join Platino Optimum (HMO SNP), you must be entitled to Medicare Part A, and/or be
enrolled in Medicare Part B, be eligible to Medicaid and live in our service area.
Our service area includes the following counties in Puerto Rico: Adjuntas, Aguada, Aguadilla,
Aguas Buenas, Aibonito, Añasco, Arecibo, Arroyo, Barceloneta, Barranquitas, Bayamón, Cabo
Rojo, Caguas, Camuy, Canóvanas, Carolina, Cataño, Cayey, Ceiba, Ciales, Cidra, Coamo,
Comerío, Corozal, Culebra, Dorado, Fajardo, Florida, Guánica, Guayama, Guayanilla,
Guaynabo, Gurabo, Hatillo, Hormigueros, Humacao, Isabela, Jayuya, Juana Díaz, Juncos, Lajas,
Lares, Las Marías, Las Piedras, Loíza, Luquillo, Manatí, Maricao, Maunabo, Mayagüez, Moca,
Morovis, Naguabo, Naranjito, Orocovis, Patillas, Peñuelas, Ponce, Quebradillas, Rincón, Río
Grande, Sabana Grande, Salinas, San Germán, San Juan, San Lorenzo, San Sebastián, Santa
Isabel, Toa Alta, Toa Baja, Trujillo Alto, Utuado, Vega Alta, Vega Baja, Vieques, Villalba,
Yabucoa, and Yauco.
2 Triple-S Advantage - Platino Optimum (HMO-SNP)
Which doctors, hospitals, and pharmacies can I use?
Platino Optimum (HMO SNP) has a network of doctors, hospitals, pharmacies, and other
providers. If you use the providers that are not in our network, the plan may not pay for these
services.
You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.
Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these
pharmacies.
You can see our plan's provider and pharmacy directory at our website
(http://www.sssadvantage.com).
Or, call us and we will send you a copy of the provider and pharmacy directories.
What do we cover?
Like all Medicare health plans, we cover everything that Original Medicare covers - and more.

Our plan members get all of the benefits covered by Original Medicare. For some of
these benefits, you may pay more in our plan than you would in Original Medicare.
For others, you may pay less.

Our plan members also get more than what is covered by Original Medicare. Some
of the extra benefits are outlined in this booklet.
We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some
drugs administered by your provider.

You can see the complete plan formulary (list of Part D prescription drugs) and any
restrictions on our website, http://www.sssadvantage.com.

Or, call us and we will send you a copy of the formulary.
How will I determine my drug costs?
Our plan groups each medication into one of five "tiers." You will need to use your formulary to
locate what tier your drug is on to determine how much it will cost you. The amount you pay
depends on the drug's tier and what stage of the benefit you have reached. Later in this document
we discuss the benefit stages that occur after you meet your deductible: Initial Coverage,
Coverage Gap, and Catastrophic Coverage.
3 Triple-S Advantage - Platino Optimum (HMO-SNP)
Summary of Benefits
January 1, 2015 – December 31, 2015
Monthly Premium, Deductible, and Limits on How Much You Pay for
Covered Services
How much is the monthly
premium?
$0 per month.
Triple S Advantage will reduce your Medicare Part B
premium by up to $25.50.
How much is the deductible?
This plan does not have a deductible.
This plan does not have a deductible for chemotherapy and
other drugs administered in your doctor's office (Part B
drugs).
This plan does not have a deductible for Part D prescription
drugs.
Is there any limit on how much
I will pay for my covered
services?
Yes. Like all Medicare health plans, our plan protects
you by having yearly limits on your out-of-pocket
costs for medical and hospital care.
In this plan, you may pay nothing for Medicare-covered
services, depending on your level of “Plan de Salud de
Gobierno de Puerto Rico (Medicaid)” eligibility.
Refer to the "Medicare & You" handbook for Medicarecovered services. For “Plan de Salud de Gobierno de Puerto
Rico (Medicaid)”-covered services, refer to the Medicaid
Coverage section in this document.
Your yearly limit(s) in this plan:

$2,500 for services you receive from in-network
providers.
If you reach the limit on out-of-pocket costs, you keep
getting covered hospital and medical services and we will
pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly
premiums and cost-sharing for your Part D prescription
drugs.
4 Triple-S Advantage - Platino Optimum (HMO-SNP)
Is there a limit on how much the Our plan has a coverage limit every year for certain
in-network benefits. Contact us for the services that
plan will pay?
apply.
Covered Medical and Hospital Benefits
Note:
 Services with a 1 may require prior authorization.
 Services with a 2 may require a referral from your doctor.
Outpatient Care and Services
Acupuncture and Other
Alternative Therapies
Not covered
Ambulance1
You pay nothing
Chiropractic Care1,2
Manipulation of the spine to correct a subluxation
(when 1 or more of the bones of your spine move out
of position): You pay nothing
Routine chiropractic visit (for up to 5 every year): You pay
nothing
Prior authorization is required after the 5th visit.
Dental Services1
Limited dental services (this does not include services
in connection with care, treatment, filling, removal, or
replacement of teeth): You pay nothing
Preventive dental services:
 Cleaning (for up to 1 every six months): You pay nothing
 Dental x-ray(s): You pay nothing
5 Triple-S Advantage - Platino Optimum (HMO-SNP)
 Fluoride treatment (for up to 1 every six months): You
pay nothing
 Oral exam (for up to 1 every six months): You pay
nothing
Comprehensive Dental Services include:
 Endodontics
 Restorative
 Periodontics
 Prosthodontics Removable
 Oral and Maxillofacial Surgery
 Adjunctive Services
Maximum Comprehensive Dental Services Coverage
amount: $550 every year
Diabetes Supplies and Services1
Diabetes monitoring supplies: You pay nothing
Diabetes self-management training: You pay nothing
Therapeutic shoes or inserts: You pay nothing
Diagnostic Tests, Lab and
Diagnostic radiology services (such as MRIs, CT
Radiology Services, and X-Rays1,2 scans): You pay nothing
Diagnostic tests and procedures: You pay nothing
Lab services: You pay nothing
Outpatient x-rays: You pay nothing
Therapeutic radiology services (such as radiation treatment
for cancer): You pay nothing
Doctor's Office Visits2
Primary care physician visit: You pay nothing
Specialist visit: You pay nothing
6 Triple-S Advantage - Platino Optimum (HMO-SNP)
Durable Medical Equipment
(wheelchairs, oxygen, etc.)1
You pay nothing
Emergency Care
You pay nothing
$0 copay for Worldwide Emergency. Worldwide Emergency
services through reimbursement in accordance with Puerto
Rico rates.
Foot Care (podiatry services)1,2
Foot exams and treatment if you have diabetes-related nerve
damage and/or meet certain conditions: You pay nothing
Routine foot care (for up to 4 visit(s) every year): You pay
nothing
Prior authorization is required after the 4th visit.
Hearing Services
Exam to diagnose and treat hearing and balance
issues: You pay nothing
Routine hearing exam (for up to 1 every year): You pay
nothing
Hearing aid fitting/evaluation (for up to 1 every year): You
pay nothing
Hearing aid: You pay nothing
Our plan pays up to $300 every three years for hearing aids.
Home Health Care1
You pay nothing
Mental Health Care1
Inpatient visit:
Our plan covers up to 190 days in a lifetime for inpatient
7 Triple-S Advantage - Platino Optimum (HMO-SNP)
mental health care in a psychiatric hospital. The inpatient
hospital care limit applies to inpatient mental services
provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are
"extra" days that we cover. If your hospital stay is longer
than 90 days, you can use these extra days. But once you
have used up these extra 60 days, your inpatient hospital
coverage will be limited to 90 days.
You pay nothing
Outpatient group therapy visit: You pay nothing
Outpatient individual therapy visit: You pay nothing
Partial Hospitalization: You pay nothing
Outpatient Rehabilitation1
Cardiac (heart) rehab services (for a maximum of 2
one-hour sessions per day for up to 36 sessions up to
36 weeks): You pay nothing
Occupational therapy visit: You pay nothing
Physical therapy and speech and language therapy
visit: You pay nothing
Outpatient Substance Abuse
Group therapy visit: You pay nothing
Individual therapy visit: You pay nothing
Outpatient Surgery1,2
Ambulatory surgical center: You pay nothing
Outpatient hospital: You pay nothing
8 Triple-S Advantage - Platino Optimum (HMO-SNP)
Over-the-Counter Items (OTC)
Not Covered
Prosthetic Devices (braces,
artificial limbs, etc.)1
Prosthetic devices: You pay nothing
Related medical supplies: You pay nothing
0% coinsurance for services rendered on the Preferred
Provider Network
10% coinsurance for services rendered on the Provider
Network
Renal Dialysis
You pay nothing
Services include Medicare-covered renal dialysis and
kidney disease education.
Transportation1
There is a limit to how much our plan will pay: You
pay nothing
Benefit is limited for transportation to annual physical
evaluation. Up to a 1 round trip. Maximum plan benefit of
$40 every year.
Urgent Care
You pay nothing
Vision Services2
Exam to diagnose and treat diseases and conditions of
the eye (including yearly glaucoma screening): You
pay nothing
Routine eye exam (for up to 1 every year): You pay nothing
Contact lenses (for up to 1 every year): You pay nothing
Eyeglasses (frames and lenses) (for up to 1 every
year): You pay nothing
9 Triple-S Advantage - Platino Optimum (HMO-SNP)
Eyeglass frames (for up to 1 every year): You pay nothing
Eyeglass lenses (for up to 1 every year): You pay nothing
Eyeglasses or contact lenses after cataract surgery: You pay
nothing
Our plan pays up to $200 every year for eyewear.
Preventive Care
You pay nothing
Our plan covers many preventive services, including:


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
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












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Abdominal aortic aneurysm screening
Alcohol misuse counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular screenings
Cervical and vaginal cancer screening
Colonoscopy
Colorectal cancer screenings
Depression screening
Diabetes screenings
Fecal occult blood test
Flexible sigmoidoscopy
HIV screening
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening and
counseling
Tobacco use cessation counseling (counseling for
people with no sign of tobacco-related disease)
Vaccines, including Flu shots, Hepatitis B shots,
Pneumococcal shots
"Welcome to Medicare" preventive visit (one-time)
Yearly "Wellness" visit
Any additional preventive services approved by Medicare
during the contract year will be covered.
10 Triple-S Advantage - Platino Optimum (HMO-SNP)
Annual physical exam: You pay nothing
Hospice

Teleconsulta- Nurse Line, service is available 24/7
and provides health information on any health topic.

Health- Fitness is limited to $25.00 per month and
must request an original invoice for the quantity to
be reimbursed.

Shower Chair, 1 per member every 5 year. Prior
authorization required.
You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the
cost for drugs and respite care.
Inpatient Care
Inpatient Hospital Care1
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are
"extra" days that we cover. If your hospital stay is longer
than 90 days, you can use these extra days. But once you
have used up these extra 60 days, your inpatient hospital
coverage will be limited to 90 days.
You pay nothing
Inpatient Mental Health Care1
For inpatient mental health care, see the "Mental
Health Care" section of this booklet.
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF.
You pay nothing
3-day hospital stay before SNF admission required
11 Triple-S Advantage - Platino Optimum (HMO-SNP)
Prescription Drug Benefits
How much do I pay?
For Part B drugs such as chemotherapy drugs1: You
pay nothing
Other Part B drugs1: You pay nothing
Initial Coverage
Preferred Retail Cost-Sharing
One-month
supply
Tier
Threemonth
supply
Tier 1 (Preferred
Generic)
$0 copay
$0 copay
Tier 2 (NonPreferred Generic)
$0 copay
$0 copay
Tier 3 (Preferred
Brand)
$0 copay
$0 copay
Tier 4 (NonPreferred Brand)
$0 copay
$0 copay
Tier 5 (Specialty
Tier)
50¢ copay
$1.50 copay
Standard Retail Cost-Sharing
Tier
One-month
supply
Three-month
supply
Tier 1
(Preferred
Generic)
$0 copay
$0 copay
Tier 2
(NonPreferred
Generic)
$0 copay
$0 copay
12 Triple-S Advantage - Platino Optimum (HMO-SNP)
Tier 3
(Preferred
Brand)
50¢ copay
$1.50 copay
Tier 4
(NonPreferred
Brand)
50¢ copay
$1.50 copay
Tier 5
(Specialty
Tier)
50¢ copay
$1.50 copay
Standard Mail Order Cost-Sharing
Tier
Three-month
supply
Tier 1 (Preferred Generic)
$0 copay
Tier 2 (Non-Preferred
Generic)
$0 copay
Tier 3 (Preferred Brand)
$0 copay
Tier 4 (Non-Preferred
Brand)
$0 copay
Tier 5 (Specialty Tier)
$1.00 copay
You may get drugs from an out-of-network pharmacy, but
may pay more than you pay at an in-network pharmacy.
13 Triple-S Advantage - Platino Optimum (HMO-SNP)
Adittional Information
What is a “PCP”?
When you become a member of Platino Optimum (HMO-SNP) you must choose a plan provider
to be your primary care physician (PCP). Your PCP is a physician who meets Puerto Rico
requirements and is trained to give you basic medical care. As we explain below, you will get
your routine or basic care from your PCP. Your PCP will also coordinate the rest of the covered
services you get as a plan member. For example, for electives surgeries you usually need to get
your PCP’s approval first (this is called getting a “referral”). For Platino Optimum (HMO-SNP)
the visits to an OBG/GYW, Urologist does not require a referral from the PCP. Also, the initial
visit to a Cardiologist, Endocrinologist, Ophthalmologist, Orthopedist, Rheumatologist,
Pneumologist and Gastroenterologist does not require a referral from the PCP. The visit to a
Psychiatrist does not require referral.
What to do if you have a medical emergency?
In an emergency, you should get care immediately. You do not have to contact your PCP or get
permission in an emergency. Call 911 for immediate help, or go directly to the nearest
emergency room, hospital, or urgent care center. In case you have doubts about if your condition
is an emergency or not, you can contact our nurse helpline, Teleconsulta, at toll free 1-800-2554375 or TTY/TDD 1-866-280-2050 for orientation (24 hours a day, 7 days a week).
Programs Available
When you enroll in Platino Optimum (HMO-SNP) you have available:
 Diabetes – the focus of this program is to educate adult plan members diagnosed with
diabetes mellitus about management and control of the condition.
 Hypertension and Chronic Heart Failure – these programs, focused to manage
members with hypertension and heart conditions, offer orientation and health education
on how to manage and take care of their health condition. Our specialists in education
teach plan members auto-control techniques and they provide printed material such as
health bulletins. If member complies with program criteria, blood pressure monitor and
weight scales are offered as part of the program to monitor pressure and weight.
 COPD Program – Chronic Obstructive Pulmonary Disease (COPD) receive counseling
on their condition, the use of prescription drugs to control it, signals and symptoms of
complications and the importance of medical monitoring of the condition. Our health
professionals help patients to know well their conditions and to adopt health lifestyles to
avoid complications and enjoy a better quality of life.
 Nutritional Training – members participating in the educational programs for diabetes,
hypertension and chronic heart failure are provided with information and educational
materials on how to modify food choices and help member:
o Make smart choices from every food group
o Find balance between food and physical activity
 Smoking Cessation – the focus of the programs is to educate plan members of the
importance of smoking cessation and the effects of smoking in their health. Plan
members are provided with printed materials such as newsletters or bulletins and will
identify community resources available as needed. This program does not include
treatment or prescription drugs for smoking cessation.
14 Triple-S Advantage - Platino Optimum (HMO-SNP)

Teleconsulta (Triple-S Advantage Nurse Line): – our demand management program,
offers advice on routine care or medical emergencies allowing our members to participate
directly in their health care while reducing the demand for unnecessary services. One of
our over 80 health care professionals evaluates plan member’s symptoms in order to help
them determine the most appropriate course of action. It is available 24 hours a day, 365
days a year.
Medication Therapy Management Program –


The Medication Therapy Management Program (MTMP) is aimed at improving your
health and quality of life by ensuring safe and effective medication use and preventing
medication-related issues.
Emotional Support Line – Access to 24/7 orientation on emotional situations such as
anxiety, emotional crisis, depression, life events such as loss of family members or
friend, economic hardship or financial issues, among others. Health needs assessment on
mental conditions and support to coordinate services or locate available community
services. Coaching for developing treatment plans Support in managing medications.
This service is available to members or immediate family member or caregivers.
15 Triple-S Advantage - Platino Optimum (HMO-SNP)
Over-the-counter (OTC) Drugs
Triple-S Advantage is adding to its pharmacy coverage certain medications that do not have a federal
legend, known as over-the-counter (OTC) drugs; without any copay for you, as part of the Step
Therapy Program. Please refer to the Drug List or Formulary for more information.
If you and your doctor determine that the OTC is a viable treatment alternative, in order to obtain
the drug through your pharmacy coverage, your doctor must provide you with a prescription
where the choice of the OTC product is clearly specified. Your doctor can use the information
below as reference for the product to be included in the prescription.
Product
ABREVA
PREVACID OTC
ZEGERID OTC
PRILOSEC OTC
OMEPRAZOLE
ZADITOR
ALAWAY
ALLER CLEAR
ALLERGY RELF
ALLERGY RELF
ALLERGY RELF
D-24
LORATADINE
LORATADINE
SYR
LORATADINE-D
LORATADINE-D
TAVIST ND
WAL-ITIN
WAL-ITIN
WAL-ITIN D
Dosage
CREAM 10%
CAP 15 MG
CAP 20/1100 MG
TAB 20 MG
TAB 20 MG
OPTH SOLN
0.025%
OPTH SOLN
0.025%
TAB 10 MG
TAB 10MG
SYR 5MG/5ML
TAB 24 HRS 10
MG/240 MG
TAB 10MG
Copay
$0.00
$0.00
$0.00
$0.00
$0.00
SYR 5MG/5ML
$0.00
TAB 12 HRS 5
MG/120 MG
TAB 24 HRS 10
MG/240 MG
TAB 10 MG
TAB 10 MG
SYR 5 MG/5 ML
TAB 24 HRS 10
MG/240 MG
$0.00
Product
CLARITIN
CLARITIN
CLARITIN D
CLARITIN RDT
CLARITIN SYR
CLARITIN-D
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
ALAVERT
ALAVERT
ALAVERT ALGY
SINUS
ALAVERT SYR
ZYRTEC CHILD
CHEWABLE
CETIRIZINE
CHEWABLE
ZYRTEC HIVES
ZYRTEC
ALLERGY
CETIRIZINE
ZYRTEC D
ALLERGY
ZYRTEC HIVES
SYR
ZYRTEC CHILD
SYR
16 Triple-S Advantage - Platino Optimum (HMO-SNP)
Dosage
TAB 10MG
CHEW TAB 5 MG
TAB 24 HRS 10
MG/240 MG
TAB 10MG
SYR 10MG/10 ML
TAB 12 HRS 5
MG/120 MG
TAB 10MG
TAB NON-DROW
TAB 12 HRS 5
MG/120 MG
SYR 10 MG/10 ML
TAB CHEWABLE 5
MG,10 MG
TAB CHEWABLE 5
MG,10 MG
TAB 10 MG
Copay
$0.00
$0.00
TAB 10 MG
$0.00
TAB 5 MG,10 MG
TAB 12 HRS 5
MG/120 MG
$0.00
SYR 1MG/ML
$0.00
SYR 1MG/ML
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Medication Therapy Management Program
The Medication Therapy Management Program (MTMP) is aimed at improving your health and
quality of life by ensuring safe and effective medication use and preventing medication-related
issues.
In addition, our MTM Program provides information, education and monitoring in health care.
If you are eligible to participate, you will receive information about the program and what you
need to do to join.. Remember, this program is offered at no additional cost.
Platino Optimum (HMO-SNP) plans’ drug list or formulary
The Pharmacy and Therapeutics Committee will constantly revise the drugs which currently are
included in the Triple-S Advantage Drug Lists or Formularies. The Drug List or Formulary
details the prescriptions drugs considered as covered. The Pharmacy and Therapeutics
Committee will evaluate each new prescription drug to be included in the Drug Lists or
Formularies. Due to the nature of this process, the Pharmacy and Therapeutics Committee can
require the inclusion or exclusion of certain drugs, according to the changes in the standard
practice of illnesses or their treatment.
We may add or remove drugs from our Drug List or Formulary during the year. Changes in the
Drug List or Formulary may affect which drugs are covered and how much you will pay when
filling your prescription. We will send written notice of changes to our Drug List or Formulary to
all Platino Optimum (HMO-SNP) members who are using a particular drug. This notice will be
sent at least 60 days before the change will take effect. However, if a drug is removed from our
Drug List or Formulary because the drug has been recalled from the market, a notice will not be
given. Instead, we will remove the drug from our Drug List or Formulary immediately and notify
members about the change as soon as possible.
Drug Exclusions
By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription
Drug Program. These drugs or categories of drugs are called “exclusions” and include:
 Non-prescription drugs (also called over-the-counter drugs), except those included in the
Drug List or Formulary
 Drugs when used to promote fertility
 Drugs when used for the relief of cough or cold symptoms
 Drugs when used for cosmetic purposes or to promote hair growth
 Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations
 Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra,
Cialis, Levitra, and Caverject
 Drugs when used for treatment of anorexia, weight loss, or weight gain
 Outpatient drugs for which the manufacturer seeks to require that associated tests or
monitoring services be purchased exclusively from the manufacturer as a condition of
sale
17 Triple-S Advantage - Platino Optimum (HMO-SNP)
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DESI drugs - DESI Medications are those marketed between 1938 and 1962, that were
approved as safe but they did not require any documentation as to their efficacy
Investigational or experimental drugs or those not approved by the FDA (Food and Drug
Administration) are not covered
New medications in the market, not considered experimental or investigative are not
covered until Triple-S Advantage P&T Committee evaluates them and recommend their
inclusion or exclusion of coverage
In addition, a Medicare Prescription Drug Program cannot cover a drug if the drug would be
available under Medicare Part A or Part B. See your Medicare & You Handbook for more
information about drugs that are covered by Medicare Part A and Part B. Some drugs are
covered under Medicare Part B in some cases and Part D in other cases. In general, your
pharmacist or provider will determine whether to bill Medicare Part B or Part D for the drug
.
Additional Benefits Covered by the Health Plan of the Government of Puerto
Rico under Medicare Platino
Being eligible for the Health Program of the Government of Puerto Rico and Medicaid, you will
receive the following services as part of your Plan, which otherwise you would have to pay. You
pay the following copayments for the services below.
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
In- Network
No limit to the number of days covered by the
plan each hospital stay.
$0 annual service category deductible
Hospitalization
Coverage Code 010: $0.00
Coverage Code 011: $3.00
$0 copay
Wrap hospitalization coverage begins on first
day on Medicare non coverage, without
limitation.
Except in an emergency, your doctor must tell
the plan that you are going to be admitted to the
hospital.
In- Network
Mental Health
Hospitalization
Coverage Code 010: $0.00
Coverage Code 011: $3.00
Contact the plan for details about coverage in a
Psychiatric hospital beyond 190 days.
$0 annual service category deductible
18 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
$0 copay
Wrap mental health hospitalization coverage
begins on first day on Medicare non coverage,
without limitation.
In-Network
Emergency and crisis intervention services
twenty four (24) hours a day, seven (7) days a
week
Outpatient Substance
Abuse Services
Coverage Code 010: $0.00
Coverage Code 011: $1.00
$0 copay for:
- each Medicare-covered individual substance
abuse outpatient treatment visit
- each Medicare-covered group substance abuse
outpatient treatment visit
In-Network
Emergency and crisis intervention services
twenty four (24) hours a day, seven (7) days a
week
Outpatient Mental
Health Coverage
Coverage Code 010: $0.00
Coverage Code 011: $1.00
$0 copay for:
- each Medicare-covered individual therapy visit
- each Medicare-covered group therapy visit
$0 copay for:
- each Medicare-covered individual therapy visit
with a Psychiatrist
- each Medicare-covered group therapy visit with
a Psychiatrist
$0 copay for Medicare-covered partial
hospitalization program services.
19 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
In-Network
Primary Care
Physician (PCP),
Specialists, and Subspecialists
Coverage Code 010: $0.00
Coverage Code 011: $1.00
Maternity Services
Coverage Code 010: $0.00
Coverage Code 011: $0.00
$0 copay for each Medicare-covered primary
care doctor visit.
$0 copay for each Medicare-covered specialist
visit.
$0 copay
$0 copay for Medicare:
-Medicared-covered diagnosis and treatment for
diseases and conditions of the eye, including an
annual glaucoma screening for people at risk

Eye Exams
Coverage Code 010: $0.00
Coverage Code 011: $1.00
Up to 1 supplemental routine eye exam(s)
every year
Coverage Code 010 and 011:
$0 copay for
- one pair of Medicare-covered eyeglasses
(lenses and frames) or contact lenses after
cataract surgery
- up to 1 pair(s) of eyeglasses (lenses and
frames) every year
- up to 1 pair(s) of contact lenses every year
$200 plan coverage limit for supplemental
eyewear every year
Medicaid Benefit:
Routine eye exam
In-Network
Hearing Exams
Coverage Code 010: $0.00
Coverage Code 011: $1.00
$0 copay for:
- Medicare-covered diagnostic hearing exams
- up to 1 supplemental routine hearing exam(s)
every year
$0 copay for up to 1 supplemental hearing aid(s)
every three years
$300 plan coverage limit for supplemental
hearing aids every three years.
20 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
Medicaid Benefit:
Routine hearing exam
Annual comprehensive physical evaluation.
Physical Exam
Coverage Code 010: $0.00
Coverage Code 011: $1.00
Health Certificates:
 Health Certificates that include VDRL
and tuberculin (TB) tests.
 This certificate must possess the seal of
the Health Department end will be
provided by a credited Health Care
Organization, up to$5.00.
 Any Certification for the GHIP
beneficiaries related to eligibility for the
Medicaid Program (i.e. Medication
History) will be provided to the
beneficiary at no charge.
 Any deductible applicable for necessary
procedures and laboratory testing related
to the emission of a Health Certificate
will be the beneficiary’s responsibility.
$0 copayment
In-Network
Ambulatory Surgery
Coverage Code 010: $0.00
Coverage Code 011: $1.00
Voluntary sterilization to men and women of
appropriate age previously oriented about
medical procedure implications. The physician
must evidence patient’s written consent.
$0 copay for each Medicare-covered ambulatory
surgical center visit.
$0 copay for each Medicare-covered outpatient
hospital facility visit.
21 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)




Coverage Coverage
Code
Code
010
011
Prescription Drugs
Generic:
Children
(0-18) $0.00
Adult ** $1.00
$0.00
$1.00
Brand:
Children
(0-18) $0.00
Adult ** $3.00
$0.00
$3.00



Wrap drug coverage begins when
Medicare Coverage ends (including the
CMS Part D Appeals Process).
MAOs Part D Drugs Formulary are
subject to Platino copayments
Drugs not included in the MAOs Part D
Drugs Formulary are subject to CMS
Exception Process or CMS Appeal
Process
Drugs not included in the PRHIA
Preferred Drug List (PDL) and in the
MAOs Part D drugs formulary but, are
subject to PLATINO WRAP-AROUND
copayments, if the drug is included in the
PRHIA Master Formulary.
Part D cost sharing premiums,
deductibles, co-insurance including
coverage gap expenses).
The following Drugs that are excluded
from part D benefit and that are actually
in the Puerto Rico health Insurance Plan
Preferred Drug List, must be covered:
1. Prescribed Vitamins
Every patient whose condition is under
control through medications, whether
bioequivalent on brand, must be
maintained on those medications based
on the criteria of the medical specialist
responsible for treating the patient.
*Copays apply to each drug included in the
same prescription page
** Copays do not apply to pregnant woman
enrolled in Medicaid, children 0-18
years of age enrolled in Medicaid and in the
CHIP Program.
In 2015, you will pay the following amounts for
prescription drugs:
Preferred Retail Pharmacy:
Preferred Generics - $0 copayment
Non-Preferred Generics – $0 copayment
22 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
Preferred Brand - $0 copayment
Non-Preferred Brand - $0 copayment
Specialty Drugs - 50¢ copayment
Standard Retail Pharmacy:
Preferred Generics - $0 copayment
Non-Preferred Generics – $0 copayment
Preferred Brand - 50¢ copayment
Non-Preferred Brand - 50¢ copayment
Specialty Drugs - 50¢ copayment
$0 copayment
Special Coverage
Coverage Code 010: $0.00
Coverage Code 011: $1.00
Services related with:
- Tuberculosis
- Leprosy
In-Network
$0 copay for Medicare-covered dental benefits
$0 copay for the following preventive dental
benefits:
Dental Services
Coverage Coverage
Code 010 Code 011
Preventive
(Child)
$0.00 $0.00
Preventive
(Adult)
$0.00 $1.00
Restorative $0.00 $1.00
-up to 1 oral exam(s) every six months
- up to 1 cleaning(s) every six months
- up to 1 fluoride treatment(s) every six months
- up to 1 dental x-ray(s) every year
Plan offers additional supplemental
comprehensive dental benefits.
$550 plan coverage limit for supplemental
comprehensive dental benefits every year.
Medicaid Services:
Preventive (children & adults)
Restoratives
Covered dental services will be identified using
the published codes of the "American Dental
Association” (ADA) for procedures established
by ASES.
23 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
- One comprehensive oral exam.
- One periodical exam every six months.
- One defined problem-limited oral exam.
- One full series of intra oral radiographies,
including bite, every three years.
- One initial periapical intra-oral radiography.
- Up to five additional periapical / intra-oral
radiographies per year.
- One single film-bite radiography.
- One two-film bite radiography per year.
- One panoramic radiography every three years.
- One child cleanse every six months.
- One adult cleanse every six months.
- One topical fluoride application every six
months for beneficiaries under 19 years.
- Fissure sealants for life for beneficiaries up to
14 years old inclusive. Includes decidual molars
up to 8 years old when clinically necessary
because of cavity tendencies.
- Amalgam restoration
- Resin restorations.
- Root Canal.
- Palliative treatment.
- Oral Surgery
Immunizations
Coverage Code 010: $0.00
Coverage Code 011: $0.00
$0.00 copay. Vaccines for children from 0 to 21
years of age:
a. Diphteria
b. Polio (ipv)
c. Polio (opv)
d. Hepatitis B
e. MMR
f. Tetanus (TD)
g. Pneumonia
h. HPV
i. Tetramune (DTP-Hip)
j. Immunoglobulin
k. Synagis (for babies)
l. Hepatitis A vaccine for children from 12 to 17
months of age
m. Tetanus/Diphteria booster every 10 year
n. Chickenpox vaccine for 12 year old child
o. PCV-7 (for girls and adolescents)
p. Influenza (for 65 years and older)
24 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Medicaid
Platino Optimum (HMO-SNP)
For Vaccines not covered by the Medicare
Benefit Package, they are to be provided by the
Puerto Rico Health Department (PRHD).
The GHIP covers the administration of the
vaccines according to the schedule established by
PRHD.
Diagnostic Test
Services
High Tech
Laboratories
Clinical Laboratories
X Rays
In-Network
$0 copay for Medicare-covered:
Coverage Code 010: $0.00
Coverage Code 011: $0.50




lab services
diagnostic procedures and tests
X-rays
therapeutic radiology services
$0 copay for Medicare-covered:
Special Diagnostic Test
Coverage Code 010: $0.00
Coverage Code 011: $1.00
-diagnostic radiology services (not including Xrays)
In-Network
Ambulatory
Rehabilitation Services
Coverage Code 010: $0.00
Coverage Code 011: $1.00
$0 copay for Medicare-covered Occupational
Therapy visits.
$0 copay for Medicare-covered Physical and/or
Speech and Language Therapy visits.
Pre-natal Services
Emergency Room
Services
Coverage Code 010: $0.00
Coverage Code 011: $0.00
Coverage Code 010:
Emergency Room (ER) Visit:
$0
Non-emergency visit: $3.80
Trauma: $0
$0 copay benefits covered by the GHIP.
$0 annual service category deductible
$0 copay for Medicare- covered emergency room
visits
Coverage Code 011:
Emergency Room (ER) Visit:
$0
Non-emergency visit: $3.80
Trauma: $0
25 Triple-S Advantage - Platino Optimum (HMO-SNP)
Benefit
Category
Basic Coverage
Exclusions
Special Coverage
Exclusions*
Medicare Coverage
Medicaid
For informational purposes
For informational purposes
For informational purposes
Platino Optimum (HMO-SNP)
$0 copay for benefits covered by the GHIP.
$0 copay for benefits covered by the GHIP.
For services covered by the plan please refer to
Platino Optimum (HMO-SNP) Summary of
Benefit
$0 copay for benefits covered by the GHIP.
For a detail of each one of the services included under each one of the above categories, please
refer to the ASES web page www.ases.pr.gov or contact Customer Service.
26 Triple-S Advantage - Platino Optimum (HMO-SNP)