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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: 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) 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)