2018 Vital Plus (HMO SNP) H5774-22-0 in PR from Triple-S Advantage, Inc. | HealthPocket

Vital Plus (HMO SNP)

$0/mo

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Zip Code00926
Applicant10/17/1983 Male
Coverage Start10/19/2018
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderTriple-S Advantage, Inc.
Plan IDH5774-22-0
Plan Year2018
CMS Rating
Plan TypeHMO SNP
Annual Deductible$0.00

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2019. see plan

Why We Like This Plan
  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium

Costs and Other Important Information

Plan Year2018
Optional Supplemental BenefitsNo
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,400 In-network
Other health plan deductibles?No
Health Plan Deductible$0
Monthly Drug Plan Premium$0.00
Monthly Health Plan Premium$0.00

Benefits

SERVICECOST
Inpatient hospital coverageTier 1
$0 copay per stay
Tier 2
$150 per stay
Outpatient hospital coverage$25 per visit
Doctor visitsPrimary:
$0 copay
Specialist:
$0-20 per visit
Preventive care$0 copay
Emergency care/Urgent careEmergency:
$75 per visit (always covered)
Urgent care:
$0 copay
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
0-15%
Lab services:
0-15%
Diagnostic radiology services (e.g., MRI):
0-15%
Outpatient x-rays:
$0 copay
Mental health services$0 copay
Outpatient group therapy visit with a psychiatrist:
$15
Outpatient individual therapy visit with a psychiatrist:
$15
Outpatient group therapy visit:
$15
Outpatient individual therapy visit:
$15
Skilled Nursing Facility$0 copay
Rehabilitation servicesOccupational therapy visit:
$15
Physical therapy and speech and language therapy visit:
$0 copay
Ambulance$65
Transportation$0 copay
Foot care (podiatry services)Foot exams and treatment:
$0-15
Routine foot care:
$0-15
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
0-20% per item
Prosthetics (e.g., braces, artificial limbs):
0-20% per item
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:
20%
Other Part B drugs:
20%

Coverage Area for Vital Plus (HMO SNP)

StatePuerto Rico
CountySan Juan

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$5 copay$10 copayNot offered
Tier 2: Non-Preferred Generic$10 copay$20 copayNot offered
Tier 3: Preferred Brand Name$35 copay$45 copayNot offered
Tier 4: Non-Preferred Brand Name$50 copay$75 copayNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered

90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$10 copay$20 copayNot offered
Tier 2: Non-Preferred Generic$20 copay$40 copayNot offered
Tier 3: Preferred Brand Name$70 copay$90 copayNot offered
Tier 4: Non-Preferred Brand Name$100 copay$150 copayNot offered
Tier 5: Specialty Tier33% coinsurance33% coinsuranceNot offered

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Care for older adults – medication review
Care for older adults – functional status assessment
Care for older adults – Pain screening
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

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