2019 Platino Advance (HMO SNP) H5774-26-0 in PR from Triple-S Advantage, Inc. | HealthPocket
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Platino Advance (HMO SNP)

$0/mo
Summary of BenefitsCovered Drugs

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Zip Code00926
Applicant7/21/1984 Male
Coverage Start7/22/2019
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderTriple-S Advantage, Inc.
Plan IDH5774-26-0
Plan Year2019
CMS Rating
Plan TypeHMO SNP
Annual Deductible$415.00
What To Know About This Plan
  • This plan has health and drug coverage
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 Year2019
Monthly Health Plan Premium$0.00
Monthly Drug Plan Premium$0.00
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$3,400 In-network
Optional Supplemental BenefitsNo

Benefits

SERVICECOST
Inpatient hospital coverage$0 or $8 per stay
Outpatient hospital coverage$0 or $2 per visit
Doctor visitsPrimary:$0 copay
Specialist:$0 or $0-2 per visit
Preventive care$0 copay
Emergency care/Urgent careEmergency:$0 copay
Urgent care:$0 copay
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:$0 or $0-1.50
Lab services:$0 or $0-1.50
Diagnostic radiology services (e.g., MRI):$0 or $0-2
Outpatient x-rays:$0 or $0-1.50
Mental health servicesInpatient hospital - psychiatric:$0 or $8 per stay
Outpatient group therapy visit with a psychiatrist:$0 or $2
Outpatient individual therapy visit with a psychiatrist:$0 or $2
Outpatient group therapy visit:$0 or $2
Outpatient individual therapy visit:$0 or $2
Skilled Nursing Facility$0 copay
Rehabilitation servicesOccupational therapy visit:$0 or $2
Physical therapy and speech and language therapy visit:$0 or $2
Ground ambulance$0 copay
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:$0 or $0-2
Routine foot care:$0 copay. There may be limits on how much the plan will provide.
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):0% or 0-20% per item
Prosthetics (e.g., braces, artificial limbs):0% or 0-20% per item
Diabetes supplies:$0 copay
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:$0 copay
Other Part B drugs:$0 copay

Benefits Services

Hearing
Hearing exam$0 or $2
Fitting/evaluationNot covered
Hearing aids - inner earNot covered
Hearing aids - outer earNot covered
Hearing aids - over the earNot covered
Preventive Dental
Oral exam$0 copay. There may be limits on how much the plan will provide.
Cleaning$0 copay. There may be limits on how much the plan will provide.
Fluoride treatment$0 copay. There may be limits on how much the plan will provide.
Dental x-ray(s)$0 copay. There may be limits on how much the plan will provide.
Comprehensive Dental
Non-routine services$2There may be limits on how much the plan will provide.
Diagnostic services$2There may be limits on how much the plan will provide.
Restorative services$2There may be limits on how much the plan will provide.
Endodontics$2There may be limits on how much the plan will provide.
PeriodonticsNot covered
Extractions$2There may be limits on how much the plan will provide.
Prosthodontics, other oral/maxillofacial surgery, other services$2There may be limits on how much the plan will provide.
Vision
Routine eye examNot covered
OtherNot covered
Contact lensesNot covered
Eyeglasses (frames and lenses)Not covered
Eyeglass framesNot covered
Eyeglass lensesNot covered
UpgradesNot covered

Coverage Area for Platino Advance (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$15 copay$20 copayNot offered
Tier 3: Preferred Brand Name$40 copay$45 copayNot offered
Tier 4: Non-Preferred Brand Name$70 copay$95 copayNot offered
Tier 5: Specialty Tier25% coinsurance25% 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$30 copay$40 copayNot offered
Tier 3: Preferred Brand Name$80 copay$90 copayNot offered
Tier 4: Non-Preferred Brand Name$140 copay$190 copayNot offered
Tier 5: Specialty Tier25% coinsurance25% 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-forwardNot Rated
Appeals upheldNot Rated

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
Statin Use in Persons with Diabetes

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Health Benefits

Types of Health Insurance

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)