Óptimo Plus (PPO) Medicare Advantage Plan H4005-004 • 2027
- Monthly Premium
- $0.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $7151.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $0.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- See List
- Total Enrollment
- 2,450 beneficiaries
Óptimo Plus (PPO) Introduction
This Medicare Advantage PPO plan, Óptimo Plus, is offered by Triple-S Advantage and uses a Preferred Provider Organization (PPO) provider network. It comes with prescription drug coverage. For the 2027 plan year, the monthly premium is $0.00, the medical deductible is $0.00, and the in-network maximum out-of-pocket is $7151.00. The plan is identified by CMS Plan ID H4005-004. The 2027 Part D prescription drug deductible is $0.00.
Plan Benefits
Óptimo Plus includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The tables below outline the most common in-network out-of-pocket costs associated with plan H4005-004.
Compare 2027 plan benefits with 2026.
Office Visits
| Covered Service | 2027 | 2026 |
|---|---|---|
| Primary care | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Specialist | In-network: $0-$5 copay Out-of-network: 50% coinsurance |
In-network: $0-$5 copay Out-of-network: 20% coinsurance |
Preventive and Wellness Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Annual wellness exam | Not covered | Not covered |
| Telehealth benefit | In-network: $0-$5 copay | In-network: $0-$5 copay |
| Routine chiropractic | In-network: $0-$5 copay Out-of-network: 50% coinsurance |
In-network: $0-$5 copay Out-of-network: 25% coinsurance |
| Fitness benefits | Coming soon | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health education | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Counseling services | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Over-the-counter drug benefits | In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Health transportation (non-emergency) | Coming soon | Not covered |
Diagnostic, Lab, and Imaging Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diagnostic radiology services | In-network: $0-$100 copay Out-of-network: 50% coinsurance |
In-network: $0-$25 copay, 0%-10% coinsurance Out-of-network: 20% coinsurance |
| Lab services | In-network: 0%-10% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-10% coinsurance Out-of-network: 20% coinsurance |
| Outpatient x-rays | In-network: 0%-10% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-10% coinsurance Out-of-network: 20% coinsurance |
| Diagnostic tests and procedures | In-network: 0%-10% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-10% coinsurance Out-of-network: 20% coinsurance |
Emergency and Urgent Care Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Emergency room care | $50 copay | $50 copay |
| Worldwide emergency care | Coming soon | $0 copay |
| Urgent care | $0 copay | $0 copay |
| Inpatient hospital care | In-network: Tier 1 $0 per stay Tier 2 $50 per stay Out-of-network: 50% per stay |
In-network: Tier 1 $0 per stay Tier 2 $50 per stay Out-of-network: 20% per stay |
| Skilled Nursing Facility | In-network: $0 copay Out-of-network: 50% per stay |
In-network: Tier 1 Tier 2 $0 copay Out-of-network: 20% per stay |
| Ground ambulance | In-network: $0 copay Out-of-network: 20% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
Mental Health Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Outpatient individual therapy | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Outpatient group therapy | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Inpatient psychiatric hospital care | In-network: Tier 1 $0 per stay Tier 2 $50 per stay Out-of-network: 50% per stay |
In-network: Tier 1 $0 per stay Tier 2 $50 per stay Out-of-network: 20% per stay |
Rehabilitation Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Physical therapy and speech and language therapy | In-network: $5 copay Out-of-network: 50% coinsurance |
In-network: $5 copay Out-of-network: 25% coinsurance |
| Occupational therapy | In-network: $5 copay Out-of-network: 50% coinsurance |
In-network: $5 copay Out-of-network: 25% coinsurance |
Medical Equipment and Supplies
| Covered Service | 2027 | 2026 |
|---|---|---|
| Diabetes supplies | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Durable medical equipment | In-network: 10% coinsurance Out-of-network: 50% coinsurance |
In-network: 10% coinsurance Out-of-network: 30% coinsurance |
| Prosthetics | In-network: 0%-10% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-10% coinsurance Out-of-network: 30% coinsurance |
Medicare Part B Drugs
| Covered Service | 2027 | 2026 |
|---|---|---|
| Chemotherapy | In-network: 0%-20% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 20% coinsurance |
| Other Part B drugs (Medicare-covered) | In-network: 0%-20% coinsurance Out-of-network: 50% coinsurance |
In-network: 0%-20% coinsurance Out-of-network: 20% coinsurance |
Dental Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Oral exam | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Dental x-rays | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Cleaning | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Periodontics | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 25% coinsurance |
| Endodontics | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 25% coinsurance |
| Restorative services | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 25% coinsurance |
| Implant services | Not covered | Not covered |
| Orthodontics | Not covered | Not covered |
| Oral/Maxillofacial surgery | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 25% coinsurance |
Vision Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Routine eye exam | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Contact lenses | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses) | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| Upgrades | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
Hearing Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Hearing exam | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Fitting/evaluation | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: 20% coinsurance |
| Prescription hearing aids | In-network: $0 copay Out-of-network: 50% coinsurance |
In-network: $0 copay Out-of-network: $0 copay, 0% coinsurance |
| OTC hearing aids | Not covered | Not covered |
Additional and Special Needs Services
| Covered Service | 2027 | 2026 |
|---|---|---|
| Adult day health services | Not covered | Not covered |
| Home-based palliative care | Not covered | Not covered |
| Personal emergency response system | Coming soon | Not covered |
| Weight management programs | Not covered | Not covered |
| Wigs for chemotherapy-related hair loss | Coming soon | Not covered |
| Alternative therapies | In-network: $5 copay Out-of-network: 50% coinsurance |
In-network: $5 copay Out-of-network: $0 copay, 0% coinsurance |
| Massage therapy | Not covered | Not covered |
| Home/bathroom safety devices | Not covered | Not covered |
Certain preventive services are covered 100% by Óptimo Plus as a Part B benefit.
Prescription Drug Coverage
Óptimo Plus includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.
This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.
Prescription Drug Plan Premium
The Part D prescription drug plan premium is included in the overall Medicare Advantage plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $0.00 |
| Low-Income Premium Subsidy: | Not Applicable |
| Low-Income Premium Subsidy Paid by CMS: | $0.00 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Triple-S Advantage starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Óptimo Plus may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $0.00 copay | Coming soon |
| Preferred Brand | $30.00 copay | Coming soon |
| Non-Preferred Brand | $50.00 copay | Coming soon |
| Specialty Tier | 33% coinsurance | Coming soon |
| Select Care Drugs | $0.00 copay | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H4005)
CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | Not enough data available |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Triple-S Advantage
- Website
- Triple-S Advantage Plan Page
- Providers
- Triple-S Advantage Providers Page
- Formulary
- Triple-S Advantage Formulary Page
- Pharmacy
- Triple-S Advantage Pharmacy Page
- New Member Health Plan Help
- (833)221-2234
- New Member Health Plan TTY
- (866)620-2520
- New Member Part D Help
- (833)221-2234
- New Member Part D TTY Users
- (866)620-2520
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Plan Availability
Óptimo Plus (H4005-004-0) is available in the following locations:
Puerto Rico Municipios Served
- Adjuntas
- Aguada
- Aguadilla
- Aguas Buenas
- Aibonito
- Anasco
- Arecibo
- Arroyo
- Barceloneta
- Barranquitas
- Bayamon
- Cabo Rojo
- Caguas
- Camuy
- Canovanas
- Carolina
- Catano
- Cayey
- Ceiba
- Ciales
- Cidra
- Coamo
- Comerio
- Corozal
- Culebra
- Dorado
- Fajardo
- Florida
- Guanica
- Guayama
- Guayanilla
- Guaynabo
- Gurabo
- Hatillo
- Hormigueros
- Humacao
- Isabela
- Jayuya
- Juana Diaz
- Juncos
- Lajas
- Lares
- Las Marias
- Las Piedras
- Loiza
- Luquillo
- Manati
- Maricao
- Maunabo
- Mayaguez
- Moca
- Morovis
- Naguabo
- Naranjito
- Orocovis
- Patillas
- Penuelas
- Ponce
- Quebradillas
- Rincon
- Rio Grande
- Sabana Grande
- Salinas
- San German
- San Juan
- San Lorenzo
- San Sebastian
- Santa Isabel
- Toa Alta
- Toa Baja
- Trujillo Alto
- Utuado
- Vega Alta
- Vega Baja
- Vieques
- Villalba
- Yabucoa
- Yauco
Frequently Asked Questions
Here are some of the most frequently asked questions about this plan (click to open).
Frequently Asked Questions About Óptimo Plus (PPO)
Is there a monthly premium for this plan in 2027?
For 2027, the monthly premium is $0.00. Medicare Part B premiums apply in addition to this amount.
What is the in-network MOOP for plan H4005-004?
For 2027, the in-network maximum out-of-pocket is $7151.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
CMS rates this plan at ★0.0 out of 5 stars for 2027.
What is the total enrollment for plan H4005-004?
Total enrollment is 2,450 beneficiaries based on the latest CMS data.
Is there a Part D deductible for this plan?
The Part D deductible is $0.00.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | CMS Version |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | CY2027 Landscape (202609.1) |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | 2027 Star Ratings Data Tables |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | PBP Benefits-2027 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | 2026-09 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Triple-S Advantage (official source) | http://www.sssadvantage.com | October 4, 2026 |
| CMS.gov | Medicare Advantage Plan Fact Sheet | 25 May, 2025 |
| Medicare.gov | Joining a plan | 25 May, 2025 |
| Medicare.gov | Your coverage options | 25 May, 2025 |
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Provenance documentation for this data is maintained under the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.