Óptimo Plus (PPO) Medicare Advantage Plan H4005-004 • 2027 • Lajas Municipio, PR
- 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
- Lajas Municipio, PR
- Local Enrollment
- 0 beneficiaries in Lajas Municipio
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.
Enrollment in this plan requires residence in Lajas Municipio, Puerto Rico. CMS enrollment data reports 0 plan members in Lajas Municipio. New members can call the plan directly at (833)221-2234 (TTY (866)620-2520) for assistance.
Compare Similar Plans in Lajas Municipio
No other PPO plans are available in Lajas Municipio, Puerto Rico using the same plan-type comparison criteria.
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.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H4005-004-0 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
Out-of-network: 50% coinsurance - Specialist
- In-network: $0-$5 copay
Out-of-network: 50% coinsurance
Preventive and Wellness Services
- Annual wellness exam
- Not covered
- Telehealth benefit
- In-network: $0-$5 copay
- Routine chiropractic
- In-network: $0-$5 copay
Out-of-network: 50% coinsurance - Fitness benefits
- Coming soon
- Health education
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Counseling services
- 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 - Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $0-$100 copay
Out-of-network: 50% coinsurance - Lab services
- In-network: 0%-10% coinsurance
Out-of-network: 50% coinsurance - Outpatient x-rays
- In-network: 0%-10% coinsurance
Out-of-network: 50% coinsurance - Diagnostic tests and procedures
- In-network: 0%-10% coinsurance
Out-of-network: 50% coinsurance
Emergency and Urgent Care Services
- Emergency room care
- $50 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $0 copay
- Inpatient hospital care
- In-network:
Tier 1
$0 per stay
Tier 2
$50 per stay
Out-of-network:
50% per stay - Skilled Nursing Facility
- In-network:
$0 copay
Out-of-network:
50% per stay - Ground ambulance
- In-network: $0 copay
Out-of-network: 20% coinsurance
Mental Health Services
- Outpatient individual therapy
- In-network: $0 copay
Out-of-network: 50% coinsurance - Outpatient group therapy
- In-network: $0 copay
Out-of-network: 50% coinsurance - Inpatient psychiatric hospital care
- In-network:
Tier 1
$0 per stay
Tier 2
$50 per stay
Out-of-network:
50% per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $5 copay
Out-of-network: 50% coinsurance - Occupational therapy
- In-network: $5 copay
Out-of-network: 50% coinsurance
Medical Equipment and Supplies
- Diabetes supplies
- In-network: $0 copay
Out-of-network: 50% coinsurance - Durable medical equipment
- In-network: 10% coinsurance
Out-of-network: 50% coinsurance - Prosthetics
- In-network: 0%-10% coinsurance
Out-of-network: 50% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance - Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Out-of-network: 50% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Dental x-rays
- In-network: $0 copay
Out-of-network: 50% coinsurance - Cleaning
- In-network: $0 copay
Out-of-network: 50% coinsurance - Periodontics
- In-network: $0 copay
Out-of-network: 50% coinsurance - Endodontics
- In-network: $0 copay
Out-of-network: 50% coinsurance - Restorative services
- In-network: $0 copay
Out-of-network: 50% coinsurance - Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: $0 copay
Out-of-network: 50% coinsurance
Vision Services
- Routine eye exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Contact lenses
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglass frames only
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglass lenses only
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglasses (frames & lenses)
- In-network: $0 copay
Out-of-network: 50% coinsurance - Upgrades
- In-network: $0 copay
Out-of-network: 50% coinsurance
Hearing Services
- Hearing exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Fitting/evaluation
- In-network: $0 copay
Out-of-network: 50% coinsurance - Prescription hearing aids
- In-network: $0 copay
Out-of-network: 50% coinsurance - OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- In-network: $5 copay
Out-of-network: 50% coinsurance - Massage therapy
- Not covered
- Home/bathroom safety devices
- 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.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
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.