SUMMARY OF BENEFITS OF THE HEALTH PLAN...

Independent Licensee of BlueCross BlueShield Association

SUMMARY OF

BENEFITS OF THE

HEALTH PLAN

2019

TSS-DVAC-0879-2018-B

JETBLUE AIRWAYS

SUMMARY OF HEALTH PLAN PROGRAM 2018 | TRIPLE-S OPTIMO PLUS

Our focus is prevention. This

innovative programs and

services for the care of your

health and well-being.

This guide will help you know

how your plan works and all

services you have available

with Triple-S Salud. Read it

with care and take advantage

You have all to overcome it all!

Welcome to

Triple-S Salud

Services Deductibles, copays and coinsurance

JetBlue Airways

Basic Covarage

Maximum Out of Pocketservices given by participating providers *

$6 350 Individual

$12 700 Familiar

PreventivePreventive Services (including those for females)

Preventive Immunization (Vaccines)

Immunizations (Vaccines) for Respiratory Syncytial Virus

Sterilization and Vasectomy

$0

$0

20%

$0

Medical VisitsGeneral Practitioner

Specialist (including psychologist and psychiatrist)

Subspecialist

Nutritionist

Chiropractor

$8

$12

$15

$7 per visit

TestLabs

X-Rays

Specialized Tests

Allergy tests

Lithotripsy

30%

30%

30%

$0 - 50 visits per policy year

25%

AmbulatoryAmbulatory FacilityAmbulatory Surgery

$75 $75

TherapyPhysical Therapy

Chiropractor Manipulations

Respiratory Therapy

$7

$7

$5

Mental HealthGroup Therapy

Collateral Visits

$10

$10

Emergency RoomAccident

Illness

Recommended by Teleconsulta

$40

$40

$25

HospitalizationRegular (including Mental Health)

Partial (due to mental illness)

Surgical Assistance

$75

$50

By reimbursement

OtherHome Health Care

Durable Medical Equipment

Services in United States

Services by Non-Participating Providers in Puerto Rico

$25

20%

$20 emergencies only or preauthorized services

Not covered

Pharmacy Coverage

Generic Medication

Brand Medication

Preferred Brand Medication

Non-Preferred Brand Medication

Specialized Medication

Oral Chemotherapy Drug

90 Day Supply for Maintenance Medications (by Mail or

Pharmacy)

Generic Medication

Brand Medication

Preferred Brand Medication

Non-Preferred Brand Medication

$5

20% min $15

20% min $10

20% min $20

30%

10%

$10

15% min $30

15% min $20

20% min $60

Glasses or Contact LensesRefraction Exam

$150 per person every 12 months25%

Diagnostic and Preventive Services

Restorative Services

Periodontics

Endodontics

Oral Surgery

Prostheses and Crowns

Orthodontics

$0

30%

$0 up to $1,000 per policy year

30%

30%

50% - 57%

By reimbursement up to $1,000 per person for life

Coinsurance 20%

Chemotherapy

Radiotherapy

Triple-S Natural (alternative medicine)

10%

25%

6 visits per year

Major Medical

Dental

Vision

Ot

This is a brief informational summary and does not replace or modify the policy. We urge you to review the Cert cate of Bene ts (Policy) so that you know indetail the bene ts, limitations and exclusions of the cover.

Services Deductibles, copays and coinsurance

Basic Covarage

JetBlue Airways

P.O. BOX 363628, SAN JUAN, PR 00936-3628 | TEL. 787-749-4949 | SSSPR.COM

MOCA

MANATÍ

UTUADO

CIALES

LARES

RINCÓN AGUADA

AGUADILLA

ISABELA

AÑASCO

HATILLO

CAMUY

QUEBRADILLA

VEGABAJA

MOROVIS

COAMO

CABO ROJO

LAJAS

SANGERMÁN

HORMIGUEROS

SANSEBASTÍAN

LAS MARÍAS

MARICAOADJUNTAS

PEÑUELAS

GUAYANILLA

YAUCOSABANAGRANDE

GUÁNICA

JAYUYAOROCOVIS

JUANA DÍAZ

VILLALBA

BARRANQUITAS

SANTAISABEL

SALINAS

CAYEY

AIBONITO

GUAYAMA

CIDRA

SANLORENZO

GURABO

JUNCOS

LASPIEDRAS

YABUCOA

MAUNABO

PATILLAS

ARROYO

HUMACAOVIEQUES

CULEBRA

NAGUABO

CIEBA

FAJARDO

LUQUILLORIOGRANDE

CANOVANAS

LOIZA

CAROLINATRUJILLOALTOGUAYNABO

VEGAALTA

TOABAJA

DORADO

COROZAL

TOAALTA

BAYAMÓN

NARANJITO

CATAÑO

COMERIO

AGUASBUENAS

ARECIBOFLORIDA

BARCELONETA

MAYAGÜEZ

PONCE

SAN JUAN

CAGUAS

787-774-6060

787-792-1370

TTY users: 1-866-215-1999

Toll free: 1-800-981-3241

SERVICE HOURS (AST):

Monday to Friday 7:30 a.m. - 8:00 p.m.

Saturday de 9:00 a.m. - 6:00 p.m.

Sunday de 11:00 a.m. - 5:00 p.m.

Service call center

ARECIBOCaribbean Cinemas Building, Suite 101Road 2 km 81.0 Arecibo, PR 00612Monday to Friday 8:00 a.m. - 5:00 p.m.

CAGUASAngora Building, Luis Muñoz Marín Ave.Corner/Street Troche, Caguas, PR 00725Monday to Friday 8:00 a.m. - 5:00 p.m.

MAYAGÜEZRoad 114 km 1.1 Castillo Community, Mayagüez, PR 00680Monday to Friday 8:00 a.m. - 5:00 p.m.

PONCE2760 Maruca Ave.Ponce, PR 00728-4108Monday to Friday 8:00 a.m. - 5:00 p.m.

MAIN OFFICE1441 F.D. Roosevelt Ave.San Juan, PR 00920Monday to Friday 8:00 a.m. - 5:00 p.m.

PLAZA LAS AMÉRICAS2nd Level(Entrada por estacionamiento norte)Monday to Friday 8:00 a.m. - 7:00 p.m.Saturday 9:00 a.m. - 6:00 p.m.Sunday 11:00 a.m. - 5:00 p.m.

PLAZA CAROLINA2nd LevelMonday to Friday 9:00 a.m. - 7:00 p.m.Saturday 9:00 a.m. - 6:00 p.m.Sunday 11:00 a.m. - 5:00 p.m.

Service centers

PUERTO RICO

Self-Service

In Telexpreso, you can:

• Pay for your health plan*

• Check your eligibility and your dependents

• Check the status of a reimbursement

• Get information on some of our processes such as

asking for a reimbursement, copies of your ID cards,

TELEXPRESO (787) 774-6060

1-800-981-3241

(free of charge)

Connect to ssspr.com

In our portal, you can:

• Check your and your dependent’s eligibility

• View information of

• Your coverage

• Your drugs and pharmacy plan though SSS pharmacy

• Your record of care received

• Ask for copies of your ID card

• Request and check the status of a reimbursement

• Make Payments*

• Address and phone changes*

INTERNET ssspr.com

• Your Card Always with You: Email your plan ID card

or your dependent’s card to doctors.

• Review your and your dependent's coverage easily.

• Find the provider nearest you.

• Pay your plan’s bill*.

• Have our main phone numbers and addresses.

• Service questions

• View the records of the care you received.

MOBILE APP Triple-S Salud

For iOS or Android

Use your online tools to handle your plan at any time and without waiting.

*If you have a group plan, some of these options must be coordinated with your employer.

STAY CONNECTED

SALUS

Quality health care as you deserve

services for adults and children from primary doctors, specialists and dentist,

all under one roof with one medical record, for more convenience.

MORE THAN 40 SPECIALISTS IN THE NETWORK:

Primary doctor

• General medicine

• Family medicine

• Internal medicine

Geriatrics

Obstetrics and gynecology

Dermatology

Breast surgery

General surgery

Gastroenterology

Pediatrics

Nutrition

Pneumology

Bariatric/ Weight Control

Preventive programs

Neurology

• Headaches

• Alzheimer

Imaging center

Laboratory

Pharmacy

Salus Carolina


SALUS GUAYNABO & CAROLINA

Appointments without long waits

Carolina

Road 190, Km. 1.8, Sabana Abajo, Carolina (entering thru UNE Carolina)Phone: (787) 789-1996Monday to Friday 7:00 a.m. - 5:00 p.m.

6

Salus Guaynabo

MORE THAN 40 SPECIALISTS

WHERE WE ARE

Guaynabo / Bayamón

Casa Linda Ave. #1, Suite 101, Road 177, Los Filtros, Km. 2.0, Bayamón, PR 00959 Appointments: (787) 789-1996Administrative services: (787) 789-1919Email: [email protected] Hours:Monday to Thurs. 7:00 a.m. - 8:00 p.m.Viernes: 7:00 a.m. - 7:00 p.m.Sábados: 8:00 a.m. - 3:00 p.m.

QUALIT Y HEALTH CARE AS YOU DESERVE

66666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666666

7) 789-1919

- 8:00 p.m.m.m.

Our professionals at TeleConsulta, with over 5 years of experience will gladly answer your questions on any healthcare topic that may interest or worry you.

• You feel sick, have some pain and don't know

what to do

• You have questions about prescription drugs

• You want to know more about some conditions

like asthma, diabetes, high blood pressure,

among others

• You have doubts about some procedure or

routine examination

• Your children are sick. Do not know what to do

to ease symptoms

• Nutrition, diet and exercise

Our nursing professionals will guide you if you need to:

• Make an appointment with your doctor

• Do something to ease the symptoms that you

have safely and reliably in the comfort of your

home

• Go to an emergency room

—

Teleconsulta es un servicio exclusivo de Triple-S Salud para sus asegurados, el cual es administrado por Axis Point Health, un contratista independiente de servicios de orientación e información telefónica de salud.

Teleconsulta is an exclusive health information hotline from Triple-S Salud, available 24 hours a day, 7 days a week, 365 days a year.

trained nursing professionals.

Our calling is to take care of you.

Call

1-800-255-4375

(the number is also on your plan card)

YOU HAVE ALL TO OVERCOME IT ALL | TRIPLE-S SALUD

Health information Hotline

TELECONSULTA


911

An emergency represents an

immediate threat to your life, an

organ or an extremity of your

body. Call 911 directly for

immediate help or go to the

nearest emergency room.

DO YOU HAVE DOUBTS ABOUT PROPER CARE?

Call Teleconsulta, available 24 hours,

at 1-800-255-4375 to get guidance

on the proper care.

Health emergencies are serious health problems that happen quickly.

These warnings may be thought as emergencies:

Make proper use ofthe Emergency Room

• Threatened abortion

• Choking

• Harsh asthma attack

• Seizures

• Foreign bodies in cavities

• Severe diarrhea and throwing up at

the same time

• Sudden and sharp stomach pain

• Sharp chest pain

• Sharp headache

• Poisoning

• Severe psychotic event

• Shock of any type

• Broken bone or dislocation

• Bleeding

• Deep wounds

• Pacemaker does not work well

• Faint

• Large burns

• Harsh allergic reaction

• Harsh and sudden nose bleeding

• Sharp wound

PREVENTIVE HEALTH CARE

EVALUATION

• Medical history

• Physical examination

• Screening of depression

• Risk behavior

• Guidance: alcohol, smoking, diet,

nutrition and others

CENTROS DE CUIDADO PREVENTIVO

SALUS, Guaynabo(787) 789-1919 ext. 1044 & 1054

(787) 999-3096

[email protected]

SALUS, Carolina(787) 789-1996

Tiger Med, Caguas(787) 646-2800

(787) 286-2800 ext. 636 & 248

[email protected]

Centro de Medicina y Cirugía Ambulatoria San Sebastián(787) 501-5324, (787) 926-0000

[email protected]

Preventive Care Service, Ponce(787) 651-1435, (787) 651-6479

(787) 651-3607, (787) 651-3914

[email protected]

Villa Los Santos, Arecibo(787) 879-1585 ext. 233

[email protected]

Bella Vista Family Medicine Center, Mayagüez(787) 834-6160 ext.203

(787) 834-6172

[email protected]

Wellness Alliance, (787) 708-6777

Preventive centers

Triple-S has Preventive Care Centers that promote the health and well-being

quality of health. Through these centers, members 21 years and over can get

their yearly checkup in one visit without copayments in most tests.

*No copayments on most preventive tests.

NO COPAYS* OR LONG WAITS!

Hipertensión Asma

Diabetes FalloCardiaco

COPD

(Enfermedad PulmonarObstructiva Crónica)

Prenatal

EDUCATIONAL PROGRAMS

Total Wellness

To participate in our programs, you can:

• Learn about your health condition,

their signs, the correct use of

drugs, how to handle it and keep it

in control.

• Prevent other health problems

linked to your condition

• Change your lifestyle with the help

of our group of nurses, health

educators and nutritionists and get

educational material.

• Take advantage of the educational

activities we provide.

If you are pregnant, in our Prenatal

Program we educate you on the

importance of early prenatal care

and the risks to which you must be

aware. We give you educational

materials, guidance by phone from

our one analyst/nurse specialist and

educational workshops.

—

Call us at Disease Management Unit

at 1-866-788-6770.

By calling 1-866-788-6770, you have within your reach a range of educational and disease management programs that will


PROMOTING BETTER CARE

Case ManagementProgram


If you are dealing with a serious illness or require long term

you this program that makes sure your care is well-coordinated.

HOW THIS PROGRAM WORKS?

A group of nurses, doctors and a

social worker with extensive clinical

experience, will evaluate your health

care needs and determine available

care options.

You can be eligible to join based on

treating your health problem. These

may include: health services at

home, durable medical equipment

or admission in a specialized care

center, among others.

Our Case Managers will coordinate

the care you need and follow up

through phone calls and personal

visits. Along with a social worker

they will work with you and your

doctor to make sure you're getting

the best care possible.

These are some of the conditions

that our program works:

• Stroke and other cerebrovascular

conditions

• Cancer in terminal stage

• Degenerative diseases

• Mental illness and substance abuse

• HIV + or AIDS

WHAT ARE THE BENEFITS I GET FROM PARTICIPATING IN THE PROGRAM?

• No additional cost

• Personalized attention

• We work directly with your doctor

and other care

• Providers Connect you with

valuable resources and services in

your community.

CONTACT US

Operating Hours:

M-F 8:00 a.m. – 4:30 p.m.

787-706-2552 or

1-800-981-4860 (toll free)

Send your request via fax at

787-774-4824 or

1-855-887-8275 (toll free)

Email: [email protected]


STAY ACTIVE AND HEALTHY

Health Risk AssesmentHRA

To help you achieve your

the Health Risk Assessment (HRA). This online tool allows you to identify risk factors and lifestyles that

and your family.

Take control of your health!

When completing the questionnaire,

the HRA tool develops a general

recommendations for improvement

of your health. Share it with your

doctor and follow his/her

instructions for tests and other

preventive diagnostic tests.*

* Requires registration at ssspr.com

INTEGRATED MEDICINE MODEL


Triple-S NaturalProgram

THE PROGRAM IS AVAILABLE ONLY THROUGH THE FOLLOWING PARTICIPATING FACILITIES:

Armonía Natural Dorado del Mar Shopping Center, Local #20, Dorado, PR 00646 Tel: (787) 796-3380

Armonía NaturalUrb. Flamboyán, B-18 Calle Marginal, Manatí, PR 00674 Tel: (787) 884-7024

Centro Universitario Medicina Alternativa Hospital Ramón Ruiz Arnau, Ave. Laurel Santa Juanita, Bayamón, PR 00960Tel: (787) 269-0988

Acupati Center55n Basora St, 102, Mayagüez, PRTel: 787-831-7173

Centro de Medicina Familiar y Medicina Integral210 Cll Arizmendi,San Juan, PRTel: 787-754-7133

The Triple-S Natural Program integrates:

• Primary Conventional Medicine

• Holistic health and Complementary

• Medical Acupuncture

• Therapeutic Massage

• Naturopathic Medicine

• Bioenergetic medicine (Pranic Healing)

• Hypnotherapy

• Traditional Chinese Medicine

• Clinical Nutrition

• Botanical Medicine

• Aromatherapy

• Music Therapy

• Chiropractic

Get medical services using an integrated model of medicine, in which complementary techniques and treatments validated by the National Institute of Health in the United States and agencies recognized at the international level are used.


BENEFITS BEYOND PUERTO RICO

BlueCrossBlueShield

By showing your Triple-S Salud health plan card to a participating doctor or hospital of the BlueCross BlueShield Association, you will be able to get the same care that you would get in Puerto Rico. As an independent licensee of BlueCross BlueShield we provide

1. Blue Card Program - The Blue

Card Program gives access to

95% of the hospitals in the USA

and the US Virgin Islands

2. BCBS Global - Our BCBS Global

program gives access to health

care outside of the USA, with

participating hospitals in more

than 131 countries.

3. Blue Distinction Centers - The

Blue Distinction Centers Program

with proven expertise in

specialized health care such as:

• Bariatric Surgery

• Cardiac Care

• Complex and Rare Cancers

• Knee and Hip Replacement

• Maternal Care

• Spinal Surgery

• Transplants

4. Blue 365 - Discount program that

in select products and services

made to improve or maintain

your health every day.

For more information visit ssspr.com

Note: This program is

not available for

dental and pharmacy

services. For

pharmacy services,

Triple-S Salud has a

contracted Network in

the United States.


PHARMACY

Your PharmacyProgram

PHARMACY NETWORK

Our network includes retail pharmacies throughout the Island, including most independent pharmacies, as well as drugstore chains. You can also purchase your prescriptions in the United Stated and US Virgin Islands.

near you:

• Visit our online site ssspr.com

• Access our app Triple-S Salud,

available for Apple and Android.

maintain an optimal state of health and will save you time and money.

DISPENSING/SUPPLY

Acute Drugs

To treat conditions that have a

end. Its onset is sudden and the

treatment is of short duration.

In general, our plans cover up to a

Maintenance Drugs

Are those that treat a life-long health

problems such as diabetes, thyroid,

asthma, and Parkinson's Disease,

among others.

These drugs are covered for 30 days

Some of these drugs may

days supply

There are pharmacy coverages that

require the dispensing of generic

EXTENDED SUPPLY PROGRAM


You can get a 90-day supply

for certain maintenance

drugs in our Program

to ask your doctor for a

prescription 90 days plus

WHAT ADVANTAGES FLEX90® OFFERS?

• Save time and visits to the

drugstore

• Savings in copayments or

coinsurances

• Improve your life-long health

problems with a higher supply on

hand

For more information about the Program, call to (787) 774-6060

90 Days Extended Supply Programat participating pharmacies

PRESCRIPTIONS THROUGH MAIL ORDER

Triple-S Salud PharmacyMail Order Program

You can get certain

maintenance drugs

through the mail,

in the comfort of

your home; up to a

HOW TO BEGIN USING THE SERVICES OF PHARMACY MAIL ORDER PROGRAM?

Request your prescription drugs by mail

in the following way:

INTERNET

• Signup in Walgreens.com/MailService.

registration, follow the instructions to

submit your recipe.

E-MAIL

• Complete the registration form

included with your registration packet.

• Send the form including the original

prescription to:

TELEPHONE

Call Customer Service Center at

1-866-560-5881 and have your

information list.

SEND THE PRESCRIPTION TO THE PHARMACY BY:

• Facsimile

• E-prescribe

IF YOU NEED THE DRUG IMMEDIATELY

Ask your doctor for two prescription,

it in your local pharmacy and other for

order pharmacy to dispense.

CONTACT INFORMATION

Walgreens.com/MailService

Telephones: 1 (800) 345-1985 (English)

1 (800) 778-5427/

TTY 1 (877) 220-6173 (Spanish)

Fax: 1 (800) 332-9581

Mail:

PO Box 29061 Phoenix, AZ 85038-9061

Opening Hours:

24 hours / 7 days a week

EXCLUSIVE PHARMACY NETWORK

Specialty Drug ManagementProgram through our ExclusivePharmacy Network

An integrated care of specialized medications for high risk and life-long

You or your doctor may call one of these pharmacies and be guided with the steps to

follow for ordering and getting your specialty drugs. You should remind your doctor

to write two prescriptions, one for specialty drugs and the other for the non-specialty

drugs.

Some of the health problems or types of drugs are handled through these pharmacies:

• Cancer (oral)

• Crohn's Disease

• Antihemophilic Factor

• Rheumatoid Arthritis

• Multiple Sclerosis

• Hepatitis C

Pharmacy Address

355 De Diego Ave. San Juan, PR 00909

1210 Américo Miranda Ave., Urb. Reparto Metropolitano San Juan, PR 00921

BestOption Healthcare

Special Care Pharmacy Services

Plaza Notre Dame 5 Luis Muñoz Marín Ave. 75 Caguas, PR 00725

SPS Specialty Pharmacy Services, Inc.

Phone

T: (787) 723-6868 F: (787) 723-6987 LC: 1(866) 981-8124

T: (787)783-8579 F: (787)783-2951 LC: 1(877) 899-8997

T: (787) 783-8579 F: (787) 781-6190 LC: 1-800-795-6164

You will get your drugs at your place of choice in Puerto Rico or USVI. You may

pick-up.

If you have questions or need help, call (787) 774-6060.


Triple-S Salud has added in most of its prescription drug coverages some OTC

therapy.

To take advantage of this program and to ensure that you are

using an appropriate therapy, you must submit a prescription from

your doctor for dispensing of the OTC drug.

Tell your doctor that he needs to write in the prescription the

name of the drug followed by OTC.

These are the OTC drug alternatives available:

OTC PROGRAM

OTC Program


Category Available OTC drugs

Omeprazole DR Tab 20 mg, Omeprazole Mag DR

Cap 20.6 mg: Prilosec OTC®*

Omeprazole-Sodium Bicarbonate Cap 20-1100 mg:

Zegerid OTC®*

Lanzoprazole DR Cap 15 mg: Prevacid 24hr®*

Esomeprazole MAG DR Tab 20 mg, Esomeprazole

MAG DR Cap 20 mg: Nexium 24hr®*

ULCERS AND REFLUX (Protom pump

inhibitors)

Cetirizine Hcl Cap 10 mg, Cetirizine HCI Tab 5 mg,

Cetirizine HCL Tab 10 mg, Cetirizine HCI Chew Tab

5 mg, Cetirizine HCI Chew Tab 10mg, Cetirizine HCI

Oral Sol 1 mg/ml (5 mg/5ml) Cetirizine HCI

Desintegrating Tab 10 mg: Zyrtec®*

ALERGIES (Non-sedative

antihistamines)

Tabla continúa en la siguiente página.

OTC PROGRAM

Category Available OTC drugs

Fexofenadine HCL Tab 60 mg, Fexofenadine HCI

Tab 180 mg, Fexofenadine HCI Susp 30 mg/5ml (6

mg/ml), Fexofenadine HCI Desintigrating Tab 30

mg: Allegra®*

Levocetirizine Tab 5 mg, Levocetirizine Soln 2.5

mg/5ml (0.5 mg/ml): Xyzal®*

Loratadine Cap 10 mg, Loratadine Tab 10 mg,

Loratadine Chew Tab 5 mg, Loratadine Syrup 5

mg/5ml, Loratadine Desintegrating Tab 5 mg,

Loratadine Desintegrating Tab 10 mg: Claritin®*

Cetirizine-Pseudoephedrine Tab ER 12hr 5-120

mg: Zyrtec-D®*

Loratadine & Pseudoephedrine ER 12hr 5-120 mg:

Claritin-D®*

Loratadine & Pseudoephedrine Tab Er 24hr 10-240

mg: Claritin-D®*

Fexofenadine-Pseudoephedrine Tab Er 12hr

60-120 mg: Allegra-D®*

Fexofenadine-Pseudoephedrine Tab 24hr 180-240

mg: Allegra-D®*

Ketotifen Fumarate Ophthalmic Solution 0.025%:

Zaditor®*

ALERGIES (Non-sedative

antihistamines)

EYE ALLERGIES

NASAL ALLERGIES

Budesonide Nasal Suspension 32 mcg/act:

Rhinocort Allergy®*

Fluticasone Furoate Nasal Suspension 27.5

mcg/spray: Flonase Sensimist®*

Fluticasone Propionate Nasal Suspension

50mcg/act: Flonase Allergy Relief®*

Triamcinolone Acetonide Nasal Aerosol

Suspension 55 mcg/act: Nasacort Allergy 24hr®*


*Trade name of product as reference


Coordination benefits you.Do it now.


WHAT IS COORDINATION OF BENEFITS?

• Avoids payments in excess when

health care is covered by two or

more health plan policies.

• The payment of deductibles and

coinsurances left to pay by the

primary plan, will be assumed by

your secondary plan when the

payment does not outpace the Net

Payment Amount if only you had a

primary plan. The payment policy

will apply as stated by the contract.

• This also applies to any request of

reimbursements you have made

where you could recover the whole

or the maximum possible of the

cost of the care received.

HOW DO I PAY THE DEDUCTIBLES AND COINSURANCES?

a. Traditional way (Medicare) -

Triple-S Salud pays the

deductibles and coinsurances left

to pay for Medicare, applying the

payment policy.

b. Triple- S Salud with another

Triple-S Salud plan or an external

private plan - the payment of

deductibles and coinsurances left

to pay for the primary plan, will be

assumed by the secondary plan

when and when this payment

does not outpace the amount of

the net payment that would have

made this same policy if only this

were your primary plan. The

payment policy applies.

c. - payment for

the secondary takes as its basis

the comparison of the net

payment of your primary with the

net payment of your secondary

plan, as if the latter is primary

WHO PAYS FIRST?

See table on next page.

—

Coordination with Government Health Plan

The government health plan will

always be secondary to any other

insurance.

Secondary

Where you are a dependent

Second birthday of the year

Primary

Where you are the policy mainholder

First birthday of the year or Oldest policy (in case both birthdays are on the same day)

Dependent /Non dependent

Birthdays

Tertiary

Spouse of custodian

Who has custody of the child

Custody Parent without custody

Retired employee insurance

Active Employee insurance

Active/inactive(mainholder)

Active Employee insurance


Active/inactive(as dependent)

MedicareActive Employee insurance

Active/inactive(retired as dependient) and Medicare


Newest policyOldest policyAntiquity

Medicare Reason* Primary

Medicare

Triple-S

Medicare

Triple-S

(OVER 65 YEARS OLD)

Less than 20 employees

20+ employees

Less than 100 employees

100+ employees

(UNDER 65 YEARS)

Secondary

Triple-S

Medicare

Triple-S

Medicare

Triple-SDoesn’t contemplate number of employees Medicare



complies with

applicable federal civil rights laws

and does not discriminate, exclude

people or treat individuals

national origin, age, disability, or sex.

1. Provides free aids and services to

people with disabilities to

such as:

interpreters

• Written information in other

formats (large print, audio,

accessible electronic formats,

other formats)

2. Provides free language services to

people whose primary language is

not English, such as:

• Information written in other

languages

If you need these services, contact a

customer a Service Representative.

Informing individuals about nondiscrimination and accessibility requirements

and nondiscrimination statement: Discrimination Is Against The Law.

If you believe that Triple S Salud, Inc.

has failed to provide these services

or has discriminated in another way

on the basis of race, color, national

origin, age, disability, or sex, you can

P.O. Box 11320, San Juan, PR

00922-3260

Telephone: (787) 620-1919 ext. 4183

Fax: (787) 706-4004

Email: [email protected]

—

by mail, fax, or email. If you need

Representative is available to help

you.

complaint with the U.S. Department

of Health and Human Services,

Portal available at

https://ocrportal.hhs.gov/ocr/porta

l/lobby.jsf or by mail or phone at:

200 Independence Ave, SW Room

509F, HHH Building, Washington,

D.C. 20201

Telephone: 1-800-368-1019,

TDD: 1-800-537-7697

NOTICE

P.O. Box 363628, San Juan, PR 00936-3628 | Tel. 787-749-4949 | ssspr.com

Call the customer service number on your ID card for assistance.

請撥打您 ID 卡上的客服號碼以尋求中文協助。

T V

Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.

.

Rele nimewo sèvis kliyantèl ki nan kat ID ou pou jwenn èd nan Kreyòl Ayisyen.

Pour une assistance en français du Canada, composez le numéro de téléphone du

Ligue para o número de telefone de atendimento ao cliente exibido no seu cartão de

numer podany na

日本語でのサポートは、IDカードに記載のカスタマーサービス番号までお電話でお問い合わせください。

Per assistenza in italiano chiamate il numero del servizio clienti riportato nella vostra

Rufen Sie den Kundendienst unter der Nummer auf Ihrer ID-Karte an, um Hilfestellung in deutscher Sprache zu erhalten.

.

NOTAS

RESUMEN DE PROGRAMA DEL PLAN DE SALUD 2018 | TRIPLE-S ÓPTIMO PLUS #

Notes


SUMMARY OF

BENEFITS OF THE

HEALTH PLAN

2019

JETBLUE AIRWAYS

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