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HEALTH PLAN SUMMARY 20 20
HEALTH PLAN SUMMARY 2020
Our focus is prevention. This is why we offer a variety of 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 of everything we offer you!
Welcome toTriple-S Salud
Health Care Benefit Summary
As a Grainger team member you have the opportunity to receive health care benefits that meet all your health care needs. The following summary will give you a general idea of the benefits that are covered under your plan.
IN-PATIENT SERVICES
• 365 days per year in a semi-private accommodation. The benefit includes the use of other facilities, equipment and materialsthat a hospital usually provides
• Hospitalization for mental illness, based on medical recommendation. Includes partial hospitalization services.
MEDICAL AND SURGICAL BENEFITS
• Physician visits including consultations with specialists
• Treatment and diagnostic services
• Surgical procedures and administration of anesthesia
• Lithotripsy (precertification is required)
OUTPATIENT SERVICES
• Unlimited visits to general practitioners, specialists and sub-specialists
• Psychiatric visits covered in accordance with medical recommendation.
• Initial visit to the chiropractor and up to fifteen (15) manipulations per policy year.
• Physical therapies, up to 30 sessions per policy year
• Respiratory therapies, up to 40 sessions per policy year.
• Chemotherapy, radiotherapy and cobalt treatment
• Emergency room for injury or trauma includes suture tray, medicines and materials
DIAGNOSTIC TESTS
• X-rays, laboratories, and diagnostic specialized tests like: sonograms, nuclear medicine, gastrointestinal endoscopies,and invasive cardiovascular tests and non-invasive cardiovascular tests
• Magnetic resonance imaging (MRI) and computerized tomography (CT) unlimited
• Electromyogram
• Doppler color flow
• Thin Prep Pap
MATERNITY AND INFANT BENEFITS
• Wellness baby care visits at the physician’s office during the first year of life
• Routine pre and postnatal care
• Immunizations
• Specialized tests like: Biophysical Profile, Amniocentesis, among others
OTHER BENEFITS
• Dialysis and hemodialysis covered for the period of the first ninety (90) days from the first dialysis or Hemodialysis
• Post-hospital services: Skilled nursing facilities and Home Health Care
• Pacemakers and valves
• Land ambulance services covered by reimbursement up to $80 per trip
• Durable Medical Equipment with 0% coinsurance
MAJOR MEDICAL This coverage provides the following services:
• Services rendered outside Puerto Rico
• Prosthesis or Implants
• Surgical assistance
• Cardiac rehabilitation • Sports Medicine
All services rendered outside Puerto Rico will not require a precertification and are subject to the deductible and coinsurance of the Major Medical coverage. Payment for services rendered by participating providers will be made according to the established fees by the Blue Cross and Blue Shield Association plans versus payments for services rendered by non-participating providers that will be paid based on the reasonable charges of the area on which the services are rendered.
ORGAN & TISSUE TRANSPLANT BENEFIT
These services will be covered only when rendered by participating Triple-S providers and facilities network in and outside of Puerto Rico. Covered at 100% of the Triple S Salud negotiated fees with these facilities, subject to no co-insurance or deductibles. Pre-certification is required for each phase of the transplant, pre-transplant, transplant and post-transplant. Covered transplants are heart, heart-lung, lung (single or double), liver, pancreas/kidney, kidney, bone marrow transplant. Pre-certification is required.
PRESCRIPTION DRUGS BENEFITS
Generic as first choice is required. The supply for acute drugs is up to 15 days and the supply for maintenance drugs is 30 days with five refills.
• Access to services in Puerto Rico and the United States: Triple-S, Inc. Pharmacy Network provides you access to over 981pharmacies in Puerto Rico and over 44,500 pharmacies in the United States.
• Supply for ninety (90) consecutive days for medications supplied through the Mail-Order Pharmacy Program or the 90-DayDrug-Dispensing Program in participating pharmacies.
• Coverage includes some smoking cessation drugs and nicotine replacement products when prescribed by a physician.
SPECIAL CONDITIONS PRESCRIPTION DRUG PROGRAM
Under this program, drugs for certain conditions are dispensed through the local network of the Special Condition Drug Program. These drugs are used for chronic and high-risk conditions that require specialized clinical management. Some of the medical conditions or drugs require management through the Special Condition Drug Program as follows: Cancer (oral treatment), HIV, Hemophilic Factor, Hepatitis C, Crohn’s Syndrome, Fibrocystic Therapy, Rheumatoid Arthritis, Growth Hormone Therapy and Multiple Sclerosis.
Out-of-pocket maximum (OOPM) effective January 1, 2015, as required by the Patient Protection and Affordable Care Act (PPACA)
Under this plan, there is a maximum of disbursements that people pay for medical services, hospital, and drugs covered according to their type of contract (services of the Basic, Major Medical, and Pharmacy Coverage). Under our plan, there is a maximum of disbursements that people pay for medical and hospital services covered according to their type of contract. The maximum amount of disbursement is $6,350 in an individual contract and $12,700 in couple or family contract. This is the maximum amount that the participant pay during the year contract by concept of essential medical services and hospital care covered under the contract when you visit providers inside the network, including the purchase of prescription drugs and payment for dental services. Once the person reaches the amount that applies according to the type of contract, he/she will not have to do additional disbursements for rest of the contract year. Services provided through non- participating providers, payments made by the participant person for services not covered under this contract as well as the monthly premium paid to Triple-S Salud by the plan, are not considered eligible expenditure for the accumulation of pocket maximum.
This is a brief informational summary and does not replace or modify the policy. We urge you to review the Certificate of Benefits (Policy) so that you know indetail the benefits, limitations and exclusions of the cover.
SERVICES DEDUCTIBLES, COPAYMENTS, AND COINSURANCES
All Hospitalizations
Ambulatory Surgery
Emergency Room
Visits to the General Practitioner
Specialists visits
Sub -specialists visits
X-ray’s, laboratories and otherspecialized testsLithotripsy (ESWL)
Physical and respiratory therapies
Vaccines $0.00
All Hospitalizations
Partial hospitalizations
Psychiatrist visits & collateral visits
Coinsurance
Preferred Generic (as first choice)
Non Preferred Generic
Preferred Brand Name Drugs
Non Preferred Brand Name Drugs
Preferred Specialty Products
Non Preferred Specialty Products
Drugs for chemotherapy
Pharmacy Program Express (Mail Order) & Flex 90Preferred Generic (as first choice)
Non Preferred Generic
Preferred Brand Name Drugs
Non Preferred Brand Name Drugs
Mental Condition Services, Alcoholism & Drug Abuse Services
Major Medical & Organ Transplant Coverage
Pharmacy Coverage
Grainger
Basic Coverage
Deductible
Alternative 1 (Open Acces)
$100.00
$0.00 $50.00 sickness / $25.00 accident/
$0 Teleconsulta
$8.00
$12.00
$15.00
0%
0%
$5.00
$100.00
$50.00
$12.00
$100.00 per insured
$300.00 per family
*Do not require preauthorization Ind - 20% up to $2,000.00 per policy year
Family - 20% up to $6,000.00 per policy year
$10.00
$10.00
$20.00
$20.00
10% maximum $250.00
10% maximum $250.00
$0.00
90 days of supply
$20.00
$20.00
$40.00
$40.00
MOCA
MANATÍ
UTUADOCIALES
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
JAYUYA OROCOVIS
JUANA DÍAZ
VILLALBA
BARRANQUITAS
SANTAISABEL
SALINAS
CAYEY
AIBONITO
GUAYAMA
CIDRA
SANLORENZO
GURABO
JUNCOS
LASPIEDRAS
YABUCOA
MAUNABO
PATILLAS
ARROYO
HUMACAOVIEQUES
CULEBRA
NAGUABOCIEBA
FAJARDO
LUQUILLORIOGRANDE
CANOVANAS
LOIZA
CAROLINATRUJILLOALTOGUAYNABO
VEGAALTA
TOABAJA
DORADO
COROZAL
TOAALTA
BAYAMÓN
NARANJITO
CATAÑO
COMERIO
AGUASBUENAS
ARECIBOFLORIDA
BARCELONETA
MAYAGÜEZ
PONCE
SAN JUAN
CAGUAS
787-774-6060Toll free: 1-800-981-3241TTY users: 787-792-1370TTY users: 1-866-215-1999
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(Entrance through north parking)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:• 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, certifications, among others.
TELEXPRESO (787) 774-60601-800-981-3241 (free of charge)
Connect to ssspr.comIn our portal, you can:• Check your and your dependent’s eligibility• Get a Coverage and Student Certificate• 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• Address and phone changes*
INTERNET ssspr.com
You can enjoy these useful benefits:• 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.
• Have our main phone numbers and addresses.• Service questions• View the records of the care you received.
MOBILE APP Triple-S SaludFor 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.
• Primary Care Physicians• Over 40 Specialists• Imaging Center• Women's Health and Breast Care• Mammograms, Sonograms, and Biopsies
• Chronic Condition Management• Preventive Programs• Laboratory• Pharmacy• Dental• And more...
A network of clinics designedto facilitate your healthcare.
MAKE AN APPOINTMENT
A single electronic medical record
HEALTH MADE EASIER
Mon – Thu 7:00 a.m. to 8:00 p.m.Fri 7:00 a.m. to 7:00 p.m.Sat 7:00 a.m. to 3:00 p.m.
Mon – Fri 8:00 a.m. to 5:00 p.m.
SERVICES BY CLINIC
GUAYNABOCasa Linda Ave. #1, Carr. 177,Los Filtros, Km. 2.0, Bayamón(entrance by the American Military Academy)
• Primary Care Physicians• Specialists• Imaging Center
• Audiology Center• Laboratory
CAROLINA Carr. 190, Km. 1.8, Sabana Abajo(entrance by Universidad Ana G. Méndez)
Mon – Fri 8:00 a.m. to 7:00 p.m.Sat 8:00 a.m. to 12:00 p.m.
• Primary Care Physicians• Pediatrics• Nutrition
• Vaccines• Accepts walk-in patients
CONDADO2 Washington Street, San Juan,Administration Building, AshfordPresbyterian Community Hospital (first floor)
Mon – Fri 8:00 a.m. to 5:00 p.m.
PONCE Torre Sofía 1825, 3rd Floor, Navarra Street
MAYAGÜEZ Urb. La Sultana, UBS Financial Building
CAGUAS Plaza del Carmen Mall, Suite 29, Carr. #1, Caguas, PR
AGUADILLA Aguadilla Medical Services
PRIMARY CARE PHYSICIANSACCEPTS WALK-IN PATIENTS
TRIPLE-SCONTIGOSPECIALIZED CARE DURINGYOUR HOSPITALIZATION
ASHFORD PRESBYTERIAN CENTRO CARDIOVASCULAR
MANATÍ MEDICAL CENTER MAYAGÜEZ MEDICAL CENTER
DOCTORS’ CENTER HOSPITALSan Juan • Bayamón • Carolina
SAN LUCAS PONCE
You deserve care as special as you. With Triple-S Contigo a personal assistant who will be you during your hospital stay and guide you for a successful transition of care with your primary doctor.
We want to help you complete your treatment as prescribed and avoid the need to return to the hospital.
Among the services given are:
• Coordination of services or equipment needed to continuetreatment at home
• Coordination of follow up visit with your doctor in the firstseven days after discharge
• Medication reconciliation
• Educational information about your medical conditions
• Member rights and duties guidance
• During admission our case manager will contact you andbecome part of your discharge planning
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.
Call us in confidence if:
• 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 is an exclusive service of Triple-S Salud for their members and it is administered by Axis Point Health, an independent contractor that provides phone health information and orientation services.
Teleconsulta is an exclusive health information hotline from Triple-S Salud, available 24 hours a day, 7 days a week, 365 days a year.Staffed by highly trained nursing professionals.
Our calling is to take care of you.
Call 1-800-255-4375(the number is also on your plan card)
Health information Hotline
At Triple-S, we go the extra mile to take care of your health. We havea group of experts available to you, including nurses, health educators, social workers, and nutritionists focused on your wellbeing.
These programs work hand-in-hand with your physician and are not a replacement for your treatments or medical visits. The programs are voluntary and free of charge –another benefit offered by Triple-S.
CLINICAL CARE PROGRAMS:
• Evaluate your health, social, and nutritional needs.• Develop a health care plan based on your specific needs.• Schedule your services (appointments and others).• Coordinate group and individual educational activities for
physical and mental health.• Manage chronic health conditions that are out of control.
INDIVIDUAL SERVICES
Our services include Clinical Care Programs to meet your specific needs and improve your quality of life. As part of the programs, we help you schedule telephone calls with health care professionals, such as nutritionists, social workers, and health educators. We will also mail you educational material related to your health conditions and your social or nutritional needs.
MODIFICATION AND CARE PROGRAMS:
Do you need help controlling a chronic condition? Our team is available to offer the tools you need to manage and care for conditions, such as: • Diabetes• Asthma• Heart Failure• Hypertension
We also have programs to help you manage: • High-risk pregnancies• Terminal stage cancer• Ulcers and homebound care needs• Children with special needs requiring service coordination• High usage of emergency room services• Cerebrovascular accidents• Mental health
SPECIAL COMMUNITY EVENTS
• Wellbeing Tours: events where we offer clinics to test glucose levels, total cholesterol, blood pressure, and weight, among others. Includes health education.
• Educational Campaigns• Ruta Asma: event designed for children with asthma. It offers different interactive orientations to manage and control the condition and endorse physical activity.
For more information about ourClinical Care Programs, please callus at 787-706-2552.
• Chronic Obstructive Pulmonary Disease (COPD)• Obesity
WE GO THE EXTRA MILE TO TAKE CARE OF YOUCLINICAL CARE PROGRAMS
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
EVALUATION• Medical history
• Physical examination
• Screening of depression
• Risk behavior
• Guidance: alcohol, smoking, diet, nutrition and others
Preventive centersTriple-S has Preventive Care Centers that promote the health and well-being of your staff. These centers simplify access to preventive checkups for better 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!
PREVENTIVE CARE CENTERSSALUS, Guaynabo(787) 789-1919 ext. 1044 & 1054(787) [email protected]
SALUS, Carolina (787) [email protected]
Tiger Med, Caguas(787) 646-2800(787) 286-2800 ext. 636 & [email protected]
Centro de Medicina y Cirugía Ambulatoria San Sebastián(787) 501-5324, (787) [email protected]
Preventive Care Service, Ponce(787) 651-1435, (787) 651-6479(787) 651-3607, (787) [email protected]
Villa Los Santos, Arecibo(787) 879-1585 ext. [email protected]
Bella Vista Family Medicine Center, Mayagüez(787) 834-6160 ext.203; (787) [email protected]
Wellness Alliance, Guaynabo(787) 708-6777, (787) 708-6778
Note: This program does not cover dental and drugstore services. For drugstore services, Triple-S Salud hascontracted a network in the USA.
YOUR TRIPLE-S SALUD CARD IS ACCEPTED ANYWHERE IN THE USA.
When traveling in the US, you can show your Triple-S Salud health plan card at participating hospitals within the Blue Cross Blue Shield Association to get urgent health care.
To get urgent health care or pre-authorized care in the USA:
1. Visit a participating healthcare provider in the Blue Cross Blue Shield Association network and show your health plan card.
2. The provider will check your eligibility and your policy deductibles, co-insurance, and conditions. They will then bill the Blue Cross Blue Shield Association plan.
3. You will pay the deductible and co-insurance corresponding to your benefit in the USA.
4. The Blue plan in the area you get the service will pay the provider and send Triple-S Salud the health plan claim electronically.
5. Triple-S Salud will pay the Blue plan corresponding to the provider who offered you service. They will also mail you a report with the benefits explanation.
To locate program providers please call 1-800-810-BLUE (2583)or visit http://provider.bcbs.com/
The Traveler’s PlanBlue Card Program
No matter where you are in the USA, yourTriple-S Salud card will make you feel rightat home.
THE PROGRAM IS AVAILABLE ONLY THROUGH THE FOLLOWING PARTICIPATING FACILITIES:
Triple-S NaturalProgram
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• Reflexology• 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. Armonia Natural - Manatí
Urb Atenas, J49 calle JP ReyesTel. 787-884-7024
Armonia Natural - DoradoDorado del Mar Shopping Center500 Carr 693 suite 20, DoradoTel. 787-796-3380
Centro Universitario de MedicinaIntegral y ComplementariaHospital Dr Ramón Ruiz Arnau100 Ave Laurel, BayamónTel. 787-269-0988
Acupati PSC32 calle Del Río, MayagüezTel. 787-831-7173
Body Align Structural MassageHealth for Wellness CSPEdif Professional PlazaCarr 2 Km 118.9, AguadillaTel. 787-238-7909
Condado WellnessSan Juan Health Centre150 Ave de Diego Piso 2, San JuanTel. 787-230-7557
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.
To find a participating pharmacy near you:
• Visit our online site ssspr.com
• Access our app Triple-S Salud, available for Apple and Android.
Understanding your pharmacy benefits and programs will help you maintain an optimal state of health and will save you time and money.
DISPENSING/SUPPLY
Acute Drugs
To treat conditions that have a clearly defined time from start and end. Its onset is sudden and the treatment is of short duration.
In general, our plans cover up to a maximum supply of fifteen (15) days for these drugs and have no refills.
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 supply and up to a maximum of five (5) refills. Some of these drugs may also be filled in an extended 90 days supply (and one refill) and through participating pharmacies or the mail order pharmacy.
There are pharmacy coverages that require the dispensing of generic drugs as a first choice.
You can get a 90-day supply for certain maintenance drugs in our Program pharmacies. All you need is to ask your doctor for a prescription 90 days plus one (1) refill of your maintenance drugs.
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
Triple-S Salud PharmacyMail Order ProgramYou can get certain maintenance drugs through the mail, in the comfort of your home; up to a 90-day supply.
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.
• From the page of confirmation of registration, follow the instructions to submit your recipe.
• 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, one for the first 30 days that you can fill it in your local pharmacy and other for 90 days with one refill for our mail 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
Specialty Drug ManagementProgram through our ExclusivePharmacy NetworkAn integrated care of specialized medications for high risk and life-long health. 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
• HIV (human immunodeficiency virus)• Multiple Sclerosis• Hepatitis C
You will get your drugs at your place of choice in Puerto Rico or USVI. You may arrange to have them sent to your home, physician’s office, or any other place for pick-up.
If you have questions or need help, call (787) 774-6060.
355 Ave. De Diego San Juan, PR 00909
Ave. Jesús T. Piñero #280,Suite B, San Juan, PR 00918
BestOption Healthcare
CVS CaremarkSpecialty Pharmacy
T: (787) 723-6868 LC: 1(866) 981-8124F: (787) 723-6987
LC: 1(888) 280-1190T: (787) 759-4162
F: (787) 759-4161 / 1(855) 297-1270
Walgreens Specialty Pharmacy
15191 65 Infantería Shopping Court Suite 101, San Juan, PR 00926
T: (787) 777-1120
Triple-S Salud has added in most of its prescription drug coverages some OTC drug alternatives; without $0 copay to you.
These choices are of great benefit for you because you can have access to effective drugs with a lower cost in your pharmacological 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
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.
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
Benefit coordination
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. Preserving benefits - 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.
* Triple-S will always be your secondary plan if you belong to a group insurance classified as: Retired, Disabled, COBRA, Direct pay individual policy.
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
Retired employee insurance
Active/inactive(as dependent)
MedicareActive Employee insurance
Active/inactive(retired as dependient) and Medicare
Retired employee insurance
Newest policyOldest policyAntiquity
Medicare Reason* Primary
Medicare
Triple-S
Medicare
Triple-S
A. AGE (OVER 65 YEARS OLD)
Less than 20 employees
20+ employees
Less than 100 employees
100+ employees
B. DISABILITY (UNDER 65 YEARS)
C. CHRONIC RENAL DISEASE
Secondary
Triple-S
Medicare
Triple-S
Medicare
Triple-SDoesn’t contemplate number of employees Medicare
Triple S Salud, Inc. complies with applicable federal civil rights laws and does not discriminate, exclude people or treat individuals differently because of race, color, national origin, age, disability, or sex.
1. Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language 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:
• Qualified interpreters
• 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 file a grievance with:
Service RepresentativeP.O. Box 11320, San Juan, PR 00922-9905Telephone: (787) 774-6081 or1-800-716-6081TTY: (787) 792-1370 or [email protected] —You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Service Representative is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically, through the Office of Civil Rights Portal available at https://ocrportal.hhs.gov/ocr/portal/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
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。
Gọi số dịch vụ khách hàng trên thẻ ID của quý vị để được hỗ trợ bằng Tiếng Việt.
Para sa tulong sa Tagalog, tumawag sa numero ng serbisyo sa customer na nasa inyong ID card.
Обратитесь по номеру телефона обслуживания клиентов, указанному на Вашей идентификационной карточке,для помощи на русском языке.
اتصلبرقمخدمةالعملاءالموجودعلىبطاقةهُويتكللحصولعلىالمساعدةباللغةالعربية.
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 service à la clientèle figurant sur votre carte d’identification.
Ligue para o número de telefone de atendimento ao cliente exibido no seu cartão de identificação para obter ajuda em português.
Aby uzyskać pomoc w języku polskim, należy zadzwonić do działuobsługi klienta pod numer podany na identyfikatorze.
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 scheda identificativa.
Rufen Sie den Kundendienst unter der Nummer auf Ihrer ID-Karte an, um Hilfestellung in deutscher Sprache zu erhalten.
جرد امش ییاسانش تراک یور رب هک یرتشم تامدخ هرامش اب ، یسراف نابز هب ییامنهار تفایرد یارب .دیریگب سامت تسا هدش
Independent Licensee of BlueCross BlueShield Association TSS-DVAC-0943-2018-B
HEALTH PLAN SUMMARY 2020
