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Óptimo Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Óptimo Plus (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Óptimo Plus (PPO) in 2025, please refer to our full plan details page.
Óptimo Plus (PPO) is a PPO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2025 to people living in Puerto Rico. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Óptimo Plus (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Óptimo Plus (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Óptimo Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $25.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $10000.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $10000.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Óptimo Plus (PPO) plan has an enhanced alternative drug benefit, and a $0 deductible. During the initial coverage phase, you will pay varying copays depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay at a preferred pharmacy. The plan also offers catastrophic coverage, where you pay nothing for Part D covered drugs after your yearly out-of-pocket drug costs reach $2000. If you qualify for the low-income subsidy, you may have reduced premium costs.
Additional Benefits
The Óptimo Plus (PPO) plan offers comprehensive coverage with a range of benefits. Inpatient hospital stays have either no copay or a $25 copay, while outpatient services have a $35 copay. Emergency services have a $50 copay, and primary care and specialist visits have $0-$5 copays. Preventive services are covered with no copay, and the plan includes hearing, vision, and dental benefits with varying levels of coverage and annual maximums. Home health services have no copay or coinsurance, and ambulance services have no copay or coinsurance. The plan also covers home infusion bundled services, dialysis services, medical equipment, and diagnostic and radiological services with coinsurance applying to some services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Inpatient Hospital-Acute has no copay for Medicare-covered stays, and additional days are covered; however, Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered. Inpatient Hospital Psychiatric has a $25 copay for Medicare-covered stays, but additional days and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services for the Óptimo Plus (PPO) plan include coverage for outpatient hospital services, observation services, and ambulatory surgical center services, each with a $35 copay. Outpatient substance abuse services include individual and group sessions, each with a copay of $5.00. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by the Óptimo Plus (PPO) plan. All Ambulance Services are covered with no copay or coinsurance, but Ground Ambulance Services and Air Ambulance Services are not covered. Transportation Services to any health-related location are also not covered.
Emergency Services See details
Emergency Services are covered by Óptimo Plus (PPO), with a $50 copay and no coinsurance. Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are also covered with no copay and no coinsurance, but Worldwide Emergency Transportation is not covered.
Primary Care See details
Óptimo Plus (PPO) covers primary care physician services, chiropractic services with a $5 copay, occupational therapy services with a $5 copay, physician specialist services with a $0-$5 copay, mental health specialty services with a $5 copay for individual and group sessions, podiatry services with a $0-$5 copay, other health care professional services with a $0-$5 copay, psychiatric services with a $5 copay for individual and group sessions, physical therapy and speech-language pathology services with a $5 copay, additional telehealth benefits with a $0-$5 copay, and opioid treatment program services. Routine chiropractic care is limited to 6 visits per year.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, as well as additional preventive services. Additional services include health education, alternative therapies (with a $5 copay per visit, up to 12 visits), nutritional/dietary benefits, fitness benefits, enhanced disease management, counseling services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs (following a welcome visit). Annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, telemonitoring services, remote access technologies, and home and bathroom safety devices and modifications are not covered.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids, with one visit covered every year for each. Prescription hearing aids are covered up to a maximum of $500 per year for both ears combined, but inner ear, outer ear, and over the ear hearing aids are not covered; OTC hearing aids are also not covered.
Vision Services See details
The Óptimo Plus (PPO) plan covers vision services, including eye exams, eyewear, and contact lenses. Routine eye exams and other eye exam services are covered once per year. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades have a combined maximum benefit of $250 per year.
Dental Services See details
The Óptimo Plus (PPO) plan covers a range of dental services, including oral exams, dental X-rays, and other diagnostic and preventive services, but excludes maxillofacial prosthetics, implant services, and orthodontics. The plan provides a maximum benefit of $4,500 per year for orthodontic services, with all other services not having a stated maximum.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered under the Óptimo Plus (PPO) plan. Coinsurance applies to these services, with a maximum of 10% for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs.
Dialysis Services See details
Dialysis Services are covered by the Óptimo Plus (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits under the Óptimo Plus (PPO) plan include Durable Medical Equipment (DME) with a 10% coinsurance and Prosthetics/Medical Supplies with a 10% coinsurance for Medicare-covered items, but Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a coinsurance of at most 10% and lab services with a coinsurance of at most 10%. Diagnostic Radiological Services have a coinsurance of at most 10% and a copay of at most $25.00, while Therapeutic Radiological Services and Outpatient X-Ray Services have a coinsurance of at most 10%.
Home Health Services See details
Home Health Services are covered by the Óptimo Plus (PPO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Óptimo Plus (PPO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered SNF and non-Medicare-covered stays are not covered. Prior authorization is required for this benefit.
Other Services See details
Under the Óptimo Plus (PPO) plan, acupuncture has a $5 copay, and OTC items are covered. Other services such as meal benefits, and home and community based services are not covered.
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