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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 2026, 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 2026.
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.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 features a $0 drug deductible, meaning your prescription coverage begins immediately with no deductible to meet. For Tier 1 preferred generics, Tier 2 generics, and Tier 6 select care drugs, you will pay no copay for a 1-month or 3-month supply at preferred pharmacies, or for a 3-month supply through standard mail order. Standard pharmacies charge low copays for these tiers, starting at $3 for select care drugs and up to $20 for generic drugs for a 1-month supply. For brand-name medications, preferred pharmacies offer Tier 3 preferred brands for a $30 copay and Tier 4 non-preferred brands for a $50 copay for a 1-month supply. Standard pharmacies charge higher copays of $45 for Tier 3 and $75 for Tier 4 drugs, though 3-month mail-order options can help reduce these costs. Specialty medications in Tier 5 require a 33% coinsurance regardless of whether you use a preferred, standard, or mail-order pharmacy.
Additional Benefits
The Óptimo Plus (PPO) plan offers robust coverage with no copays and no coinsurance for many essential services, including inpatient hospital stays, primary care visits, and skilled nursing facility care. Outpatient services and emergency room visits are highly affordable, requiring low copays of $35 and $50 respectively with no coinsurance, while urgently needed care has no copay. Additionally, diagnostic services, lab tests, and home health services are fully covered with no copays or coinsurance. This plan also features valuable everyday benefits, offering routine dental, vision, and hearing exams with no copays or coinsurance, alongside annual allowances of $1,000 for dental and $200 each for eyewear and hearing aids. Members can also take advantage of over-the-counter items with no copay via a debit card and low-cost specialist visits ranging from $0 to $5. Durable medical equipment and dialysis services are also accessible, requiring no copays and coinsurance ranging from 10% to 20%.
Inpatient Hospital See details
Óptimo Plus (PPO) covers inpatient acute hospital stays with no copay, no coinsurance, and unlimited additional days, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital stays are covered with a $25 copay per admission and no coinsurance, but additional days are not covered.
Outpatient Services See details
Óptimo Plus (PPO) covers outpatient hospital, observation, and ambulatory surgical center services for a $35 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance. Outpatient substance abuse services are not covered under this plan.
Partial Hospitalization See details
Óptimo Plus (PPO) covers partial hospitalization with no copay and no coinsurance, though prior authorization is required for these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Óptimo Plus (PPO) plan with no copay and no coinsurance, requiring prior authorization. While some services are covered, ground ambulance, air ambulance, and health-related transportation services are not covered.
Emergency Services See details
Óptimo Plus (PPO) covers emergency services with a $50 copay (waived if admitted to the hospital within 24 hours) and no coinsurance, while urgently needed services are covered with no copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $75 maximum limit with no copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under Óptimo Plus (PPO) feature no copay and no coinsurance for primary care physician visits, opioid treatment, and telehealth, while specialists, occupational and physical therapies, and podiatry require copays of $0 to $5 with no coinsurance. Chiropractic care is partially covered, excluding other chiropractic services, and individual or group sessions for mental health and psychiatric services are not covered.
Preventive Services See details
Preventive services are partially covered by Óptimo Plus (PPO) with no copay and no coinsurance for most Medicare-covered services, though alternative therapies require a $5 copay and no coinsurance. This benefit does not cover several sub-services, including annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, therapeutic massage, and weight management programs.
Hearing Services See details
Óptimo Plus (PPO) partially covers hearing services, offering one routine exam and one fitting evaluation per year with no copay, no coinsurance, and no deductible. Prescription hearing aids are covered with no copay or coinsurance up to a $200 annual limit for both ears, but inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are covered by Óptimo Plus (PPO) with no copay and no coinsurance for both eye exams and eyewear. Members receive one routine eye exam and one eyewear exam annually, alongside a combined maximum allowance of $200 per year for contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Dental services are partially covered under the Óptimo Plus (PPO) plan with no copay and no coinsurance for covered preventive and comprehensive care, though prior authorization is required for some services. Comprehensive care is subject to a $1,000 annual maximum, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Óptimo Plus (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy may apply. Under this benefit, insulin is covered with no copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other drugs feature no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Óptimo Plus (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Óptimo Plus (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment and medical supplies carry a 10% coinsurance, prosthetic devices have a 0% to 10% coinsurance, and diabetic equipment is partially covered with no coinsurance, as diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Óptimo Plus (PPO) covers diagnostic and radiological services, with prior authorization required for all services. Diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-rays are covered with no copay and no coinsurance, while therapeutic radiological services require a copay and no coinsurance.
Home Health Services See details
Óptimo Plus (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the Óptimo Plus (PPO) plan with no copay and no coinsurance, though prior authorization is required. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Óptimo Plus (PPO) covers Skilled Nursing Facility (SNF) services with no copay and no coinsurance per stay, though prior authorization is required. While the plan does not require a prior three-day inpatient hospital stay for admission, additional days beyond Medicare-covered days are not covered.
Other Services See details
Other Services covered under the Óptimo Plus (PPO) plan are partially covered, featuring acupuncture with a $5.00 copay and no coinsurance for up to 12 treatments annually, alongside over-the-counter (OTC) items with no copay and no coinsurance via a debit card. Meal benefits, nicotine replacement therapy, and naloxone are not covered.
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