A non-government entity
Guidewell Mutual Holding Corporation
Plan ID: H5774-41-3
Plan Summary PagePLATINO ADVANCE (HMO D-SNP)
2025 PLATINO ADVANCE (HMO D-SNP) H5774 — 041 — 3 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2025.
Learn more about PLATINO ADVANCE (HMO D-SNP) H5774 - 041 - 3, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
4 / 5 stars for 2025
$0.00 /mo
Monthly premium
$590.00
Drug deductible
$3650.00
Out-of-pocket maximum (Out-of-Network)
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Plan Overview
2025 PLATINO ADVANCE (HMO D-SNP) H5774 — 041 — 3 is a HMO D-SNP offered in Puerto Rico by Guidewell Mutual Holding Corporation. It has a monthly premium of $0.00 and includes a Part B premium discount of $20.00.
Important:
2025 PLATINO ADVANCE (HMO D-SNP) H5774 — 041 — 3 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Standard Part B Premium
$185.00
Part B premium reduction
- $20.00
Monthly Plan Premium
$0.00
Total Premium:
$165.00
Note:
The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$3650.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
Guidewell Mutual Holding Corporation
Plan Type:
HMO D-SNP
Location:
Puerto Rico
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$590
Note:
This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.
Sign up for PLATINO ADVANCE (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
PLATINO ADVANCE (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Defined Standard
Prescription drug deductible
$590.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | - | - | - | - |
2. Standard Generic | - | - | - | - |
3. Preferred Brand | - | - | - | - |
4. Non-Preferred Drug | - | - | - | - |
5. Specialty Tier | - | - | - | - |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
PLATINO ADVANCE (HMO D-SNP) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered.
More Details:
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Observation Services
Observation Services benefits are covered. Prior Authorization is required.
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered.
Individual Sessions for Outpatient Substance Abuse
Not covered.
Group Sessions for Outpatient Substance Abuse
Not covered.
Outpatient Blood Services
Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit
Three (3) Pint Deductible Waived
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Ground Ambulance Services
Not covered.
Air Ambulance Services
Not covered.
Transportation Services
Transportation Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit (10b)
Any Health-related Location
Is there a service specific maximum plan benefit coverage amount?
No
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Transportation Services - Any Health-related Location benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of trips
12
Periodicity
Every year
Type of transportation
One-way
Mode of Transportation
Taxi, Rideshare Services, Medical Transport
Description
Other methods of transportation are available, such as an automobile through a contracted provider.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage?
Yes
Is the maximum plan benefit coverage amount unlimited?
No
Maximum amount
75.00
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Chiropractic Services
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
More Details:
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care
Routine Chiropractic Care benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Visits
5
Periodicity
Every year
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Physician Specialist Services
Physician Specialist Services benefits are covered. Prior Authorization and a doctor referral are required.
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Individual Sessions for Mental Health Specialty Services
Not covered.
Group Sessions for Mental Health Specialty Services
Not covered.
Podiatry Services
Podiatry Services benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
No
Visits
4
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional
Other Health Care Professional benefits are covered. Prior Authorization and a doctor referral are required.
Psychiatric Services
Psychiatric Services benefits are covered.
Individual Sessions for Psychiatric Services
Not covered.
Group Sessions for Psychiatric Services
Not covered.
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans. A doctor referral is required.
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
7a: Primary Care Physician Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7h1: Individual Sessions for Psychiatric Services, 14d: Kidney Disease Education Services, 14e2: Diabetes Self-Management Training
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Not covered.
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education
Health Education benefits are covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Alternative Therapies benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
12
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Nutritional/Dietary Benefit benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
12
Setting for Nutritional/Dietary Benefit
Individual Sessions
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Not covered.
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Counseling Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Setting for Counseling Services
Individual Sessions
Session duration (in minutes)
20
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Barium Enemas
Barium Enemas benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
More Details:
Service maximum plan benefit coverage
Yes
Select Coverage
Both ears combined
Maximum plan benefit coverage type
Plan-specified amount per period
Maximum amount
300.00
Periodicity
Every year
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Other Eye Exam Services
Other Eye Exam Services benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Service Name
Eyewear Exam
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
300.00
Periodicity
Every year
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglass lenses
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Upgrades
Upgrades benefits are covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. Prior Authorization is required.
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Maximum amount
1750.00
Periodicity
Every year
Restorative Services
Restorative Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association(ADA).
Adjunctive General Services
Adjunctive General Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).
Endodontics
Endodontics benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association(ADA).
Periodontics
Periodontics benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).
Prosthodontics, removable
Prosthodontics, removable benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).
Maxillofacial Prosthetics
Not covered.
Implant Services
Not covered.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association(ADA).
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are administered with the CDT codes and procedures established by the American Dental Association (ADA).
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
More Details:
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
Yes
Does the benefit step from?
Part B to Part B, Part B to Part D, Part D to Part B
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
Yes
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Medicare Part B Chemotherapy/Radiation Drugs
Not covered.
Dialysis Services
Dialysis Services benefits are covered.
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered.
More Details:
Is there a coinsurance?
Yes
Minimum coinsurance
0
Maximum coinsurance
5
Is there a copayment ?
No
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
Yes
Authorization required for this benefit?
Yes
Durable Medical Equipment for use outside the home
Not covered.
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered.
More Details:
Is there a coinsurance?
Yes
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
5
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered.
More Details:
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Not covered.
Diabetic Therapeutic Shoes/Inserts
Not covered.
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
No
Diagnostic Procedures/Tests
Not covered.
Lab Services
Not covered.
All Radiological Services
All Radiological Services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
No
Diagnostic Radiological Services
Not covered.
Therapeutic Radiological Services
Not covered.
Outpatient X-Ray Services
Not covered.
Home Health Services
Home Health Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Hours of Care
Not covered.
Personal Care Services
Not covered.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. Prior Authorization is required.
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
No
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
No
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Non-Medicare-covered Stay for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
12
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items
Not covered.
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Other Services
Other Services benefits are covered.
More Details:
Is Authorization required for one or more Additional Services?
No
Is a referral required for one or more Additional Services?
No
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
Not covered.
Private Duty Nursing Services
Not covered.
Case Management (Long Term Care)
Not covered.
Institution for Mental Disease Services for Individuals 65 or Older
Not covered.
Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities
Not covered.
Case Management
Not covered.
Tobacco Cessation Counseling for Pregnant Women
Not covered.
Freestanding Birth Center Services
Not covered.
Respiratory Care Services
Not covered.
Family Planning Services
Not covered.
Nursing Home Services
Not covered.
Home and Community Based Services
Not covered.
Personal Care Services
Not covered.
Self-Directed Personal Assistance Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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