Platinum

Maximum protection and peace of mind

The Platinum Plan provides expanded medical coverage, greater flexibility, and enhanced protection against hospital costs.

Hospital and physician services without referral

Access to advanced services

Laboratory tests and diagnostic services covered

Life insurance benefit

Summary of Benefits:

Click any category to see detailed copays and coverage.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual

N/A

Family

N/A

Annual Prescription Drug Deductible

Annual amount before prescriptions are covered

Individual

N/A

Family

N/A

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual

$3,500

Family

$7,000

Emergency Services

Immediate emergency care

Accident / Illness

$25

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician

$5

Specialist

$10

Sub-specialist

$15

Psychiatrist

$10

Psychologist

$10

Podiatrist

$10

Chiropractor

$10

Audiologist

$10

Optometrist

$10

Ambulatory Surgery Center

$50

In-office diagnostic / surgical procedures

20%

Endoscopic procedures

20%

Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory

20%

X-Ray

20%

Ultrasound

20%

PET Scan, CT Scan, MRI, or PET CT (1 per year)

20%

Hospitalization

Hospital stays and inpatient care

Partial (including Mental Health)

$30

With preauthorization (including Mental Health)

$50

Without preauthorization (including Mental Health)

$50

Skilled nursing care

$50

Surgical assistant

Subscriber pays 20%

Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical therapy

$10

Respiratory therapy

$10

Home health care

20%

Durable medical equipment

20% up to $5,000; excess 80%

Chiropractic Manipulations

$10

Mental Health

Group therapy and emotional support

Group therapy

$10

Collateral visits

$10

Pharmacy

Covered prescription medications

Generic Bioequivalent – Level 1

$5

Preferred Brand – Level 2

20% min $20 ($0–$1,200); over $1,201:
60% Generic First Option

Non-Preferred Brand – Level 3

30% min $30 ($0-$1,200) over $1,201:
60% Generic First Option

Specialty Drugs – Level 4

50% ($0-$1,200) over $1,201:
60% Generic First Option

Over-the-Counter (OTC) medications

$1

Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive services including women’s services

0%

Preventive vaccines

0%

Respiratory Syncytial Virus vaccine

20%

Vision Services

Exams, lenses, and vision benefits

Adult refraction exam

$10

Adult reimbursement coverage

100% reimbursement up to $125
for lenses and frames

Pediatric refraction exam

0%

Pediatric vision – corrective lenses

20% coinsurance up to $250
for lenses and frames

Other Services

Air ambulance and U.S. coverage

Air ambulance in Puerto Rico

$10

Emergency services in the U.S.

20% coinsurance

Services in the U.S. (not available in PR)

20% coinsurance

Bariatric Surgery for Morbid Obesity

Procedure for severe obesity management

Bariatric surgery procedure

$50

Included Programs

Nutritionist and support programs

Nutritionist

Reimbursement up to $20 per visit
(max. 4 per year)

Dental Coverage

Diagnosis, prevention, and dental treatments

Preventive Diagnostics

0%

Minor Restorative

20%

Major Restorative

50%

Space maintainers

Not covered

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual	N/A
Family	N/A

Annual Prescription Drug Deductible

Annual amount before prescriptions are covered

Individual	N/A
Family	N/A

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual	$3,500
Family	$7,000

Emergency Services

Immediate emergency care

Accident / Illness

$25

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician	$5
Specialist	$10
Sub-Especialist	$15
Psychiatrist	$10
Psychologist	$10
Podiatrist	$10
Chiropractor	$10
Audiologist	$10
Optometrist	$10
Ambulatory Surgery Center	$50
In-office diagnostic / surgical procedures	20%
Endoscopic procedures	20%

Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory	20%
X-Ray	20%
Ultrasound	20%
PET Scan, CT Scan, MRI o PET CT (1 year)	20%

Hospitalization

Hospital stays and inpatient care

Partial (including Mental Health)	$30
With preauthorization (including Mental Health)	$50
Without preauthorization (including Mental Health)	$50
Skilled nursing care	$50
Surgical assistant	Subscriber pays 50%

Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical therapy	$10
Respiratory therapy	$10
Home health care	20%
Durable medical equipment	20% up to $5,000; excess 80%
Chiropractic Manipulations	$10

Mental Health

Group therapy and emotional support

Group therapy	$10
Collateral visits	$10

Pharmacy

Covered prescription medications

Generic Bioequivalent – Level 1	$5
Preferred Brand – Level 2	20% min $20 ($0-$1,200); over $1,201: 60% Generic First Option
Non-Preferred Brand – Level 3	30% min $30 ($0-$1,200); over $1,201: 60% Generic First Option
Specialty Drugs – Level 4	50% ($0-$1,200); over $1,201: 60% Generic First Option
Over-the-Counter (OTC) medications	$1

Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive services including women’s services	0%
Preventive vaccines	0%
Respiratory Syncytial Virus vaccine	20%

Vision Services

Exams, lenses, and vision benefits

Adult refraction exam	$10
Adult reimbursement coverage	100% reimbursement up to $125 for lenses and frames.
Pediatric refraction exam	0%
Pediatric vision – corrective lenses	20% coinsurance up to $250 for lenses and frames.

Other Services

Air ambulance and U.S. coverage

Air ambulance in Puerto Rico	$10
Emergency services in the U.S.	Coseguro de 20%
Services in the U.S. (not available in PR)	20% coinsurance

Bariatric Surgery for Morbid Obesity

Procedure for severe obesity management

Bariatric surgery procedure

$50

Included Programs

Nutritionist and support programs

Nutritionist

Reimbursement up to $20 per visit (max. 4 per year)

Dental Coverage

Diagnosis, prevention, and dental treatments

Preventive Diagnostics	0%
Minor Restorative	20%
Major Restorative	50%
Space maintainers	Not Covered

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Other benefits

Choose additional benefits that suit your needs. You can add an Extended Dental Plan or Life Insurance for greater peace of mind.

Extended Dental Plan

Extensive dental coverage including crowns.

Preventive Diagnostics

Coinsurance

Dental Exam (1 every 3 years)

Dental Exam Periodic

Dental Preventive - adult (1 every 6 months)

Fluoride Treatment (1 every 6 months) (up 19 yr)

Sealant (under 14 yrs)

20%

Dental Spacer (up 14 yr) (1 per lifetime)

Dental X-ray Complete Series (1 every 3 years)

Dental Periapical Film-Initial (1 per year)

Dental Periapical Films (5 per year)

Dental Bitewings

Dental X-ray (panoramic every 3 years)

Minor Restorative

Dental Restorative (every 3 years)

20%

Sedative Filling (every 5 years per tooth) (1 piece per day)

20%

Simple Extraction

20%

Emergency Dental Visit (every 6 months)

20%

Major Restorative

Dental Endodontics (every 5 years per tooth)

20%

Dental Periodontics (per quadrant)

20%

Dental Oral Surgery

20%

Extended Dental (Optional)

Dental Crowns Restoration (every 5 years)

50%

Cost: $10.00 Individual, $20.00 Couple, $22 Family

Personal Protective Equipment for the Dentist

20%

Life Insurance

Includes life insurance for your peace of mind.

Annually Renewable Term Life Insurance

The company will pay the designated beneficiary in effect on the date of the insured subscriber's death, the amount of $5,000 for death.

Accidental Death Insurance

The company will pay an additional $5,000 to the life insurance benefit to the designated beneficiary, should the insured subscriber die due to an accident.

Accidental Death and Dismemberment

The amount indicated in the following table will be paid to the designated beneficiary in case of accidental death and to the insured in case of dismemberment when, within a period of ninety (90) days from the date of the accident, one of the following losses occurs:

For the Loss of:

The amount of: will be paid

Life

$5,000

Both hands or both feet

$5,000

Sight of both eyes

$5,000

One hand and one foot

$5,000

One hand and the sight of one eye

$5,000

One foot and the sight of one eye

$5,000

Loss of speech

$5,000

Hearing in both ears

$5,000

One hand, one foot, or the sight of one eye

$2,500

Hearing in one ear

$5,000

Thumb and index finger of the same hand

$1,250

Accelerated Death Benefit Endorsement for Early Payment

This Accelerated Death Benefit Endorsement for early payment is an excellent benefit available to all insureds who qualify for the insurance. The endorsement provides for the advance payment of 50% of the basic coverage amount (life insurance) in the event that the insured is diagnosed with a terminal illness and a physician certifies that the insured's life expectancy is 12 months or less.

The 50% advance of the insurance amount may only be requested once. The advance is not a loan and does not incur a penalty on the remaining life insurance amount. The endorsement has a cost that is calculated at the time the advance is requested.

Subscriber's Insurance Reduction by Age

The insurance amount will be reduced according to the following table:

Age

Insurance Amount
(% of Principal Insurance Amount)

65-69

65%

70-74

45%

75-79

30%

80-84

30%

85-89

15%

90 or more

10%

Life and Accidental Death Insurance

In the event that death was caused by an accident, the insurance would pay the basic amount of $5,000 plus the accidental death insurance of $5,000, for a total of $10,000.

Extended Dental Plan

Extensive dental coverage including crowns.

Preventive Diagnostics	Coinsurance
Dental Exam (1 every 3 years)	0%
Dental Exam Periodic	0%
Dental Preventive - adult (1 cada 6 meses)	0%
Fluoride Treatment (1 every 6 months) (up 19 yr)	0%
Sellante (under 14 yrs)	20%
Dental Spacer (up 14 yr) (1 per lifetime)	0%
Dental Xray Complete Series (1 every 3 years)	0%
Dental Periapical Film-Initial (1 per year)	0%
Dental Periapical Films (5 per year)	0%
Dental Bitewings	0%
Dental X-ray (panoramic every 3 years)

Dental Endodoncy (every 5 years per tooth)	20%
Dental Periodoncy (per quadrant)	20%
Dental Oral Surgery	20%

Dental Crowns Restoration (cada 5 años)	50%
Cost: $10.00 Individual, $20.00 Couple, $22 Family

Personal Protective Equipment for Dentists	20%

Life Insurance

Includes life insurance for your peace of mind.

Annually Renewable Term Life Insurance

The company will pay the designated beneficiary in effect on the date of the insured subscriber's death, the amount of $5,000 for death.

Accidental Death Insurance

The company will pay an additional $5,000 to the life insurance benefit to the designated beneficiary, should the insured subscriber die due to an accident.

Accidental Death and Dismemberment

The amount indicated in the following table will be paid to the designated beneficiary in case of accidental death and to the insured in case of dismemberment when, within a period of ninety (90) days from the date of the accident, one of the following losses occurs:

For the Loss of:	The amount of will be paid:
Life	$5,000
Both hands or both feet	$5,000
Sight of both eyes	$5,000
One hand and one foot	$5,000
One hand and the sight of one eye	$5,000
One foot and the sight of one eye	$5,000
Loss of speech	$5,000
Hearing in both ears	$5,000
One hand, one foot, or the sight of one eye	$2,500
Hearing in one ear	$5,000
Thumb and index finger of the same hand	$1,250

Accelerated Death Benefit Endorsement for Early Payment

This Accelerated Death Benefit Endorsement for early payment is an excellent benefit available to all insureds who qualify for the insurance. The endorsement provides for the advance payment of 50% of the basic coverage amount (life insurance) in the event that the insured is diagnosed with a terminal illness and a physician certifies that the insured's life expectancy is 12 months or less.

The 50% advance of the insurance amount may only be requested once. The advance is not a loan and does not incur a penalty on the remaining life insurance amount. The endorsement has a cost that is calculated at the time the advance is requested.

Subscriber's Insurance Reduction by Age

The insurance amount will be reduced according to the following table:

Age	Insurance Amount
65-69	65%
70-74	45%
75-79	30%
80-84	30%
85-89	15%
90 or older	10%

Life and Accidental Death Insurance

In the event that death was caused by an accident, the insurance would pay the basic amount of $5,000 plus the accidental death insurance of $5,000, for a total of $10,000.

Loading...

You've seen everything this plan includes! Now it's your turn: Get a quote and start enjoying the benefits today.

Still not sure which one to choose?

We’ll help you find the ideal plan for you.

Platinum

Summary of Benefits:

Benefit / Service Category

Individual

N/A

Family

N/A

Individual

N/A

Family

N/A

Individual

$3,500

Family

$7,000

Accident / Illness

$25

Primary Care Physician

$5

Specialist

$10

Sub-specialist

$15

Psychiatrist

$10

Psychologist

$10

Podiatrist

$10

Chiropractor

$10

Audiologist

$10

Optometrist

$10

Ambulatory Surgery Center

$50

In-office diagnostic / surgical procedures

20%

Endoscopic procedures

20%

Laboratory

20%

X-Ray

20%

Ultrasound

20%

PET Scan, CT Scan, MRI, or PET CT (1 per year)

20%

Partial (including Mental Health)

$30

With preauthorization (including Mental Health)

$50

Without preauthorization (including Mental Health)

$50

Skilled nursing care

$50

Surgical assistant

Subscriber pays 20%

Physical therapy

$10

Respiratory therapy

$10

Home health care

20%

Durable medical equipment

20% up to $5,000; excess 80%

Chiropractic Manipulations

$10

Group therapy

$10

Collateral visits

$10

Generic Bioequivalent – Level 1

$5

Preferred Brand – Level 2

20% min $20 ($0–$1,200); over $1,201:60% Generic First Option

Non-Preferred Brand – Level 3

30% min $30 ($0-$1,200) over $1,201: 60% Generic First Option

Specialty Drugs – Level 4

20% min $20 ($0–$1,200); over $1,201:
60% Generic First Option

30% min $30 ($0-$1,200) over $1,201:
60% Generic First Option

50% ($0-$1,200) over $1,201:
60% Generic First Option

100% reimbursement up to $125
for lenses and frames

20% coinsurance up to $250
for lenses and frames

Reimbursement up to $20 per visit
(max. 4 per year)