Platino POS

Additional flexibility with out-of-network options

The Platino POS Plan offers solid coverage, affordable copays, and full access to the provider network.

Low and predictable copays

Protection against excessive expenses

Provider and pharmacy network

No-cost preventive care

Summary of Benefits:

Click any category to see detailed copays and coverage.

Benefit / Service Category

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual

$3,500 Preferred Network
and Out-of-Network

Family

$7,000 Preferred Network
and Out-of-Network

Emergency Services

Immediate emergency care

Accident

$25 Preferred Network,
$75 Out-of-Network

Illness

$25 Preferred Network,
$75 Out-of-Network

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

Nutritionist

Reimbursement up to $20 per visit, 4 per year

Ambulatory Surgery Center

$50 Preferred Network, $150 Out-of-Network

In-office diagnostic / surgical procedures

20% Preferred Network, 50% Out-of-Network

Endoscopic procedures

20% Preferred Network, 50% Out-of-Network

Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory

20% Preferred Network, 50% Out-of-Network

X-Ray

20% Preferred Network, 50% Out-of-Network

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

20% Preferred Network, 50% Out-of-Network

Hospitalization

Hospital stays and inpatient care

Partial (including Mental Health)

$30 Preferred Network, $100 Out-of-Network

Complete with Pre-authorization
including Mental Health

$50 Preferred Network, $200 Out-of-Network

Complete without Pre-authorization
including Mental Health

$50 Preferred Network, $200 Out-of-Network

Diestra Nursing Facilities
or "Skilled Nursing"

$50 Preferred & Out-of-Network

Surgical assistant

20% Preferred, 80% Out-of-Network

Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical therapy

$10 Preferred and Out-of-Network

Respiratory therapy

$10 Preferred and Out-of-Network

Home health care

20% Preferred, 50% Out-of-Network

Durable medical equipment

30% up to $5,000, Excess 80%

Chiropractic Manipulations

$10 In-Network and Out-of-Network

Mental Health

Group therapy and emotional support

Group therapy

$10 In-Network and Out-of-Network

Collateral visits

$10 In-Network and Out-of-Network

Pharmacy

Covered prescription medications

Pharmacy Benefit

$0–$1,000: applicable copays
and coinsurance;
$1,001+: 60% coinsurance

Generic Bioequivalent

$5 for $0-$1,000
$1,001+: 60%

Preferred Brand

20% min $20 for $0-$1,000,
$1,001+ 60%

Non-Preferred Brand

30% min $30 for $0-$1,000,
$1,001+ 60%

Specialty Drugs

50% for $0-$1,000,
$1,001+ 60%

Over-the-Counter (OTC) medications

Not covered

Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive Services

0% Preferred Network and Out-of-Network

Preventive vaccines

0% Preferred Network and Out-of-Network

Respiratory Syncytial Virus vaccine

20% Preferred Network and Out-of-Network

Pediatric Vision Services

Exams, lenses, and vision benefits

Eye Exam (Refraction)

$0 Preferred Network and Out-of-Network

Pediatric Vision (Corrective Lenses or Frames)

20% up to $250 per glasses; over $250: 80%

Other Services

Adult Vision, Air Ambulance, coverage in the U.S.

Refraction Exam (Adults)

$10 Preferred Network and Out-of-Network

Adult Vision

100% reimbursement up to $125
per pair of lenses and frame per year

Air ambulance in Puerto Rico

$20 Preferred Network and Out-of-Network

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 Preferred Network, $200 Out-of-Network

Dental Coverage

Diagnosis, prevention, and dental treatments

Dental Benefit

$0–$1,000: coinsurance applies
$1,001+: 60%

Diagnostic & Preventive

$0 Preferred Network and Out-of-Network

Minor Restorative

$20 Preferred Network and Out-of-Network

Major Restorative

$50 Preferred Network and Out-of-Network

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

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual $3,500 Preferred and Out-of-Network
Family $7,000 Preferred and Out-of-Network
Emergency Services

Immediate emergency care

Accident $25 Preferred, $75 Out-of-Network
Illness $25 Preferred, $75 Out-of-Network
Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician $5
Specialist $10
Sub-Specialist $15
Psychiatrist $10
Psychologist $10
Podiatry $10
Chiropractor $10
Audiologist $10
Optometrist $10
Nutritionist Reimbursement up to $20 per visit, 4 per year
Ambulatory Surgery Center $50 Preferred, $150 Out-of-Network
In-office Diagnostic / Surgical Procedures 20% Preferred, 50% Out-of-Network
Endoscopic Procedures 20% Preferred, 50% Out-of-Network
Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory 20% Preferred, 50% Out-of-Network
X-Ray 20% Preferred, 50% Out-of-Network
PET Scan, CT Scan, MRI, or PET CT (1 year) 20% Preferred, 50% Out-of-Network
Hospitalization

Hospital stays and inpatient care

Partial including Mental Health $30 Preferred, $100 Out-of-Network
Complete with Preauthorization including Mental Health $50 Preferred, $200 Out-of-Network
Complete without Preauthorization including Mental Health $50 Preferred, $200 Out-of-Network
Skilled Nursing Facilities $50 Preferred and Out-of-Network
Surgical Assistance 20% Preferred, 80% Out-of-Network
Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical Therapy $10 Preferred and Out-of-Network
Respiratory Therapy $10 Preferred and Out-of-Network
Home Health Care 20% Preferred, 50% Out-of-Network
Durable Medical Equipment 30% up to $5,000, Excess 80%
Chiropractic Manipulations $10 Preferred and Out-of-Network
Mental Health

Group therapy and emotional support

Group Therapy $10 Preferred and Out-of-Network
Collateral Visits $10 Preferred and Out-of-Network
Pharmacy

Covered prescription medications

Pharmacy Benefit $0-$1,000: applicable copays and coinsurance; $1,001+: 60% coinsurance
Bioequivalent Generic $5 for $0-$1,000; $1,001+: 60%
Preferred Brand 20% min $20 for $0-$1,000; $1,001+: 60%
Non-Preferred Brand 30% min $30 for $0-$1,000; $1,001+: 60%
Specialty Products 50% for $0-$1,000; $1,001+: 60%
Over-the-Counter (OTC) Medications Not Covered
Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive Services 0% Preferred and Out-of-Network
Preventive Vaccinations 0% Preferred and Out-of-Network
Respiratory Syncytial Virus (RSV) Vaccine 20% Preferred and Out-of-Network
Pediatric Vision Services

Exams, lenses, and vision benefits

Vision Exam (Refraction) $0 Preferred and Out-of-Network
Pediatric Vision (Corrective Lenses or Frames) 20% up to $250 per lenses; over $250: 80%
Other Services

Adult Vision, Air Ambulance, coverage in the U.S.

Adult Vision Exam (Refraction) $10 Preferred and Out-of-Network
Adult Vision 100% reimbursement up to $125 for one pair of lenses and frame per year
Air Ambulance in Puerto Rico $20 Preferred and Out-of-Network
Emergency Services in the US 20% Coinsurance
Services in the US (not available in PR) 20% Coinsurance
Bariatric Surgery for Morbid Obesity

Procedure for severe obesity management

Bariatric Surgery Procedure $50 Preferred, $200 Out-of-Network
Dental Coverage

Diagnosis, prevention, and dental treatments

Dental Benefit $0-$1,000: Coinsurance; $1,001+: 60%
Diagnostic & Preventive $0 Preferred and Out-of-Network
Minor Restorative $20 Preferred and Out-of-Network
Major Restorative $50 Preferred and Out-of-Network

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

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Thank you for contacting us!

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One of our Sales Representatives will be in touch with you to provide personalized guidance
and share details about the plan you are interested in.




Thank you for considering Plan de Salud Menonita as
your health insurance provider.


Thank you for contacting us!

We have received your information and appreciate your interest in our health plans.
One of our Sales Representatives will be in touch with you to provide personalized guidance
and share details about the plan you are interested in.




Thank you for considering Plan de Salud Menonita as
your health insurance provider.


Do you need guidance?

Complete the form so we can help you with your questions.

Do you need guidance?

Complete the form and we’ll help you choose the best option.