Highlights for PPO Plans 2013

First+Plus Advantage
MA-Only (PPO)

• $0 Monthly Plan Premium
• $25 monthly Medicare Part B Reduction
• $100 every year for eyewear
• $300 every 3 years for Hearing Aids

Click one of the following links to download the document in PDF format:
Summary of Benefits
H4011_FP_13_1061_01_I F&U
Evidence of Coverage
H4011_FP_13_1127_01_I F&U
Enrollment Form
H4011_FP_13_1070_01_I CMS Approved 09/13/2012

First+Plus Advantage Plus
MA-PD (PPO)

• $0 Monthly Plan Premium
• $100 every year for eyewear
• $300 every 3 years for Hearing Aids
• $500 every year for Comprehensive Dental benefits
• $5 copay for Generic drugs, unlimited
• $25 copay for Preferred Brand Name Drugs
• $45 copay for Non-Preferred Brand Name Drugs

Click one of the following links to download the document in PDF format:
Summary of Benefits
H4011_FP_13_1061_01_I F&U
Evidence of Coverage
H4011_FP_13_1127_02_I F&U
Enrollment Form
H4011_FP_13_1070_01_I CMS Approved 09/13/2012

Employer Group Health Plans

First+Plus Gobierno Premium
MA-PD (PPO Employer Group)

• $50.00 Monthly Medicare Part B Reduction
• $0 Copay for Hospitalization
• $0 Copay for Medical Office Visits
• $100 every year for eyewear
• $300 every 3 years for Hearing Aids
• $1000 every year for Comprehensive Dental Benefits
• $35 per quarter for OTC Drugs
• $2 copay for Generic drugs, unlimited

Conditions and Limitations

• To join this plan you must be a retiree of the Goverment of Puerto Rico.

Click one of the following links to download the document in PDF format:
Summary of Benefits
H4011_FP_GOB_13_1061_01_I FYI
Evidence of Coverage
H4011_FP_GOB_13_1127_01_I FYI
Enrollment Form
H4011_FP_GOB_13_1070_01_I FYI

First+Plus Gobierno VIP
MA-PD (PPO Employer Group)

• $65 Monthly Medicare Part B Reduction
• $0 Copay for Hospitalization
• $0 Copay for Medical Office Visits
• $100 every year for eyewear
• $400 every 3 years for Hearing Aids
• $1000 every year for Comprehensive Dental Benefits
• $150 a year for Acupuncture, Gym and Nutritionist
• 2 annual visits to the Nutritionist
• $75 per quarter for OTC Drugs
• $3 copay for Generic drugs, unlimited

Click one of the following links to download the document in PDF format:
Summary of Benefits
H4011_FP_GOB_13_1061_01_I FYI
Evidence of Coverage
H4011_FP_VIP_13_1127_01_I FYI
Enrollment Form
H4011_FP_GOB_13_1070_01_I FYI

First+Plus Gobierno Plus
MA-PD (PPO Employer Group)

• $0 Copay for Hospitalization
• $0 Copay for Primary Doctor Visits
• $100 every year for eyewear
• $300 every 3 years for Hearing Aids

Click one of the following links to download the document in PDF format:
Summary of Benefits
H4011_FP_GOB_13_1061_01_I FYI
Evidence of Coverage
H4011_FP_GOB_PLUS_13_1127_01_I FYI
Enrollment Form
H4011_FP_GOB_13_1070_01_I FYI