Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H4005-004

Medicare Plan

Óptimo Plus (PPO) · Triple-S Advantage · Local PPO · Puerto Rico

Full CMS plan ID: H4005-004-000

H4005-004-000 is the full CMS identifier for the H4005-004 Medicare plan. Common searches include H4005 004 and H4005004.

Historical 2026 record. Benefits and service areas shown apply to that year.

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Óptimo Plus (PPO)

H4005-004-000 Puerto Rico Local PPO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Cost-sharing tier 1

Per admission $0 per stay
Plan-listed inpatient copay $0

Cost-sharing tier 2

Per admission $50 per stay
Plan-listed inpatient copay $50

inpatient cost sharing varies by a CMS plan-defined group

02

Emergency transport

Ambulance

Ground · in-networkCost share not reported
Air · in-networkCost share not reported
03

Emergency services

Emergency room

$50 copay

Waived if admitted within 24 hours

04

Medical maximum

Maximum out-of-pocket

In-network$6,751
Combined in + out$10,000
05

Skilled care at home

Home health

In-networkCost share not reported
Out-of-network20% coinsurance
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkCost share not reported
Out-of-network20% coinsurance

Specialist

In-network$0–$5 copay
Out-of-network20% coinsurance

Preventive care

In-networkCost share not reported
Out-of-networkCost share not reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-network0%–10% coinsurance
Out-of-network20% coinsurance

Laboratory services

In-network0%–10% coinsurance
Out-of-network20% coinsurance

X-rays & standard imaging

In-network$0–$25 copay + 0%–10% coinsurance
Out-of-network20% coinsurance

MRI, CT & PET imaging

In-network0%–10% coinsurance
Out-of-network20% coinsurance
Urgent & hospital care6 benefits

Urgent care

In-networkCost share not reported
Out-of-networkNot separately reported

Emergency room

In-network$50 copay
Out-of-networkNot separately reported

Ground ambulance

In-networkCost share not reported
Out-of-network20% coinsurance

Air ambulance

In-networkCost share not reported
Out-of-network20% coinsurance

Outpatient hospital

In-network$35 copay
Out-of-network20% coinsurance

Outpatient surgery / ASC

In-network$35 copay
Out-of-network20% coinsurance
Recovery & therapy5 benefits

Home health

In-networkCost share not reported
Out-of-network20% coinsurance

Skilled nursing facility

In-networkCost share not reported
Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-networkCost share not reported
Out-of-network25% coinsurance

Occupational therapy

In-network$5 copay
Out-of-network25% coinsurance

Physical & speech therapy

In-network$5 copay
Out-of-network25% coinsurance
Behavioral health2 benefits

Mental health services

In-networkCost share not reported
Out-of-network20% coinsurance

Substance use treatment

In-networkCost share not reported
Out-of-network20% coinsurance
Specialty care2 benefits

Podiatry

In-network$0–$5 copay
Out-of-network20% coinsurance

Chiropractic

In-network$0–$5 copay
Out-of-network25% coinsurance
Supplemental benefits7 benefits

Dental

In-networkCost share not reported
Out-of-network20% coinsurance

Vision

In-networkCost share not reported
Out-of-network20% coinsurance

Hearing

In-networkCost share not reported
Out-of-network20% coinsurance

Transportation

Not reported in this CMS export

Not reported in this CMS export

Fitness & wellness

In-networkCost share not reported
Out-of-networkCost share not reported

Over-the-counter allowance

Not reported in this CMS export

Not reported in this CMS export

Meals

In-networkCost share not reported
Out-of-networkCost share not reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$6,751
Combined in + out$10,000

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

Local PPO · Referrals: Not required · Out-of-network coverage: Yes

Prescription drugs6 tiers

Part D deductible

Not reported

Drug tier 1

$8 retail copay · 30-day supply

Drug tier 2

$20 retail copay · 30-day supply

Drug tier 3

$45 retail copay · 30-day supply

Drug tier 4

$75 retail copay · 30-day supply

Drug tier 5

33% retail coinsurance · 30-day supply

Drug tier 6

$3 retail copay · 30-day supply

Using this plan

Understand H4005-004-000

Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Óptimo Plus (PPO) is a 2026 Local PPO offered by Triple-S Advantage in Puerto Rico. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. The plan record does not require referrals. Its listed inpatient copay stages total $0 across null charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Cost share not reported
Specialist
$0–$5 copay
Laboratory services
0%–10% coinsurance

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
0%–10% coinsurance
MRI, CT & PET imaging
0%–10% coinsurance
Outpatient hospital
$35 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$50 copay
Listed inpatient stages
$0 total

null charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Availability

Who can enroll

Service area
Puerto Rico (PR)
Plan type
Local PPO
Contract / plan
H4005-004
Coverage year
2026

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

DentalCost share not reported
VisionCost share not reported
HearingCost share not reported
Fitness & wellnessCost share not reported
MealsCost share not reported

Plan-specific answers

Frequently asked questions

Where is H4005-004-000 available?

Óptimo Plus (PPO) is listed for Puerto Rico (PR). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H4005-004-000?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,751. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H4005-004-000?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H4005-004-000?

The plan record lists $50 copay, waived when an admission meets the plan's stated timing rule.

Does H4005-004-000 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness, meals. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H4005-004-000 fits

Full CMS plan ID
H4005-004-000
Contract
H4005
Base plan code
H4005-004
Segment
000
Carrier
Triple-S Advantage
Plan type
Local PPO
Service area
Puerto Rico (PR)

County/service-area foundation

CMS service-area entries

Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.

  • Adjuntas, PR
  • Adjuntas, PR
  • Aguada, PR
  • Aguada, PR
  • Aguadilla, PR
  • Aguadilla, PR
  • Aguas Buenas, PR
  • Aguas Buenas, PR
  • Aibonito, PR
  • Aibonito, PR
  • Anasco, PR
  • Anasco, PR

144 additional service-area entries are retained in the data record.

Same CMS contract

H4005-801-000 Óptimo (PPO) Puerto Rico · Local PPO H4005-802-000 Óptimo Plus A (PPO) Puerto Rico · Local PPO H4005-804-000 Óptimo Plus B (PPO) Puerto Rico · Local PPO H4005-807-000 Óptimo Plus C (PPO) Puerto Rico · Local PPO H4005-808-000 Óptimo Plus D (PPO) Puerto Rico · Local PPO H4005-809-000 Óptimo Plus E (PPO) Puerto Rico · Local PPO H4005-810-000 Óptimo Plus F (PPO) Puerto Rico · Local PPO

About this code

What H4005-004-000 identifies

H4005-004-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H4005-004, H4005 004, or the compact full CMS ID H4005004000 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.