Page 7 - 2023 SpecialtyCare Puerto Rico Benefit Guide
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2023 Benefits Guide
Medical Plan Provisions-Triple S
Triple S
Plan Provisions In-Network
Annual Deductible (Individual/Family Maximum) $0/$0
Out-of-Pocket Maximum (Includes Deductible) $6,350/$12,700
Primary Physician Office Visit $10 co-pay
Specialist Office Visit $15 co-pay
X-Ray and Lab 75%
Hospital (Regular/ Partial) $50
Major Medical 50%
Emergency Room Care $75
Retail Prescription Drugs
(30-day supply)
• Generic $5 co-pay
• Brand Preferred $20 co-pay
• Brand Non-preferred 70%, max $100
Dental Plan Provisions-Triple S (through medical)
SpecialtyCare offers you dental coverage through your medical coverage with Triple S.
Triple S
Plan Provisions In-Network
Diagnostic and Preventive Care: 70%
Includes cleanings, fluoride treatments, sealants and x-rays
Basic Services: 70%
Includes fillings, periodontics, scaling and root planing, and oral surgery
Note: This is a summary of coverage only. Please refer to the summary of benefits coverage for complete
information. In-network services are based on negotiated charges; out-of-network services are based on
Reasonable and Customary (R&C) charges.
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