Triple-S FarmaMed (PDP) Enrollment Form

Fill out all parts of the Enrollment Form and enjoy all the benefits that Triple-S FarmaMed (PDP) offers you. 

Let us help you: 1-877-207-8777Other ways to contact us

It is easy to enroll in Triple-S FarmaMed (PDP). Complete the Enrollment Form in all its parts, as well as the Benefits Coordination Form, and deliver them at any of our Service Centers, or mail them to the following address:

Triple-S FarmaMed
Customer Service Department
PO Box 363628
San Juan PR 00936-3628

Obtener Adobe Acrobat Reader

To view or print the following documents your computer must have installed Adobe Acrobat Reader.

Enrollment Form

Fill out the Enrollment Form in all its parts and enjoy all the benefits that Triple-S FarmaMed offers you. The premiums included in this Enrollment Form are for 2012.

Benefit Plan Selection Form

This form offers you information about the benefits and prices of our plans options, in which you may enroll.

Health Risk Assesment Form

Through this evaluation, we will know your state of health so that we may offer you benefits, services and programs geared towards your specific needs.


Updated on: October 1, 2011 

Triple-S FarmaMed (PDP) and Triple-S FarmaMed Plus (PDP) are stand-alone prescription drug plans with a Medicare contract. The plan is available to all Medicare beneficiaries with Parts A, B, or both that reside in the service area. Beneficiaries must use network pharmacies to access their prescription drug benefits, except in non-routine circumstances. Quantity limitations and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.

Y0082_WEB2012 CMS Approved 12142011

 Return to the beginning of this page