2022 Brillante (HMO-POS)

Brillante (HMO-POS) H5774-031 is a 2022 Medicare Advantage Plan or Part-C by Triple S Advantage available to residents in Puerto Rico. This plan includes additional prescription drug (Part-D) coverage. The Brillante (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out-of-pocket. This can be a extremely nice safety net.

Brillante (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Triple S Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Brillante (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Triple S Advantage and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Triple S Advantage except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Triple S Advantage Medicare Advantage Plan Costs

Brillante (HMO-POS) Part-C Premium

Triple S Advantage charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5774-031 Part-D Deductible and Premium

Brillante (HMO-POS) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Triple S Advantage plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Triple S Advantage above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Triple S Advantage Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Triple S Advantage plan does offer additional coverage through the gap.

H5774-031 Formulary or Drug Coverage

Brillante (HMO-POS) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Brillante (HMO-POS) H5774-031 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$0	$8
Tier 3	$5	$20
Tier 4	$10	$45
Tier 5	25%	25%
Tier 6	$0	$3

*Initial Coverage Phase and 30 day supply

2021 Brillante (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	35% coinsurance (Out-of-Network)
Endodontics	$0 copay
Endodontics	35% coinsurance (Out-of-Network)
Extractions	$0 copay
Extractions	35% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Non-routine services	35% coinsurance (Out-of-Network)
Periodontics	$0 copay
Periodontics	35% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	35% coinsurance (Out-of-Network)
Restorative services	$0 copay
Restorative services	35% coinsurance (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-20 copay
Diagnostic radiology services (e.g., MRI)	35% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Diagnostic tests and procedures	35% coinsurance (Out-of-Network)
Lab services	$0 copay
Lab services	35% coinsurance (Out-of-Network)
Outpatient x-rays	$0 copay
Outpatient x-rays	35% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	35% coinsurance per visit (Out-of-Network)
Specialist	$0-3 copay per visit
Specialist	35% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$50 copay per visit (always covered)
Urgent care	$0 copay

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Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Foot exams and treatment	35% coinsurance (Out-of-Network)
Routine foot care	$0 copay
Routine foot care	35% coinsurance (Out-of-Network)

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Ground Ambulance

$0 copay
35% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	35% coinsurance (Out-of-Network)
Hearing aids	$0 copay
Hearing aids	35% coinsurance (Out-of-Network)
Hearing exam	$0 copay
Hearing exam	35% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

35% per stay (Out-of-Network)
Tier 1 $0 copay per stay Tier 2 $25 per stay

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	35% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	0-10% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	35% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	0-10% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	35% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	10% coinsurance
Chemotherapy	35% coinsurance (Out-of-Network)
Other Part B drugs	0-20% coinsurance
Other Part B drugs	35% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$0 copay
Inpatient hospital - psychiatric	35% per stay (Out-of-Network)
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit	35% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$0 copay
Outpatient group therapy visit with a psychiatrist	35% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit	35% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$0 copay
Outpatient individual therapy visit with a psychiatrist	35% coinsurance (Out-of-Network)

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MOOP

$3,400 In-network

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Option

Yes, contact plan for further details

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$25 copay per visit
35% coinsurance per visit (Out-of-Network)

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Preventive Care

$0 copay
35% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay
Cleaning	35% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	35% coinsurance (Out-of-Network)
Fluoride treatment	$0 copay
Fluoride treatment	35% coinsurance (Out-of-Network)
Oral exam	$0 copay
Oral exam	35% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	$0 copay
Occupational therapy visit	35% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$0 copay
Physical therapy and speech and language therapy visit	35% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 copay
35% per stay (Out-of-Network)

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay
Contact lenses	35% coinsurance (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass frames	35% coinsurance (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglass lenses	35% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	35% coinsurance (Out-of-Network)
Other	$0 copay
Other	35% coinsurance (Out-of-Network)
Routine eye exam	$0 copay
Routine eye exam	35% coinsurance (Out-of-Network)
Upgrades	$0 copay
Upgrades	35% coinsurance (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Brillante (HMO-POS) H5774

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Brillante (HMO-POS) Plans Performance

Health Plan Customer Service Rating for Brillante (HMO-POS)

Brillante (HMO-POS) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Brillante (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.