Brillante (HMO-POS)
Available to residents of Vega Alta County, PR for 2026. Contract H5774, plan 031, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Vega Alta County
- Plan website
- Browse the Brillante (HMO-POS) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $20.00 a month?You must continue to pay your Medicare Part B premium. |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $4,200.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO-POS? |
| Contract / plan | H5774-031-0 |
| Offered by | Triple S Advantage |
| Parent organization | Guidewell Mutual Holding Corporation |
| Formulary drugs | 3,148 |
| Formulary exception tier | 4? |
| Pharmacy search | www.sssadvantage.com |
| Member services | (833)533-4330TTY (866)620-2520 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H5774 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0–$15 copay(authorization required) |
| Other health care professional | $0–$15 copay(authorization required) |
| Additional telehealth services | $0–$15 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 0%–20% coinsurance(authorization required) |
| Lab services | 0%–20% coinsurance(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$75 copay(authorization required) |
| Therapeutic radiology | $0 copay(authorization required) |
| Outpatient x-rays | $0 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $50 copay |
| Urgent care | $0 copay |
| Worldwide emergency coverage | $0 copay · $75 plan limit |
| Worldwide urgent care | $0 copay · $75 plan limit |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $50 per stay; varies by hospital tier(authorization required) |
| Outpatient hospital services | $25–$50 copay(authorization required) |
| Outpatient observation | $0 copay(authorization required) |
| Ambulatory surgical center | $25 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per stay(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $0 copay(authorization required) |
| Physical therapy and speech-language therapy | $0 copay(authorization required) |
| Cardiac rehabilitation | $0 copay(authorization required) |
| Pulmonary rehabilitation | $0 copay(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $0 per stay |
| Outpatient mental health, individual session | $0 copay |
| Outpatient mental health, group session | $0 copay |
| Psychiatrist, individual session | $0 copay |
| Psychiatrist, group session | $0 copay |
| Partial hospitalization | $0 copay(authorization required) |
| Intensive outpatient program | $0 copay(authorization required) |
| Outpatient substance use, individual session | $0 copay |
| Outpatient substance use, group session | $0 copay |
| Opioid treatment program | $0 copay |
| Ambulance and transportation | |
| Ground ambulance | $65 copay(authorization required) |
| Air ambulance | $65 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(authorization required) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–10% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 0%–20% coinsurance(authorization required) |
| Medical supplies | 0%–10% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $0–$5 copay |
| Routine chiropractic care | $0–$5 copay(limits apply) |
| Acupuncture | $0 copay(limits apply) |
| Foot exams and treatment (Medicare-covered) | $0 copay |
| Routine foot care | $0 copay(limits apply) |
| Dental? | |
| Medicare-covered dental services | $0 copay(authorization required) |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | $0 copay(limits apply) |
| Other preventive dental services | $0 copay(limits apply) |
| Comprehensive dental plan limit | $2,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $300 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $0 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay(limits apply) |
| Hearing aid plan limit | $1,250 plan limit every year |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $0 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $25 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | Not covered |
| Health education | $0 copay |
| Nutritional / dietary benefit | $0 copay |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | $0 copay |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | $0 copay |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | $0 copay |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $25.00 |
| Tier 4 | $40.00 |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | n/a | $0.00 | $10.00 | $0.00 |
| Tier 2: Generic | $0.00 | $10.00 | n/a | $0.00 | $20.00 | $0.00 |
| Tier 3: Preferred Brand | $25.00 | $45.00 | n/a | $50.00 | $90.00 | $50.00 |
| Tier 4: Non-Preferred Drug | $40.00 | $60.00 | n/a | $80.00 | $120.00 | $80.00 |
| Tier 5: Specialty Tier | 33% | 33% | n/a | 33% | 33% | 33% |
| Tier 6: Select Care Drugs | $0.00 | $3.00 | n/a | $0.00 | $6.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 77 other PR counties
- Adjuntas
- Aguada
- Aguadilla
- Aguas Buenas
- Aibonito
- Anasco
- Arecibo
- Arroyo
- Barceloneta
- Barranquitas
- Bayamon
- Cabo Rojo
- Caguas
- Camuy
- Canovanas
- Carolina
- Catano
- Cayey
- Ceiba
- Ciales
- Cidra
- Coamo
- Comerio
- Corozal
- Culebra
- Dorado
- Fajardo
- Florida
- Guanica
- Guayama
- Guayanilla
- Guaynabo
- Gurabo
- Hatillo
- Hormigueros
- Humacao
- Isabela
- Jayuya
- Juana Diaz
- Juncos
- Lajas
- Lares
- Las Marias
- Las Piedras
- Loiza
- Luquillo
- Manati
- Maricao
- Maunabo
- Mayaguez
- Moca
- Morovis
- Naguabo
- Naranjito
- Orocovis
- Patillas
- Penuelas
- Ponce
- Quebradillas
- Rincon
Benefits in plain text
Brillante (HMO-POS) (H5774-031-0) is a 2026 HMO-POS Medicare Advantage plan offered by Triple S Advantage, available to residents of Vega Alta County, PR.
The monthly premium is $0.00 (Part C and Part D together).
The plan reduces the member's Medicare Part B premium by $20.00 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $4,200.00.
The drug deductible is $0.00.
The plan's formulary lists 3,148 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $25.00; tier 4: $40.00; tier 5: 33%; tier 6: $0.00.
CMS gives the plan's contract (H5774) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.