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

Name:
Brillante (HMO-POS)
Plan ID:
H5774-031
Provider:Triple S Advantage
Year:2022
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $3,400
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H5774-003
New Plan: 2023 H5774-003




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.



Additional Benefits


No



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)



Deductible


$0



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)



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)



Emergency care/Urgent Care


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



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)



Ground Ambulance


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



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)



Inpatient Hospital Coverage


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



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)



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)



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)



MOOP


$3,400 In-network



Option


Yes, contact plan for further details



Optional supplemental benefits


No



Outpatient Hospital Coverage


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



Preventive Care


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



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)



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)



Skilled Nursing Facility


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



Transportation


$0 copay



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)



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Brillante (HMO-POS) H5774



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


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

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


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

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Brillante (HMO-POS) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



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.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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