In-network
Inpatient hospital
Cost-sharing tier 1
Per admission $50 per stay
Cost-sharing tier 2
Per admission $150 per stay
Out-of-network
Not separately reported
Point of service
Tier 1: 35% coinsurance
● CMS 2027 plan record
Brillante (HMO-POS)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network$65 copay
Air · in-network$65 copay
Emergency services
Emergency room
$50 copay
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$4,200
Combined in + outNo combined out-of-pocket maximum
Skilled care at home
Home health
In-network$0 cost share
Out-of-networkNot separately reported
Monthly cost
Premium & giveback
Part C premium$0 / month
Consolidated C + D$0 / month
CMS reports a Part B premium reduction of $40 per month.
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Primary care physician
In: Primary Care Physician Services: $0 cost share · Out: Not separately reported
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Specialist
In: Physician Specialist Services: $0–$15 copay · Out: Not separately reported
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Preventive care
In: Annual Physical Exam: Not applicable; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share · Out: Not separately reported
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Diagnostic procedures & tests
In: Diagnostic Procedures/Tests: 0%–20% coinsurance · Out: Not separately reported
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Laboratory services
In: Lab Services: 0%–20% coinsurance · Out: Not separately reported
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X-rays & standard imaging
In: Not separately reported · Out: Not separately reported
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MRI, CT & PET imaging
In: Diagnostic Radiological Services: $0–$75 copay · Out: Not separately reported
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Urgent care
In: Urgently Needed Services: $0 cost share · Out: Not separately reported
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Emergency room
In: $50 copay · Out: Not separately reported
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Ground ambulance
In: $65 copay · Out: Not separately reported
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Air ambulance
In: $65 copay · Out: Not separately reported
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Outpatient hospital
In: Outpatient Hospital Services: $25–$50 copay · Out: Not separately reported
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Outpatient surgery / ASC
In: Ambulatory Surgical Center (ASC) Services: $25 copay · Out: Not separately reported
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Home health
In: $0 cost share · Out: Not separately reported
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Skilled nursing facility
In: Skilled nursing facility: $0 cost share · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: Cardiac Rehabilitation Services: $0 cost share; Intensive Cardiac Rehabilitation Services: $0 cost share; Pulmonary Rehabilitation Services: $0 cost share; SET for PAD Services: $0 cost share; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable · Out: Not separately reported
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Occupational therapy
In: Occupational Therapy Services: $0 cost share · Out: Not separately reported
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Physical & speech therapy
In: Physical Therapy and Speech-Language Pathology Services: $0 cost share · Out: Not separately reported
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Mental health services
In: Partial Hospitalization Program: $0 cost share; Individual Sessions for Mental Health Specialty Services: $0 cost share; Group Sessions for Mental Health Specialty Services: $0 cost share; Individual Sessions for Psychiatric Services: $0 cost share; Group Sessions for Psychiatric Services: $0 cost share; Inpatient psychiatric hospital: $0 cost share · Out: Not separately reported
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Substance use treatment
In: Intensive Outpatient Program Services: $0 cost share; Individual Sessions for Outpatient Substance Abuse: $0 cost share; Group Sessions for Outpatient Substance Abuse: $0 cost share · Out: Not separately reported
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Podiatry
In: Podiatry Services: $0 cost share; 7f(NMC): $0 cost share · Out: Not separately reported
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Chiropractic
In: Chiropractic Services: $0–$5 copay · Out: Not separately reported
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Dental
In: Medicare Dental Services: $0 cost share; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share; Adjunctive General Services: $0 cost share · Out: Not separately reported
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Vision
In: Eye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share · Out: Not separately reported
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Hearing
In: Hearing Exams: $0 cost share; Routine Hearing Exams: $0 cost share; Fitting/Evaluation for Hearing Aid: $0 cost share; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable · Out: Not separately reported
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Transportation
In: 10b(NMC): $0 cost share · Out: Not separately reported
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Fitness & wellness
In: Fitness Benefit: Not applicable · Out: Not separately reported
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Over-the-counter allowance
In: Over-the-Counter (OTC) Items: $0 cost share · Out: Not separately reported
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Meals
In: Meal Benefit: Not applicable · Out: Not separately reported
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-networkPrimary Care Physician Services: $0 cost share
Out-of-networkNot separately reported
Specialist
In-networkPhysician Specialist Services: $0–$15 copay
Out-of-networkNot separately reported
Preventive care
In-networkAnnual Physical Exam: Not applicable; Kidney Disease Education Services: $0 cost share; Glaucoma Screening: $0 cost share; Diabetes Self-Management Training: $0 cost share; Digital Rectal Exams: $0 cost share; EKG following Welcome Visit: $0 cost share
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-networkDiagnostic Procedures/Tests: 0%–20% coinsurance
Out-of-networkNot separately reported
Laboratory services
In-networkLab Services: 0%–20% coinsurance
Out-of-networkNot separately reported
X-rays & standard imaging
Not reported in this CMS exportIn-networkNot separately reported
Out-of-networkNot separately reported
MRI, CT & PET imaging
In-networkDiagnostic Radiological Services: $0–$75 copay
Out-of-networkNot separately reported
Urgent & hospital care6 benefits
Urgent care
In-networkUrgently Needed Services: $0 cost share
Out-of-networkNot separately reported
Emergency room
In-network$50 copay
Out-of-networkNot separately reported
Ground ambulance
In-network$65 copay
Out-of-networkNot separately reported
Air ambulance
In-network$65 copay
Out-of-networkNot separately reported
Outpatient hospital
In-networkOutpatient Hospital Services: $25–$50 copay
Out-of-networkNot separately reported
Outpatient surgery / ASC
In-networkAmbulatory Surgical Center (ASC) Services: $25 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits
Home health
In-network$0 cost share
Out-of-networkNot separately reported
Skilled nursing facility
In-networkSkilled nursing facility: $0 cost share
Out-of-networkNot separately reported
Point of serviceSkilled nursing facility: Tier 1: 35% coinsurance
Cardiac & pulmonary rehabilitation
In-networkCardiac Rehabilitation Services: $0 cost share; Intensive Cardiac Rehabilitation Services: $0 cost share; Pulmonary Rehabilitation Services: $0 cost share; SET for PAD Services: $0 cost share; 3-1(NMC): Not applicable; 3-2(NMC): Not applicable; 3-3(NMC): Not applicable; 3-4(NMC): Not applicable
Out-of-networkNot separately reported
Occupational therapy
In-networkOccupational Therapy Services: $0 cost share
Out-of-networkNot separately reported
Physical & speech therapy
In-networkPhysical Therapy and Speech-Language Pathology Services: $0 cost share
Out-of-networkNot separately reported
Behavioral health2 benefits
Mental health services
In-networkPartial Hospitalization Program: $0 cost share; Individual Sessions for Mental Health Specialty Services: $0 cost share; Group Sessions for Mental Health Specialty Services: $0 cost share; Individual Sessions for Psychiatric Services: $0 cost share; Group Sessions for Psychiatric Services: $0 cost share; Inpatient psychiatric hospital: $0 cost share
Out-of-networkNot separately reported
Point of serviceInpatient psychiatric hospital: Tier 1: 35% coinsurance
Substance use treatment
In-networkIntensive Outpatient Program Services: $0 cost share; Individual Sessions for Outpatient Substance Abuse: $0 cost share; Group Sessions for Outpatient Substance Abuse: $0 cost share
Out-of-networkNot separately reported
Specialty care2 benefits
Podiatry
In-networkPodiatry Services: $0 cost share; 7f(NMC): $0 cost share
Out-of-networkNot separately reported
Chiropractic
In-networkChiropractic Services: $0–$5 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits
Dental
In-networkMedicare Dental Services: $0 cost share; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share; Adjunctive General Services: $0 cost share
Out-of-networkNot separately reported
Vision
In-networkEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
Out-of-networkNot separately reported
Hearing
In-networkHearing Exams: $0 cost share; Routine Hearing Exams: $0 cost share; Fitting/Evaluation for Hearing Aid: $0 cost share; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Out-of-networkNot separately reported
Transportation
In-network10b(NMC): $0 cost share
Out-of-networkNot separately reported
Fitness & wellness
Not applicableIn-networkFitness Benefit: Not applicable
Out-of-networkNot separately reported
Over-the-counter allowance
In-networkOver-the-Counter (OTC) Items: $0 cost share
Out-of-networkNot separately reported
Meals
Not applicableIn-networkMeal Benefit: Not applicable
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview
Premium & Part B giveback
$0 Part C premium / month · CMS reports a Part B premium reduction of $40 per month.
Maximum out-of-pocket (MOOP)
In-network$4,200
Combined in + outNo combined out-of-pocket maximum
Medical deductibles
In-network$0
Out-of-network$0
Annual health deductible
Not separately reported
Combined network deductible
$0
Part D premium
$0 / month
Network & referrals
HMOPOS · Referrals: Not required · Out-of-network coverage: Not reported
Prescription drugs6 tiers
Part D deductible
$0 / year
Drug tier 1
Standard retail: $5 copay · Preferred retail: $0 copay · 30-day supply
Drug tier 2
Standard retail: $10 copay · Preferred retail: $0 copay · 30-day supply
Drug tier 3
Standard retail: $45 copay · Preferred retail: $10 copay · 30-day supply
Drug tier 4
Standard retail: $60 copay · Preferred retail: $40 copay · 30-day supply
Drug tier 5
Standard retail: 33% coinsurance · Preferred retail: 33% coinsurance · 30-day supply
Drug tier 6
Standard retail: $3 copay · Preferred retail: $0 copay · 30-day supply
Using this plan
Understand H5774-031-000
Plain-language context built from this plan’s 2027 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
Brillante (HMO-POS) is a 2027 HMOPOS offered by Triple S Advantage in Puerto Rico. The plan record does not require referrals.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- Primary Care Physician Services: $0 cost share
- Specialist
- Physician Specialist Services: $0–$15 copay
- Laboratory services
- Lab Services: 0%–20% coinsurance
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- Diagnostic Procedures/Tests: 0%–20% coinsurance
- MRI, CT & PET imaging
- Diagnostic Radiological Services: $0–$75 copay
- Outpatient hospital
- Outpatient Hospital Services: $25–$50 copay
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- $50 copay
Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Part B premium reduction (“giveback”)
A giveback may reduce the amount you pay toward Medicare Part B; it is not usually paid to you as cash. The CMS record notes: CMS reports a Part B premium reduction of $40 per month.
Availability
Who can enroll
- Service area
- Puerto Rico (PR)
- Plan type
- HMOPOS
- Contract / plan
- H5774-031
- Coverage year
- 2027
Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
DentalMedicare Dental Services: $0 cost share; Diagnostic and Preventive Dental: $0 cost share; Oral Exams: $0 cost share; Dental X-Rays: $0 cost share; Other Diagnostic Dental Services: $0 cost share; Prophylaxis (Cleaning): $0 cost share; Fluoride Treatment: $0 cost share; Other Preventive Dental Services: $0 cost share; Restorative Services: $0 cost share; Endodontics: $0 cost share; Periodontics: $0 cost share; Prosthodontics, removable: $0 cost share; Prosthodontics, fixed: $0 cost share; Oral and Maxillofacial Surgery: $0 cost share; Adjunctive General Services: $0 cost share
VisionEye Exams: $0 cost share; Routine Eye Exams: $0 cost share; Other Eye Exam Services: $0 cost share; Eyewear: $0 cost share; Contact Lenses: $0 cost share; Eyeglasses (lenses and frames): $0 cost share; Eyeglass lenses: $0 cost share; Eyeglass frames: $0 cost share; Upgrades: $0 cost share
HearingHearing Exams: $0 cost share; Routine Hearing Exams: $0 cost share; Fitting/Evaluation for Hearing Aid: $0 cost share; Prescription Hearing Aids (all types): $0 cost share; Prescription Hearing Aids - Inner Ear: Not applicable; Prescription Hearing Aids - Outer Ear: Not applicable; Prescription Hearing Aids - Over the Ear: Not applicable
Over-the-counter allowanceOver-the-Counter (OTC) Items: $0 cost share
Transportation10b(NMC): $0 cost share
Plan-specific answers
Frequently asked questions
Where is H5774-031-000 available?
Brillante (HMO-POS) is listed for Puerto Rico (PR). Enrollment generally requires Medicare eligibility and residence in the plan's service area.
What is the in-network maximum out-of-pocket limit for H5774-031-000?
The 2027 CMS record lists an in-network medical maximum out-of-pocket limit of $4,200. Prescription drug spending generally does not count toward this medical limit.
What is the monthly plan premium for H5774-031-000?
The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.
What does an emergency room visit cost on H5774-031-000?
The plan record lists $50 copay, waived when an admission meets the plan's stated timing rule.
Does H5774-031-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, over-the-counter allowance, transportation. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2027
Plan identity and benefits come from CMS PBP data. Benefits and drug cost sharing come from the approved annual PBP tabular extract and its CMS dictionary. Premiums and drug deductibles are cross-checked with the annual Landscape. Geography comes from annual PlanArea and PlanRegionArea records, including exact segments and partial-county or employer/group qualifiers. Quick-reference values should be confirmed in current official plan documents.
Plan context
Where H5774-031-000 fits
- Full CMS plan ID
H5774-031-000- Contract
H5774- Base plan code
H5774-031- Segment
000- Carrier
- Triple S Advantage
- Plan type
- HMOPOS
- Service area
- Puerto Rico (PR)
County/service-area foundation
CMS service-area entries
Service areas come from the annual CMS PlanArea and PlanRegionArea tables for this exact contract, plan, and segment. Partial-county and employer/group qualifiers remain part of the coverage area. Regional PPO county entries use the matching annual Landscape expansion of the CMS region.
- Adjuntas, PR
- Aguada, PR
- Aguadilla, PR
- Aguas Buenas, PR
- Aibonito, PR
- Anasco, PR
- Arecibo, PR
- Arroyo, PR
- Barceloneta, PR
- Barranquitas, PR
- Bayamon, PR
- Cabo Rojo, PR
66 additional service-area entries are retained in the data record.
Exact county navigation
Counties with exact segment geography
These links are limited to named counties tied to this exact medical plan segment. Partial-county entries remain labeled for verification.
Show 78 county links
Puerto Rico
- Adjuntas County, Puerto Rico
- Aguada County, Puerto Rico
- Aguadilla County, Puerto Rico
- Aguas Buenas County, Puerto Rico
- Aibonito County, Puerto Rico
- Anasco County, Puerto Rico
- Arecibo County, Puerto Rico
- Arroyo County, Puerto Rico
- Barceloneta County, Puerto Rico
- Barranquitas County, Puerto Rico
- Bayamon County, Puerto Rico
- Cabo Rojo County, Puerto Rico
- Caguas County, Puerto Rico
- Camuy County, Puerto Rico
- Canovanas County, Puerto Rico
- Carolina County, Puerto Rico
- Catano County, Puerto Rico
- Cayey County, Puerto Rico
- Ceiba County, Puerto Rico
- Ciales County, Puerto Rico
- Cidra County, Puerto Rico
- Coamo County, Puerto Rico
- Comerio County, Puerto Rico
- Corozal County, Puerto Rico
- Culebra County, Puerto Rico
- Dorado County, Puerto Rico
- Fajardo County, Puerto Rico
- Florida County, Puerto Rico
- Guanica County, Puerto Rico
- Guayama County, Puerto Rico
- Guayanilla County, Puerto Rico
- Guaynabo County, Puerto Rico
- Gurabo County, Puerto Rico
- Hatillo County, Puerto Rico
- Hormigueros County, Puerto Rico
- Humacao County, Puerto Rico
- Isabela County, Puerto Rico
- Jayuya County, Puerto Rico
- Juana Diaz County, Puerto Rico
- Juncos County, Puerto Rico
- Lajas County, Puerto Rico
- Lares County, Puerto Rico
- Las Marias County, Puerto Rico
- Las Piedras County, Puerto Rico
- Loiza County, Puerto Rico
- Luquillo County, Puerto Rico
- Manati County, Puerto Rico
- Maricao County, Puerto Rico
- Maunabo County, Puerto Rico
- Mayaguez County, Puerto Rico
- Moca County, Puerto Rico
- Morovis County, Puerto Rico
- Naguabo County, Puerto Rico
- Naranjito County, Puerto Rico
- Orocovis County, Puerto Rico
- Patillas County, Puerto Rico
- Penuelas County, Puerto Rico
- Ponce County, Puerto Rico
- Quebradillas County, Puerto Rico
- Rincon County, Puerto Rico
- Rio Grande County, Puerto Rico
- Sabana Grande County, Puerto Rico
- Salinas County, Puerto Rico
- San German County, Puerto Rico
- San Juan County, Puerto Rico
- San Lorenzo County, Puerto Rico
- San Sebastian County, Puerto Rico
- Santa Isabel County, Puerto Rico
- Toa Alta County, Puerto Rico
- Toa Baja County, Puerto Rico
- Trujillo Alto County, Puerto Rico
- Utuado County, Puerto Rico
- Vega Alta County, Puerto Rico
- Vega Baja County, Puerto Rico
- Vieques County, Puerto Rico
- Villalba County, Puerto Rico
- Yabucoa County, Puerto Rico
- Yauco County, Puerto Rico
About this code
What H5774-031-000 identifies
H5774-031-000 is a Contract Year 2027 Medicare plan segment code. Searches written as H5774-031, H5774 031, or the compact full CMS ID H5774031000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.