Exhibit 10.4
 2007-000057-D
 MEDICARE PLATINO CONTRACT AMENDMENT
(Medicaid Wraparound)
  Puerto Rico Health Insurance Administration (PRHIA) PRHIA
  TRIPLE-S SALUD, INC., ###-##-#### CONTRACTOR
  For the Provision of the wraparound coverage for the Government Health Insurance Dual-Eligible
Population




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WITNESSETH
  WHEREAS: 07-057, 07-057A, 07-057B, and 07-057C
 WHEREAS:
 PRHIA Triple-S Salud, Inc.
 Article I
 2.1 Term
 st
 Article II




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3.1 Premium Payments
 a.
    
    ...b.
    
    The monthly premiums are attached hereto as Appendix B (1)(10) and shall be
deemed incorporated into this Agreement without further action by the parties...
 Article III.
  Article IV.
 6.5
    
    Contractor Liability
  Appendix
    
    C (1) (10)Medicare Advantage ProductAppendix
    
    C (2) (10)Medicaid Product (Wraparound) of this Agreement;
With co-payments for Enrollees whose names appear on the prepaid Premium Plan
Roster.
 Article V.
  Appendix
    
    C-1(10)Medicare Advantage ProductC-2(10)Medicaid WraparoundC-3(10)Services not covered by Medicare Platino but provided by the Department of
Health which are hereby made a part of this agreement as if set forth fully herein.




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C-4(10)Summary of Benefits Report  The Summary Benefits (SB) included as Appendix
C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to
be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the
SB does not mean that the same have already been approved and that, if necessary,
changes could be requested. Therefore, since the SB needs the approval of the
PRHIA, this section could be amended subject to PRHIAs review.
 Article VI:
 13.
    
    Access Requirements

The Contractor agrees to provide enrollees access to Medicare Platino Benefit
Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner
consistent with professionally recognized standards of health care and access
standards required by 42CFR Section 422.11/438.206 and Law 72 of
September 7, 1993
respectively.
 Article VII:
  PUERTO RICO HEALTH
    
    TRIPLE-S SALUD, INC.INSURANCE ADMINISTRATION-s- Domingo Nevárez Ramírez
    
    -s- Socorro RivasDomingo
Nevárez Ramírez, MHSA 
Executive Director
    
    Socorro Rivas
Chief Executive Officer
Triple-S Salud, Inc.(SEAL)
    

-s- Dr. Luis A. MariniDr. Luis A. Marini
Chief Executive Officer
Triple C, Inc.10/2/09
    
    10/2/09Date
    
    DateCifra de Cuenta 5000-100




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APPENDIX A(1)(10)
 SERVICE AREA




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APPENDIX A(1)(10)
 TRIPLE-S SALUD, INC.
 Geographic Areas:North East Health Area
    
    composed of the municipalities of Canóvanas, Carolina, Ceiba, Culebra, Fajardo, Loíza, Luquillo, Rio
Grande, Trujillo Altoand Vieques.West Health Area
    
    composed of the municipalities of Aguada, Aguadilla, Añasco, Cabo Rojo, Hormigueros, Isabela, Lajas, Las
Marías, Maricao, Mayaguez, Moca, Rincón, Sabana Grande, San
Germán, and San Sebastián.South East Health Area
    
    composed of the municipalities of
Aibonito, Orocovis, Arroyo, Barranquitas,
Coamo, Guayama, Juana Díaz, Maunabo, Patillas, Salinas, Santa Isabeland Villalba.East Health Area/Region
    
    composed of Aguas Buenas, Caguas, Cayey, Cidra, Gurabo, Humacao, Juncos, Las Piedras, Naguabo, San Lorenzo,and Yabucoa.North Health Area
    
    composed of the municipalities of Arecibo, Barceloneta, Camuy, Ciales, Florida, Hatillo, Lares, Manatí, Morovis, Quebradillas, Utuado and Vega Baja.Metro-North Health Area
    
    composed of the municipalities of Bayamón, Cataño, Comerío, Corozal,
Dorado, Guaynabo, Naranjito, Toa Alta, Toa Baja and Vega Alta.South West Health Area
    
    composed of the municipalities of Adjuntas, Guánica, Guayanilla, Jayuya,
Peñuelas, Ponce and Yauco.San Juan Region
    
    composed only of the municipality of San Juan.




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APPENDIX B(1)(10)
 PREMIUM PAYMENT




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Appendix B(1)(10)
 Monthly Payment of Premiums per Member
by Geographic Areas
 TRIPLE-S Salud, Inc. Plans
Product: SSS Selecto
 DSH SNPBlendedArea:
    
    H4012-003East
    
    $
    35.00Metro-North
    
    $
    35.00North
    
    $
    35.00North East
    
    $
    35.00San Juan
    
    $
    35.00South East
    
    $
    35.00South-West
    
    $
    35.00West
    
    $
    35.00




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C-4(10)Summary of Benefits Report  The Summary Benefits (SB) included as Appendix
C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to
be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the
SB does not mean that the same have already been approved and that, if necessary,
changes could be requested. Therefore, since the SB needs the approval of the
PRHIA, this section could be amended subject to PRHIAs review.
 Article VI:
 13.
    
    Access Requirements

The Contractor agrees to provide enrollees access to Medicare Platino Benefit
Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner
consistent with professionally recognized standards of health care and access
standards required by 42CFR Section 422.11/438.206 and Law 72 of
September 7, 1993
respectively.
 Article VII:
  PUERTO RICO HEALTH
    
    TRIPLE-S SALUD, INC.INSURANCE ADMINISTRATION-s- Domingo Nevárez Ramírez
    
    -s- Socorro RivasDomingo
Nevárez Ramírez, MHSA 
Executive Director
    
    Socorro Rivas
Chief Executive Officer
Triple-S Salud, Inc.(SEAL)
    

-s- Dr. Luis A. MariniDr. Luis A. Marini
Chief Executive Officer
Triple C, Inc.10/2/09
    
    10/2/09Date
    
    DateCifra de Cuenta 5000-100