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Para asistencia en español, llame al:

(877) 364-4566; TTY: 711 y oprima el número 2

Nuestro horario es

de 8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana.
Si llama del 1ro de abril al 30 de septiembre, se usará sistema
automatizado de voz (correo de voz) durante los fines de semana
y los días feriados.

Our Contacts

To learn more, please call
1 (877) 364-4566; TTY: 711
Clear Spring Health,

PO Box 278530
Miramar, FL 33027

Hours of Operation

8:00 a.m. – 8:00 p.m., 7 days a week

(Between April 1 – September 30, voicemail will be available on Saturday, Sunday and federal holidays.)

Clear Spring Health Deluxe (D-SNP)

Home    >     Clear Spring Health Deluxe (D-SNP)

Discover Clear Spring Health Deluxe (D-SNP)

Overview

Keep your costs low with a Health Maintenance Organization (HMO) plan that has a SO or low monthly premium.

Additional Information

Keep your costs low with a Health Maintenance Organization (HMO) plan that has a SO or low monthly premium.

Premium
$0.00 monthly
Provider
Find a Participating Provider
Covered Prescription Drug
Find a Covered Drug
Pharmacy
Find a Participating Pharmacy

Medical Coverage

Medical Deductible

$0.00

Maximum Out-of-Pocket

$3,450 applies to in-network Medicare-covered benefits

Primary Care Physician (PCP)
Office Visit

$0

Specialist Office Visit

$20

Inpatient Hospital Care

$195 per day for days 1-7
$0 per day for days 8-90

Skilled Nursing Facility (SNF)

$0 per day for days 1-20
$184 per day for days 21-100

Outpatient Services/Surgery

$0 – $175

Ambulatory Surgery Center

$0 – $125

Inpatient Hospital Mental Health Care

$195 per day for days 1-7
$0 per day for days 8-90

Outpatient Mental Health Care

$0

Outpatient Substance Abuse

$20

Physical and Speech Therapy

$20

Telehealth Services

MD Live Telehealth Services: For nonemergency care, you can talk with an MDLIVE telehealth provider about a number of health issues, including allergies, cough, headache, sore throat, and other low-risk illnesses. Communication with an MDLIVE doctor can be by phone or video.

Virtual Physical Therapy: You may have access to Virtual Physical Therapy services in the convenience of your home via audio or video. Check with your Physical Therapist for virtual physical therapy service offerings.

Emergency Room

$120
The copay is waived if hospital admittance occurs within 24 hours

International: $120

Urgently Needed Care

$0 – $25
The copay is waived if hospital admittance occurs within 24 hours

International: $120

Ambulance Services

Ambulance – Ground: $260
Ambulance – Air: 20%

Diagnostic Tests, Lab and Radiology Services, and X-Rays

Lab Services: $0
Diagnostic Radiological Services: $0 – $175
X-Ray Services: $0 – $25

Home Health Care

$0

Diabetes Supplies and Services

0 – 20%

Dental Care

Preventive Services: No max plan coverage amount
Comprehensive Services: $2,000 every year

Hearing Services

Routine Hearing Exams: $0 for one routine exam every year
Fitting/Evaluation for hearing aid every three years
Maximum Coverage for Hearing Aids: $700 per ear per device every 3 years

Vision Services

Routine Eye Exams: $0 for one routine exam every year
Routine Eye Wear Coverage
Contact lenses: unlimited
Eyeglasses (lenses and frames): one every year
Eyeglass lenses: one every year
Eyeglass frames: one every year
Upgrades
Max Coverage Amount for Routine Eye Wear Coverage :
$250 every year

Fitness Benefit

Fitness Benefit: $0
Fitness Benefit Program offers a fitness center membership and home fitness program in addition to enhanced technology options and senior lifestyle coaching.

Over-the-Counter Items

$70 per quarter

Transportation

$0 for 20 one-way trips every year
Customers are required to coordinate with Cigna vendor for transportation to plan-approved locations at least 48 hours in advance.
Mileage restrictions may apply

Durable Medical

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Pharmacy Deductible
$0.00
Initial Coverage Limit
$4,130.00
Covered Prescription Drug Benefits
Pharmacy Option
Edit
.
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty
Retail – Preferred Pharmacy
Edit
30-day supply
$1
$3
$40
40%
25%
Edit
90-Day Supply
$3
$9
$120
40%
25%
Mail-Order
Edit
30-day supply
$1
$3
$40
40%
25%
Edit
90-Day Supply
$3
$9
$120
40%
25%
Standard Pharmacy Cost-Sharing
Pharmacy Option
Edit
.
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty
Retail – Standard Pharmacy
Edit
30-day supply
$10
$20
$47
50%
25%
Edit
90-Day Supply
$30
$60
$141
50%
25%
Mail-Order
Edit
30-day supply
$10
$20
$47
50%
25%
Edit
90-Day Supply
$30
$60
$141
50%
25%
Summary of Benefits
Evidence of Coverage
LIS Premium Chart
Formulary
Over-the-Counter Catalog
Multi language Interpreter Services
Notice of Non-Discrimination
Enrollment Form
Pre-Enrollment Checklist
Provider and Pharmacy Directory
Star Rating

Clear Spring Health
Deluxe (D-SNP)

Monthly Premium

$24.00

Contract Number:

H6672-001

  • Enrollee must continue to pay their Medicare Part B premium. This information is not a complete description of benefits.

  • Call 1-877-364-4566 (TTY: 711) for more information.

  • Clear Spring Health’s pharmacy network includes limited lower-cost, preferred pharmacies. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call or consult the online Pharmacy Locator.

  • Other pharmacies and other providers are available in our network.

  • Out-of-network/non-contracted providers are under no obligation to treat Clear Spring Health plan members, except in emergency situations. Please call Member Service or review the Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Provider

Additional Information

Keep your c

Additional Information

Keep your c

Additional Information

Keep your c

Enrollment is Easy!

Preferred Pharmacy Cost-Sharing

Pharmacy Option

.
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty

Retail – Standard Pharmacy

30-day supply
$1
$3
$40
40%
25%

90-Day Supply
$3
$9
$120
40%
25%

Mail-Order

30-day supply
$1
$3
$40
40%
25%

90-Day Supply
$3
$9
$120
40%
25%

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