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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 Essential Plus (PPO) - North Carolina

Home > Clear Spring Health Essential Plus (PPO) - North Carolina

Discover Clear Spring Health Essential Plus (PPO) - North Carolina

Overview

Beneficiaries who want the freedom of network choice, are cost conscious and are more concerned with lower cost-sharing and OOP maximum than premiums.

Additional Information

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

Monthly Premium

$76

Provider
Find a Participating Provider
Covered Prescription Drug
Find a Covered Drug
Pharmacy
Find a Participating Pharmacy

Medical Coverage

Medical Deductible

$0

Maximum Out-of-Pocket

In-network: $4,000; Combined in- and out-of-network: $10,000

Primary Care Physician (PCP) Visit

In-network: $0 copay per visit; Out-of-Network: 45% of total cost

Specialist Office Visit

In-Network: $35 copay per visit; Out-of-Network: 45% of total cost

Inpatient Hospital Care

In-network: $325 copay per day (days 1-5); $0 copay per day (days 6-90); Out-of-Network: 45% of total cost (days 1-5); 45% of total cost (days 6-90)

Outpatient Services/Surgery

In-network: $35 - $250 copay per stay; Out-of-network: 45% of total cost per stay

Ambulatory Surgery Center

In-network: $35 - $200 copay; Out-of-Network: 45% of total cost per stay

In-network: $90 copay per visit; Out-of-network: $90 copay per visit

Ambulance Services

In-network: $300 copay (ground or air) per service; Out-of-network: $300 copay (ground or air) per service

Urgently Needed Care

In-network: $30 copay per visit

Diagnostic Tests, Lab & Radiology Services and X-rays

In-network: $10 - $175 copay or 20% of total cost depending upon test/service; Out-of-Network: 45% of total cost; see Evidence of Coverage for details

Skilled Nursing Facility (SNF)

In-Network: $0 copay per day (days 1-20) $178 copay per day (days 21-100); Out-of-Network: 45% of total cost (days 1-20); 45% of total cost (days 21-100)

Home Health Care

In-network: $0 copay; Out-of-network: 45% of total cost

Durable Medical Equipment (DME)

In-network: 20% of total cost; Out-of-network: 45% of total cost

Outpatient Mental Health

In-Network: $40 copay per visit (individual and group); Out-of-Network: 45% of total cost (individual and group)

Chiropractic Services

In-Network: $20 copay per visit; Out-of-Network: 45% of total cost

Podiatry Services

In-network: $40 copay per visit; Out-of-Network: 45% of total cost

Dental

In-network: $0 copay per visit for preventive services and coverage for comprehensive services; Out-of-network: 45% of total cost; $1500 combined preventive and comprehensive services maximum; see Evidence of Coverage for details

Vision

In-network: $0 -$ 40 copay for eye exam; Out-of-Network: 45% of total cost for exam; Combined in- and out-of-network eyewear maximum of $75; see Evidence of Coverage for details

Hearing

In-network: $0 - $40 copay for hearing exam and 1 hearing aid every 3 years; Out-of-Network: 45% of total cost for hearing exams; see Evidence of Coverage for details

Over the Counter (OTC) Items

Not Covered

Transportation

Not Covered

Telehealth Services

Covered

Fitness

Available through Silver Sneakers Fitness Program

Prescription Drug Deductible

$0 deductible on Tiers 1 and 2; $100 on Tiers 3, 4 and 5

Initial Coverage Limit

$4,430

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
$0
$5
$42
$95
33%
Edit
90-Day Supply
$0
$15
$126
$285
33%
Mail-Order
Edit
30-day supply
$0
$5
$42
$95
33%
Edit
90-Day Supply
$0
$15
$126
$285
33%
Covered Prescription Drug Benefits (cont.)
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
$7
$12
$47
$100
33%
Edit
90-Day Supply
$21
$36
$141
$300
33%
Mail-Order
Edit
30-day supply
$7
$12
$47
$100
33%
Edit
90-Day Supply
$21
$36
$141
$300
33%
Disenrollment Form
Enrollment Form
Evidence of Coverage
Formulary
LIS Premium Chart
Multi language Interpreter Services
Notice of Non-Discrimination
Over-the-Counter Catalog
Pharmacy Directory
Pre-Enrollment Checklist
Provider Directory
Star Rating
Summary of Benefits

Clear Spring Health
Essential Plus (PPO) - North Carolina

Monthly Premium

$76

Contract Number:

H2020-005

Enroll Now
  • 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

Preferred 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
$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%

Enrollment is Easy!

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