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Clear Spring Health Gold Plus (PPO) - South Carolina
Home > Clear Spring Health Gold Plus (PPO) - South Carolina
Discover Clear Spring Health Gold Plus (PPO) - South 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
$19 per month
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: $6,700; Combined in- and out-of-network: $10,000
Primary Care Physician (PCP) Visit
In-network: $0 copay per visit; Out-of-Network: $20 copay per visit
Specialist Office Visit
In-Network: $45 copay per visit; Out-of-Network: $45 copay per visit
Inpatient Hospital Care
In-network: $295 copay per day (days 1-5); $0 copay per day (days 6-90); Out-of-Network: $395 copay per day (days 1-4); $0 copay per day (days 5-90)
Outpatient Services/Surgery
In-network: $250 copay per stay; Out-of-network: 20% of total cost per stay
Ambulatory Surgery Center
In-network: $200 copay; Out-of-Network: 20% of total cost per stay
In-network: $90 copay per visit; Out-of-network: $90 copay per visit
Ambulance Services
In-network: $275 copay (ground) or 20% (air) per service; Out-of-network: 20% of total cost per service
Urgently Needed Care
In-network: $35 copay per visit
Diagnostic Tests, Lab & Radiology Services and X-rays
In-network: $0 - $100 copay or 20% of total cost depending upon test/service; Out-of-Network: $10 copay or 20% - 40% coinsurance depending upon test/service; see Evidence of Coverage for details
Skilled Nursing Facility (SNF)
In-Network: $0 copay per day (days 1-20) $160 copay per day (days 21-100); Out-of-Network: $195 copay per day (days 1-35); $0 copay per day (days 36-100)
Home Health Care
In-network: $0 copay; Out-of-network: 20% 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: $40 copay per visit (individual and group)
Chiropractic Services
In-Network: $20 copay per visit; Out-of-Network: 20% of total cost
Podiatry Services
In-network: $50 copay per visit; Out-of-Network: $45 copay per visit
Dental
Preventive services covered in- and out-of-network; Comprehensive services covered in- and out-of-network with a combined $2000 maximum; see Evidence of Coverage for details
Vision
In-network: $0 - $50 copay for eye exam and $200 eyewear maximum; Out-of-Network: 20% of total cost for exam and eyewear; see Evidence of Coverage for details
Hearing
In-network: $40 copay for hearing exam and 2 hearing aids every 3 years; Out-of-Network: 20% - 50% of total cost for hearing exams and aids; see Evidence of Coverage for details
Over the Counter (OTC) Items
In-network: $45 allowance every three months; Out-of-Network: 50% of total cost
Transportation
Not Covered
Telehealth Services
Covered
Fitness
Available through Silver Sneakers Fitness Program
Prescription Drug Deductible
$0 for Tiers 1 and 2; $200 for Tiers 3, 4 and 5
Initial Coverage Limit
$4,430
Covered Prescription Drug Benefits
Pharmacy Option
| . |
| Tier 1: Preferred Generic |
| Tier 2: Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Drug |
| Tier 5: Specialty |
Covered Prescription Drug Benefits (cont.)
Pharmacy Option
| . |
| Tier 1: Preferred Generic |
| Tier 2: Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Drug |
| Tier 5: Specialty |
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
Gold Plus (PPO) - South Carolina
Monthly Premium
$19 per month
Contract Number:
H2334-005
Enroll Now
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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.
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Clear Spring Healthâs 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.
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Other pharmacies and other providers are available in our network.
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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
| . |
| Tier 1: Preferred Generic |
| Tier 2: Generic |
| Tier 3: Preferred Brand |
| Tier 4: Non-Preferred Drug |
| Tier 5: Specialty |
Enrollment is Easy!
Complete our
online enrollment form
in just a few minutes.
Call 1 (877) 364-4566 TTY:711 and a trained sales representative will answer any questions and enroll you right over the phone.