Clear Spring Health Select Plus (HMO) - Georgia
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Beneficiaries who want the freedom of network choice, are cost conscious and are more concerned with lower cost sharing and OOP maximum than premiums.
Keep your costs low with a Health Maintenance Organization (HMO) plan that has a SO or low monthly premium.
$0 copay per visit
$45 copay per visit
$295 copay per day (days 1-7); $0 copay per day (days 8-90)
Outpatient Surgery at a Hospital
$250 per stay
Ambulatory Surgery Center (ASC)
$90 copay per visit
$265 copay for service and 20% of total cost for air service
Urgently Needed Care
$35 copay per visit
Diagnostic Tests, Lab and Radiology Services, and X-Rays
$0 - $100 copay or 20% coinsurance depending upon test/service; see Evidence of Coverage for details
Skilled Nursing Facility (SNF)
$0 copay per day (days 1-20) $167 copay per day (days 21-100)
Home Health Care
Durable Medical Equipment (DME)
20% of cost
Outpatient Mental Health
$40 copay per visit (individual and group)
$20 copay per visit
$40 copay per visit
$0 copay per visit for preventive services; $40 copay per visit for comprehensive services; $3000 maximum for comprehensive services; see Evidence of Coverage for details
$40 copay for eye exam and $200 allowance for eyewear; see Evidence of Coverage for details
$25 - $40 copay for hearing exam and 2 hearing aids every 3 years; see Evidence of Coverage for details
Over the Counter (OTC) Items
$90 allowance every three months
36 one-way trips per year
Available through Silver Sneakers Fitness Program
Clear Spring Health
(HMO) – Georgia
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.
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Preferred Pharmacy Cost-Sharing