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(877) 364-4566; TTY: 711
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Clear Spring Health Select Plus (HMO) - Georgia
Home > Clear Spring Health Select Plus (HMO) - Georgia
Discover Clear Spring Health Select Plus (HMO) - Georgia
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
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
$3,450 annually
PCP Visit
$0 copay per visit
Specialist Visit
$45 copay per visit
Inpatient Hospitalization
$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)
$200 copay
Emergency Room
$90 copay per visit
Ambulance Services
$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
$0 copay
Durable Medical Equipment (DME)
20% of cost
Outpatient Mental Health
$40 copay per visit (individual and group)
Chiropractic Services
$20 copay per visit
Podiatry Services
$40 copay per visit
Dental
$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
Vision
$40 copay for eye exam and $200 allowance for eyewear; see Evidence of Coverage for details
Hearing
$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
Transportation
36 one-way trips per year
Telehealth Services
Covered
Fitness
Available through Silver Sneakers Fitness Program
Prescription Drug Deductible
$0
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
Select Plus
(HMO) – Georgia
Monthly Premium
$19
Contract Number:
H6672-005
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
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Additional Information
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Additional Information
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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.
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 |