Clear Spring Health Select Plus (HMO) - Georgia

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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.

Costs

Monthly Premium

$19

Your Information

Provider

Find a Participating Provider

Provider Search

Covered Prescription Drug

Find a Covered Drug

Formulary Search

Pharmacy

Find a Participating Pharmacy

Pharmacy Locator

Benefits

Medical Coverage

Medical Deductible

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

Pharmacy Coverage

Prescription Drug Deductible

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
$12
$42
$95
33%

Edit
90-Day Supply
$0
$30
$105
$237.50
33%

Mail-Order

Edit
30-day supply
$0
$12
$42
$95
33%

Edit
90-Day Supply
$0
$30
$105
$237.50
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
$5
$17
$47
$100
33%

Edit
90-Day Supply
$5
$42.50
$117.50
$250
33%

Mail-Order

Edit
30-day supply
$5
$17
$47
$100
33%

Edit
90-Day Supply
$5
$42.50
$117.50
$250
33%

Plan Documents (Click links in the right column to access the document.)

Disenrollment Form

2022 Disenrollment Form

Enrollment Form

2022 Enrollment Form

Evidence of Coverage

2022 Evidence of Coverage

Formulary

2022 Formulary

LIS Premium Chart

2022 LIS Premium Chart

Multi language Interpreter Services

2022 Multi language Interpreter Services

Notice of Non-Discrimination

2022 Notice of Non-Discrimination

Over-the-Counter Catalog

2022 Over-the-Counter Catalog

Pharmacy Directory

2022 Pharmacy Directory

Pre-Enrollment Checklist

2022 Pre-Enrollment Checklist

Provider Directory

2022 Provider Directory

Star Rating

2022 Star Rating

Summary of Benefits

2022 Summary of Benefits

Clear Spring Health
Select Plus
(HMO) – Georgia

Monthly Premium

$19

Contract Number:

H6672-005

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!

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

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%