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Para asistencia en español, llame al:

(877) 364-4566; TTY: 711 y oprima el número 2

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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 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
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%
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
  • 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!

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%

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