2022 Clear Spring Health Choice Plan (PPO)

Clear Spring Health Choice Plan (PPO) H9589-003 is a 2022 Medicare Advantage Plan or Part-C by Clear Spring Health available to residents in Georgia. This plan includes additional prescription drug (Part-D) coverage. The Clear Spring Health Choice Plan (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Clear Spring Health Choice Plan (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Clear Spring Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Clear Spring Health Choice Plan (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Clear Spring Health and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Clear Spring Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Clear Spring Health Medicare Advantage Plan Costs

Clear Spring Health Choice Plan (PPO) Part-C Premium

Clear Spring Health charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H9589-003 Part-D Deductible and Premium

Clear Spring Health Choice Plan (PPO) has a monthly drug premium of $0.00 and a $250.00 drug deductible. This Clear Spring Health plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Clear Spring Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Clear Spring Health Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Clear Spring Health plan does not offer additional coverage through the gap.

H9589-003 Formulary or Drug Coverage

Clear Spring Health Choice Plan (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Clear Spring Health Choice Plan (PPO) H9589-003 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$12	$17
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	28%	28%

*Initial Coverage Phase and 30 day supply

2021 Clear Spring Health Choice Plan (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

---

Additional Benefits

No

---

Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	20% coinsurance (Out-of-Network)
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	20% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	20% coinsurance (Out-of-Network)
Restorative services	$0 copay

---

Deductible

$0

---

Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-100 copay or 20% coinsurance
Diagnostic radiology services (e.g., MRI)	20% coinsurance (Out-of-Network)
Diagnostic tests and procedures	20% coinsurance
Diagnostic tests and procedures	20% coinsurance (Out-of-Network)
Lab services	$10 copay (Out-of-Network)
Lab services	$10 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)
Outpatient x-rays	$0-100 copay

---

Doctor Visits

Primary	$0 copay
Primary	$20 copay per visit (Out-of-Network)
Specialist	$0-45 copay per visit
Specialist	$45 copay per visit (Out-of-Network)

---

Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$35 copay per visit (always covered)

---

Foot Care (podiatry services)

Foot exams and treatment	$45 copay
Foot exams and treatment	$45 copay (Out-of-Network)
Routine foot care	$45 copay (Out-of-Network)
Routine foot care	$45 copay

---

Ground Ambulance

$275 copay
20% coinsurance (Out-of-Network)

---

Hearing

Fitting/evaluation	50% coinsurance (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids	50% coinsurance (Out-of-Network)
Hearing aids	$0 copay
Hearing exam	20% coinsurance (Out-of-Network)
Hearing exam	$45 copay

---

Inpatient Hospital Coverage

$295 per day for days 1 through 5 $0 per day for days 6 through 90
$395 per day for days 1 through 4 $0 per day for days 5 through 90 (Out-of-Network)

---

Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	45% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)

---

Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

---

Mental Health Services

Inpatient hospital - psychiatric	$395 per day for days 1 through 4 $0 per day for days 5 through 90
Inpatient hospital - psychiatric	$395 per day for days 1 through 4 $0 per day for days 5 through 90 (Out-of-Network)
Outpatient group therapy visit	$30 copay
Outpatient group therapy visit	$40 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$30 copay
Outpatient group therapy visit with a psychiatrist	$40 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay (Out-of-Network)

---

MOOP

$7,550 In and Out-of-network $7,550 In-network $7,550 Out-of-network

---

Option

No

---

Optional supplemental benefits

No

---

Outpatient Hospital Coverage

$250 copay per visit
20% coinsurance per visit (Out-of-Network)

---

Preventive Care

$0 copay
$0 copay (Out-of-Network)

---

Preventive Dental

Cleaning	$0 copay
Cleaning	50% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	50% coinsurance (Out-of-Network)
Fluoride treatment	Not covered
Oral exam	50% coinsurance (Out-of-Network)
Oral exam	$0 copay

---

Rehabilitation Services

Occupational therapy visit	$40 copay (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay (Out-of-Network)

---

Skilled Nursing Facility

$0 per day for days 1 through 20 $160 per day for days 21 through 62 $0 per day for days 63 through 100
$195 per day for days 1 through 35 $0 per day for days 36 through 100 (Out-of-Network)

---

Transportation

Not covered

---

Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	50% coinsurance (Out-of-Network)
Other	Not covered
Routine eye exam	50% coinsurance (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

---

Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Clear Spring Health Choice Plan (PPO)

(Click county to compare all available Advantage plans)

Go to top

Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.