Clear Spring Health Community Flex Plan (HMO-POS) is a Medicare Advantage (Part C) Plan by Clear Spring Health.
This page features plan details for 2022 Clear Spring Health Community Flex Plan (HMO-POS) H3071 – 003 – 0 available in Rockford Area, Chicago Area.
Clear Spring Health Community Flex Plan (HMO-POS) is offered in the following locations.
Clear Spring Health Community Flex Plan (HMO-POS) offers the following coverage and cost-sharing.
Insurer: | Clear Spring Health |
Health Plan Deductible: | $0 |
MOOP: | $2,500.00 |
Drugs Covered: | Yes |
Ready to sign up for Clear Spring Health Community Flex Plan (HMO-POS) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $0.00 | $19.00 | $0.00 | $189.10 |
Clear Spring Health Community Flex Plan (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $4,430.00 |
Catastrophic Coverage Limit: | $7,050.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | No |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$19.00 | $14.20 | $9.50 | $4.70 | $0.00 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
Drug Type | Cost Share |
---|---|
Generic drugs | 25% |
Brand-name drugs | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Tier | Cost |
---|---|
Generic | $4.15 copay or 5% (whichever costs more) |
Brand-name | $10.35 copay or 5% (whichever costs more) |
Clear Spring Health Community Flex Plan (HMO-POS) also provides the following benefits.
In-Network: No |
Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) |
Endodontics: | Not covered |
Extractions: | Not covered |
Non-routine services: | Not covered |
Periodontics: | Not covered |
Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: $0 copay (limits may apply) (authorization required) |
Restorative services: | In-Network: $0 copay (limits may apply) (authorization required) |
Cleaning: | In-Network: $0 copay (limits may apply) |
Dental x-ray(s): | In-Network: $0 copay (limits may apply) |
Fluoride treatment: | In-Network: $0 copay (limits may apply) |
Oral exam: | In-Network: $0 copay (limits may apply) |
Diagnostic radiology services (e.g., MRI): | In-Network: $0-100 copay (authorization required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: 20% coinsurance (authorization required) |
Diagnostic tests and procedures: | In-Network: $0 copay (authorization required) |
Diagnostic tests and procedures: | Out-of-Network: 20% coinsurance (authorization required) |
Lab services: | In-Network: $0 copay (authorization required) |
Lab services: | Out-of-Network: 20% coinsurance (authorization required) |
Outpatient x-rays: | In-Network: $0-100 copay (authorization required) |
Outpatient x-rays: | Out-of-Network: 20% coinsurance (authorization required) |
Primary: | In-Network: $0 copay |
Specialist: | In-Network: $0 copay |
Specialist: | Out-of-Network: 20% coinsurance per visit |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $35 copay per visit (always covered) |
Foot exams and treatment: | In-Network: $0 copay |
Foot exams and treatment: | Out-of-Network: 20% coinsurance |
Routine foot care: | Not covered |
In-Network: $100 copay | |
Out-of-Network: 20% coinsurance |
$0.00 |
In-Network: No |
Fitting/evaluation: | In-Network: $0 copay (limits may apply) |
Hearing aids: | In-Network: $0 copay (limits may apply) |
Hearing exam: | In-Network: $0 copay |
Hearing exam: | Out-of-Network: 20% coinsurance |
In-Network: $220 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) | |
Out-of-Network: 20% per stay (authorization required) |
In-Network: $225 copay per visit (authorization required) | |
Out-of-Network: 20% coinsurance per visit (authorization required) |
$2,500 In and Out-of-network $2,500 In-network |
Diabetes supplies: | In-Network: $0 copay (authorization required) |
Diabetes supplies: | Out-of-Network: 20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 20% coinsurance per item (authorization required) |
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | In-Network: $220 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) |
Inpatient hospital – psychiatric: | Out-of-Network: 20% per stay (authorization required) |
Outpatient group therapy visit with a psychiatrist: | In-Network: $0 copay |
Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 20% coinsurance |
Outpatient group therapy visit: | In-Network: $0 copay |
Outpatient group therapy visit: | Out-of-Network: 20% coinsurance |
Outpatient individual therapy visit with a psychiatrist: | In-Network: $0 copay |
Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 20% coinsurance |
Outpatient individual therapy visit: | In-Network: $0 copay |
Outpatient individual therapy visit: | Out-of-Network: 20% coinsurance |
No |
In-Network: $0 copay | |
Out-of-Network: 20% coinsurance |
Occupational therapy visit: | In-Network: $20 copay (authorization required) |
Occupational therapy visit: | Out-of-Network: 20% coinsurance (authorization required) |
Physical therapy and speech and language therapy visit: | In-Network: $20 copay (authorization required) |
Physical therapy and speech and language therapy visit: | Out-of-Network: 20% coinsurance (authorization required) |
In-Network: $0 per day for days 1 through 20 $150 per day for days 21 through 100 (authorization required) | |
Out-of-Network: 20% per stay (authorization required) |
In-Network: $0 copay (limits may apply) |
Contact lenses: | In-Network: $0 copay (limits may apply) |
Eyeglass frames: | In-Network: $0 copay (limits may apply) |
Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) |
Other: | Not covered |
Routine eye exam: | In-Network: $0 copay (limits may apply) |
Upgrades: | In-Network: $0 copay (limits may apply) |
Covered |
Ready to sign up for Clear Spring Health Community Flex Plan (HMO-POS) ?
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SMID: MULTIPLAN_HCIHNDOGMED01_M
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