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Clear Spring Health Silver Plan (HMO C-SNP)

H6672 - 003 - 0

Plan Not Rated

Clear Spring Health Silver Plan (HMO C-SNP) is a Medicare Advantage Special Needs Plan by Clear Spring Health.

This page features plan details for 2025 Clear Spring Health Silver Plan (HMO C-SNP) H6672 – 003 – 0.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

Locations

Clear Spring Health Silver Plan (HMO C-SNP) is offered in the following locations.

Baker County, Georgia

Baldwin County, Georgia

Banks County, Georgia

Click to see more locations

Plan Overview

Clear Spring Health Silver Plan (HMO C-SNP) offers the following coverage and cost-sharing.

Special Needs Plan Type:	Chronic or Disabling Condition
Conditions Covered:	CardiovascularDisorders, ChronicHeartFailure, DiabetesMellitus

Insurer:	Clear Spring Health
Health Plan Deductible:	$0
MOOP:	$6,751 In-network
Drugs Covered:	Yes

Ready to sign up for Clear Spring Health Silver Plan (HMO C-SNP) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.

Clear Spring Health Silver Plan (HMO C-SNP) qualifies for a monthly Medicare Give Back Benefit of $5.50.

Premium Reduction:

$5.50

Premium Breakdown

Clear Spring Health Silver Plan (HMO C-SNP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$0.00	$0.00	$5.50	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Clear Spring Health Silver Plan (HMO C-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$250.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$0.00	$0.00

Initial Coverage Phase

After you pay your $250.00 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 $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$5.00 Copay		$5.00 Copay
2) Generic		$20.00 Copay		$20.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$42.00 Copay	$47.00 Copay
4) Non-Preferred Drug	$95.00 Copay	$100.00 Copay	$95.00 Copay	$100.00 Copay
5) Specialty Tier	29.00% Coinsurance	29.00% Coinsurance	29.00% Coinsurance	29.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$10.00 Copay		$10.00 Copay
2) Generic		$40.00 Copay		$40.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$84.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$200.00 Copay	$190.00 Copay	$200.00 Copay
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$5.00 Copay		$5.00 Copay
2) Generic		$50.00 Copay		$50.00 Copay
3) Preferred Brand	$105.00 Copay	$117.50 Copay	$105.00 Copay	$117.50 Copay
4) Non-Preferred Drug	$237.50 Copay	$250.00 Copay	$237.50 Copay	$250.00 Copay
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Clear Spring Health Silver Plan (HMO C-SNP) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – No Co pay
Endodontics
- In-Network: No Coins – No Co pay
Implant Services
- In-Network: No Coins – No Co pay
Maxillofacial Prosthetics
- In-Network: No Coins – No Co pay
Oral and Maxillofacial Surgery
- In-Network: No Coins – No Co pay
Orthodontics
- In-Network: No Coins – No Co pay
Periodontics
- In-Network: No Coins – No Co pay
Prosthodontics, fixed
- In-Network: No Coins – No Co pay
Prosthodontics, removable
- In-Network: No Coins – No Co pay
Restorative Services
- In-Network: No Coins – No Co pay

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay
Other Preventive Dental Services
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Lab services
- $0 copay
Outpatient x-rays
- $25 copay (Authorization Required)
Diagnostic tests and procedures
- 20% coinsurance
Diagnostic radiology services (e.g., MRI)
- 20% coinsurance (Authorization Required)

Doctor visits

Primary
- $0 copay
Specialist
- $0-25 copay per visit

Emergency care/Urgent care

Urgent care
- $45 copay per visit (always covered)
Emergency
- $80 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $30 copay
Routine foot care
- Not covered

Ground ambulance

- $225 copay

Health plan deductible

- $0

Hearing

Fitting/evaluation
- $0 copay (Limits Apply)
Hearing aids
- $0 copay (Limits Apply)
Medicare-Covered Hearing Exam
- $30 copay
Hearing aids OTC
- Not covered

Inpatient hospital coverage

- $300 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $6,751 In-network

Medical equipment/supplies

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

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- $300 per day for days 1 through 5
  $0 per day for days 6 through 90 (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- $30 copay
Outpatient group therapy visit
- $30 copay
Outpatient group therapy visit with a psychiatrist
- $30 copay
Outpatient individual therapy visit
- $30 copay

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $225 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $40 copay (Authorization Required)
Occupational therapy visit
- $35 copay (Authorization Required)

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $167 per day for days 21 through 100 (Authorization Required)

Transportation

- $0 copay (Limits Apply)

Vision

Contact lenses
- Not covered
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglass frames
- Not covered
Eyeglass lenses
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered