Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H9589-003-000
Plan Organization Clear Spring Health
Plan Type Local PPO
Plan Name EON CHOICE (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Not enough data available
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $150.00
Annual Drug Deductible $150.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $6700.00
Gap Coverage No
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes Out-of-Network Yes No 20%
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 20%
Non-routine services No - - - Not covered
Restorative services Yes In-Network Yes No $0 copay
Extractions No - - - Not covered
Endodontics No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - Out-of-Network Yes No 20%
Lab services - In-Network Yes No $10
Outpatient x-rays - Out-of-Network Yes No $14
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 20%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $20 per visit
Specialist - In-Network No No $25 per visit
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - In-Network No No $45
Routine foot care No In-Network No No $45
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - $250
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing exam - In-Network Yes No $25
Fitting/evaluation Yes Out-of-Network Yes No 50%
Hearing aids Yes Out-of-Network Yes No 50%
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In and Out-of-network $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network No - 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 45% per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 20% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20%
Other Part B drugs - In-Network Yes - 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $395 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit - In-Network Yes No $30
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $40
Outpatient individual therapy visit - In-Network Yes No $40
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 20% per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network Yes No 50%
Dental x-ray(s) Yes In-Network Yes No $0 copay
Oral exam Yes In-Network Yes No $0 copay
Fluoride treatment No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - In-Network Yes No $40
Physical therapy and speech and language therapy visit - In-Network Yes No $40
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $195 per day for days 1 through 35 $0 per day for days 36 through 100
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass lenses No - - - Not covered
Routine eye exam Yes Out-of-Network No No 50%
Contact lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No 50%
Upgrades - - - - Not covered
Eyeglass frames No - - - Not covered
Other No - - - Not covered
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $35 per visit (always covered)
Emergency - - - - $80 per visit (always covered)
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $395 per day for days 1 through 4 $0 per day for days 5 through 90
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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