Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H9589-001-000
Plan Organization Clear Spring Health
Plan Type Local PPO
Plan Name EON GOLD (PPO C-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Chronic or Disabling Condition
Conditions Covered Cardiovascular Disorders
Overall Star Rating Not enough data available
Plan Cost Sharing
Premium $15.00
Total Premium (Includes Part B) $150.50
Monthly Part D Basic Premium $15.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $15.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $3.70
Monthly Part D Premium 50% Assistance $7.50
Monthly Part D Premium 25% Assistance $11.20
Part D Drug Deductible $250.00
Annual Drug Deductible $250.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 40%
Diagnostic services Yes In-Network Yes No $0 copay
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Endodontics No - - - Not covered
Extractions No - - - Not covered
Restorative services Yes Out-of-Network Yes No 40%
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - In-Network Yes No 20%
Diagnostic radiology services (e.g., MRI) - In-Network Yes No 20%
Outpatient x-rays - In-Network Yes No $25
Lab services - In-Network Yes No $5
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - In-Network - - $0 copay
Specialist - In-Network No No $25 per visit
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $225
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per stay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - In-Network Yes No $40
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 40%
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 40%
Inpatient hospital - psychiatric - Out-of-Network Yes No 40% per stay
Outpatient individual therapy visit - Out-of-Network Yes No 40%
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $225 per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network Yes No 50%
Oral exam Yes Out-of-Network Yes No 50%
Dental x-ray(s) Yes In-Network Yes No $0 copay
Fluoride treatment No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - In-Network Yes No $40
Occupational therapy visit - In-Network Yes No $40
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No 50%
Other No - - - Not covered
Routine eye exam Yes In-Network No No $0 copay
Upgrades - - - - Not covered
Eyeglass frames No - - - Not covered
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $50 per visit (always covered)
Emergency - - - - $80 per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care No Out-of-Network Yes No 40%
Foot exams and treatment - In-Network Yes No $0 copay
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing exam - Out-of-Network No No 40%
Hearing aids Yes In-Network Yes No $0 copay
Fitting/evaluation Yes Out-of-Network No 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 - In-Network Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - In-Network Yes - 20% per item
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes No $0 per day for days 1 through 20 $167 per day for days 21 through 100
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $500 annual deductible
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 40%
Other Part B drugs - Out-of-Network Yes - 40%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
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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