Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H6672-004-000
Plan Organization Clear Spring Health
Plan Type Local HMO
Plan Name EON SELECT (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
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
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No $0 copay
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Restorative services Yes - No No $25
Diagnostic services Yes - No No $25
Endodontics No - - - Not covered
Extractions 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)
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $195
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids Yes - No No $0 copay
Hearing exam - - No No $25
Fitting/evaluation Yes - No No $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $300 per day for days 1 through 5 $0 per day for days 6 through 90
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient individual therapy visit with a psychiatrist - - Yes No $40
Outpatient group therapy visit - - Yes No $40
Inpatient hospital - psychiatric - - Yes No $300 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist - - Yes No $40
Outpatient individual therapy visit - - Yes No $40
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Fluoride treatment No - - - Not covered
Dental x-ray(s) Yes - No No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - No No $10
Eyeglass lenses No - - - Not covered
Upgrades - - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - - Yes No 20%
Diagnostic radiology services (e.g., MRI) - - Yes No 20%
Lab services - - Yes No $5
Outpatient x-rays - - Yes No $25
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $25 per visit
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes No $45
Routine foot care - - - - Not covered
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Diabetes supplies - - Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Other Part B drugs - - Yes - 20%
Chemotherapy - - Yes - 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - - Yes No $40
Occupational therapy visit - - Yes No $40
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
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $225 per visit
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20 $167 per day for days 21 through 100
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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