Affordable, Value-Packed Medicare Advantage Prescription Drug Plan

• Clear Spring Health Essential (PPO)

FOR THESE VIRGINIA COUNTIES AND CITIES: Chesterfi eld, Colonial Heights, Hanover, Henrico, Hopewell City, Petersburg City, Richmond City

Clearly Simpler • Clearly Smarter

CLEAR SPRING HEALTH

VIRGINIA

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that’s packed with EXCEPTIONAL VALUE and SIMPLE TO USE. Clear Spring Health has the Medicare Advantage Prescription Drug plan for you!

You want a Smart,All-inclusive Health Plan…

More than Original Medicare OffersOur Medicare Advantage plans provide all the benefi ts of original Medicare…and more. We’ll help you embrace health and enjoy life by providing important extra benefi ts. Plus, we provide services that help you manage your healthcare wisely, like our Nursing Hotline, care management programs and more.

Service that Makes You SmileFrom answering your questions to processing claims, our award-winning customer service team will work hard to earn your ongoing satisfaction.

Making Healthcare and Meds More Affordable On a fi xed income? You’ll appreciate our competitive copays and deductibles. They’ll make it less daunting to get the healthcare and prescription drugs you need—without derailing your budget.

A Breath of Fresh AirWe may be new to this market, but our leadership has decades of successful industry experience, plus a rock-solid commitment to making insurance more useful, accessible and value-driven.

Are You Eligible?

Yes to both? You’re good to go!

Confi rming your eligibility is simple. You must:

• Have Medicare Part A and Part B,AND

• Reside in one of these Virginiacounties: Chesterfi eld, ColonialHeights, Hanover, Henrico,Hopewill City, Petersburg City orRichmond City

Ask your agent to help you enroll or enroll online at www.clearspringhealthcare.com

www.clearspringhealthcare.com

Chesterfield

Hanover

Henrico

Hopewell

PetersburgColonialHeights

Richmond

Key AdvantagesWhen reviewing our plan overview, please take note of these highlights. In addition to our expert Care Management Programs and award-winning service, they make our plan an excellent healthcare value:

• Low monthly plan premium• Low or $0 in-network copays• $0 plan deductibles

• Coverage for Routine Eye & Hearing Exams, plus Eyeglasses• Coverage for Smoking & Tobacco Cessation• Fitness Benefi ts• Worldwide Emergency Coverage – ideal for snowbirds & travelers• A fast-growing provider network – 175+ providers and counting

An Enhanced Prescription Drug PlanWe partnered with EnvisionRx Plus to bring you an exceptional, Medicare-approved drug plan. You’ll get access to a nationwide network of thousands of pharmacies (including Rite Aid), plus the convenience of mail order and a a $0 Rx deductible plan.

Keep in mind, with PPO plans:• You have relative freedom to choose your physicians, hospitals

and other providers.• You can use hospitals, physicians and other providers in the

Clear Spring Health network, or can use out-of-network provid-ers, as long as these providers accept Medicare.

• You are not required to obtain specialist referrals.• Your in-network benefi ts will typically be richer than those for

out-of-network procedures.

If you prize fl exibility in choosing your providers, our PPO plan is an excellent value!

Choose the Plan that offers real Value

Our Preferred Provider Organization (PPO) plan, Clear Springs Health Essential, offers many important benefi ts and advantages.

Plan Name Clear Spring Health Essential (PPO)

Plan Number/Service Area

H2020-002 – Chesterfi eld, Colonial Heights, Hanover, Henrico, Hopewell City, Petersburg City, Richmond City

Member Premium $29.00 COPAYS In-Network Out-of-Network

PCP $15 50%Specialist $45 50%

Outpatient Mental Health $40 50%

Inpatient Hospital

$304 days 1 through 6; $0 days 7 through 90

50% days 1 through 6; 50% days 7 through 90

Inpatient Mental Health

$330 days 1 through 5; $0 days 6 through 90

50% days 1 through 5; 50% days 6 through 90

Emergency Care $90 50%

Outpatient Surgery $265 50%

Diagnostic Lab $25 50%Rx Deductible $0 $0

RX COPAYS In-Network Out-of-Network

Retail 30 day supply

Retail 90 day supply

Mail order 30 day supply

Mail order

90 day supply

Retail 30 day supply

Tier 1 $2 $6 $2 $0 $2Tier 2 $5 $15 $5 $10 $5Tier 3 $42 $126 $42 $121 $42Tier 4 $100 $300 $100 $300 $100

Tier 5 33% NA 33% NA 31%Out-of-Pocket

Maximum $5,500 $10,000 (Combined with In-Network)

Extra Benefi ts

Worldwide Emergency Coverage, Smoking and Tobacco Cessation, Routine Eye and Hearing Exams, Fitness Benefi t, Remote Access Technologies including Nursing Hotline, Enhanced Alternative Rx Coverage

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About Clear Spring HealthClear Spring Health is a subsidiary of Delaware Life Insurance Company and its parent, Group One Thousand One, LLC. Delaware Life (DelawareLife. com) has 40 years of insurance experience, has earned an A- (Excellent) rating from A.M. Best and holds $36.5 billion in assets under management.

Group One Thousand One (Group1001.com) is on a mission to make insurance more useful, intuitive and accessible to everyone, developing user-centric insurance solutions that can make a real difference in people’s lives.

As result, Clear Spring Health is dedicated to making Medicare Advantage plans simpler, smarter and packed with value for Medicare benefi ciaries, while operating from a foundation of integrity, successful leadership and rock-solid fi nancial strength.

DisclaimersClear Spring Health is an HMO and PPO plan with a Medicare contract. Enrollment in Clear Spring Health depends on contract renewal. This information is not a complete description of benefi ts. Call 1-877-384-1241/TTY 711 for more information. Clear Spring Health complies with applicable Federal civil rights and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-877-384-1241/TTY 711. Out-of-Network/non-contracted providers are underno obligation to treat Clear Spring Health members, except in emergency situations.Please call our customer service number or see your Evidence of Coverage for moreinformation, including the cost sharing that applies to out-of-network services.

www.clearspringhealthcare.com

For more information, contact Clear Spring Health Toll-free: 877-384-1241 (TTY: 711)

Our call center is open from 8:00 am to 8:00 pm, Monday through Friday, from April 1 through September 30 and 8:00 am to 8:00 pm, Monday through

Sunday from October 1 through March 31. You may leave a voicemail Saturday, Sunday and Federal Holidays.

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