Affordable, Value-Packed Medicare Advantage Prescription Drug Plans

• Clear Spring Health Essential (HMO)• Clear Spring Health Essential Plus (HMO)

FOR THESE ILLINOIS COUNTIES: Rockford, Downstate — Boone, Clinton, Macoupin, Madison, Ogle, St. Clair, Stephenson, WinnebagoChicago Area — Cook, DuPage, Kane, Kankakee, LaSalle, McHenry, Will

Clearly Simpler • Clearly Smarter

CLEAR SPRING HEALTH

ILLINOIS

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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 Rockford, Downstate counties — Boone, Clinton, Macoupin, Madison, Ogle, St. Clair, Stephenson, Winnebago

OR one of these Chicago Area counties — Cook, DuPage, Kane, Kankakee, LaSalle, McHenry, Will

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

www.clearspringhealthcare.com

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

• Low or $0 monthly plan premium • Low copays• $0 plan deductibles • Low out-of-pocket maximums• Coverage for Routine Eye & Hearing Exams• Coverage for Eyeglasses & Hearing Aids• Fitness Benefi ts• Worldwide Emergency Coverage – ideal for snowbirds & travelers• A fast-growing provider network – 4,500 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 $0 Rx deductible plan.

Keep in mind, with HMO plans:• Out-of-Network/non-contracted providers are under no obligation

to treat Clear Spring Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

• You must choose a Primary Care Physician (PCP) from a network of local providers.

• All care is coordinated through your PCP.• You must obtain a referral before seeing practitioners and

specialists other than your PCP.

In return, you enjoy enhanced benefi ts and low out-of-pocket costs that make it easy to get the most from your healthcare.

Choose the Plan that’s Best for You

You have a choice of two quality Health Maintenance Organization (HMO) plans: Clear Springs Health Essential and Essential Plus. They differ in terms of premiums, copays, etc. (see chart), but both offer many important advantages.

Plan Name Clear Spring Health Essential (HMO) Clear Spring Health Essential Plus (HMO)

Plan Number/Service Area

H5454-001 – Boone, Clinton, Macoupin, Madison, Ogle, St. Clair, Stephenson, Winnebago

H5454-003 – Boone, Clinton, Macoupin, Madison, Ogle, St. Clair, Stephenson, Winnebago

Plan Number/Service Area

H5454-002 – Cook, DuPage, Kane, Kankakee, LaSalle, McHenry, Will

H5454-004 – Cook, DuPage, Kane, Kankakee, LaSalle, McHenry, Will

Member Premium $0.00 $47.00

COPAYS

PCP $0 $0Specialist $30 $15

Outpatient Mental Health $30 $15

Inpatient Hospital

$225 days 1 through 8; $0 days 9 through 90

$175 days 1 through 5; $0 days 6 through 90

Inpatient Mental Health

$225 days 1 through 8; $0 days 9 through 90

$175 days 1 through 5; $0 days 6 through 90

Emergency Care $120 $120

Outpatient Surgery $200 $100

Diagnostic Lab $2 $0

Rx Deductible $0 All Tiers $0 All Tiers

RX COPAYS Retail 30 day supply

Retail 90 day supply

Mail order 90 day supply

Retail 30 day supply

Retail 90 day supply

Mail order 90 day supply

Tier 1 $3 $9 $0 $0 $0 $0Tier 2 $12 $36 $0 $6 $12 $12Tier 3 $47 $141 $131 $35 $70 $70Tier 4 $100 $300 $290 $85 $255 $255

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

Maximum $3,400 $3,400

Referral Required Yes Yes

Extra Benefi ts Worldwide Emergency Coverage, Routine Eye and Hearing Exams, Eyeglasses, Hearing Aids, Fitness Benefi t, Remote Access Technologies including Nursing Hotline, Enhanced Alternative Rx Coverage

Worldwide Emergency Coverage, Enhanced Dental, Routine Eye and Hearing Exams, Eyeglasses, Hearing Aids, Fitness Benefi t, Remote Access Technologies including Nursing Hotline, Enhanced Alternative Rx Coverage

About Clear Spring HealthClear Spring Health is a subsidiary of Delaware Life Insurance Company and its parent, Group One Thousand One Insurance Holdings. 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 under no obligation to treat Clear Spring Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, 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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