Clover Health Choice (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Clover Health Choice (PPO) by Clover Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a New Jersey Medicare Part-C plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Clover Health Choice (PPO)(H5141-004) plan has a $150 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However, some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Clover Insurance Company will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Clover Health Choice
Plan ID: H5141-004
Provider: Clover Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$150
Initial Coverage Limit:$4660
Coverage Area:New Jersey
Similar Plan:H5141-007


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Cabergoline
3Y$37$47NANN
Cabometyx
530%30%NA30/30YN
Calcipotriene
4Y$90$100NA120/30YN
Calcitriol
4Y$90$100NAYN
Calcium Acetate
3Y$37$47NA360/30NN
Calquence
530%30%NA60/30YN
Camila
2N$10$15NANN
Candesartan
1N$0$10NA30/30NN
Candesartan Cilexetil And Hydrochlorothiazide
1N$0$10NA30/30NN
Caplyta
4Y$90$100NA30/30YN
Caprelsa
530%30%NAYN
Captopril
1N$0$10NANN
Carbamazepine
4Y$90$100NANN
Carbidopa
4Y$90$100NANN
Carbidopa And Levodopa
2N$10$15NANN
Carbidopa, Levodopa, And Entacapone
4Y$90$100NANN
Carglumic Acid
530%30%NAYN
Carteolol Hydrochloride
2N$10$15NANN
Cartia
2N$10$15NANN
Caspofungin Acetate
4Y$90$100NANN
Cayston
530%30%NAYN
Caziant
3Y$37$47NANN
Cefaclor
4Y$90$100NANN
Cefadroxil
2N$10$15NANN
Cefazolin
3Y$37$47NANN
Cefdinir
2N$10$15NANN
Cefixime
4Y$90$100NANN
Cefoxitin
4Y$90$100NANN
Cefpodoxime Proxetil
4Y$90$100NANN
Cefprozil
3Y$37$47NANN
Ceftazidime
4Y$90$100NANN
Ceftriaxone Sodium
4Y$90$100NANN
Cefuroxime
3Y$37$47NANN
Celecoxib
3Y$37$47NA60/30NN
Celontin
4Y$90$100NANN
Cephalexin
3Y$37$47NANN
Cerdelga
530%30%NAYN
Cevimeline
4Y$90$100NANN
Chemet
4Y$90$100NANN
Chlorpromazine Hydrochloride
4Y$90$100NANN
Chlorthalidone
2N$10$15NANN
Cholestyramine
3Y$37$47NANN
Ciclopirox Olamine
3Y$37$47NA60/30NN
Cilostazol
2N$10$15NANN
Ciloxan
3Y$37$47NANN
Cimduo
530%30%NANN
Cinacalcet Hydrochloride
530%30%NA120/30YN
Cipro
4Y$90$100NANN
Ciprofloxacin
4Y$90$100NANN
Ciprofloxacin And Dexamethasone
4Y$90$100NANN
Citalopram Hydrobromide
3Y$37$47NANN
Claravis
4Y$90$100NAYN
Clarithromycin
4Y$90$100NANN
Clindamycin
3Y$37$47NANN
Clindamycin Hydrochloride
2N$10$15NANN
Clindamycin In 5 Percent Dextrose
4Y$90$100NANN
Clindamycin Palmitate Hydrochloride (pediatric)
4Y$90$100NANN
Clindamycin Phosphate
3Y$37$47NANN
Clinimix
4Y$90$100NAYN
Clobazam
4Y$90$100NA480/30YN
Clomipramine Hydrochloride
4Y$90$100NAYN
Clonazepam
3Y$37$47NA300/30NN
Clonidine Hydrochloride
1N$0$10NANN
Clonidine Transdermal System
3Y$37$47NANN
Clorazepate Dipotassium
4Y$90$100NA180/30YN
Clotrimazole
4Y$90$100NA150/30NN
Clotrimazole Topical Solution Usp, 1%
3Y$37$47NA30/30NN
Clozapine
4Y$90$100NA120/30NN
Coartem
4Y$90$100NANN
Colchicine
3Y$37$47NA120/30NN
Colesevelam Hydrochloride
4Y$90$100NANN
Colestipol Hydrochloride
3Y$37$47NANN
Collagenase Santyl
4Y$90$100NA180/30NN
Combivent Respimat
4Y$90$100NA8/30NN
Complera
530%30%NANN
Compro
4Y$90$100NANN
Corlanor
4Y$90$100NANN
Cotellic
530%30%NAYN
Creon
3Y$37$47NANN
Cromolyn Sodium
2N$10$15NANN
Cryselle
3Y$37$47NANN
Cyclobenzaprine Hydrochloride
3Y$37$47NAYN
Cyclophosphamide
3Y$37$47NAYN
Cyclosporine
4Y$90$100NAYN
Cyproheptadine Hydrochloride
3Y$37$47NAYN
Cyred Eq
2N$10$15NANN
Cystadrops
530%30%NAYN
Cystagon
4Y$90$100NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H5141-004

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $150. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2023 is $505. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on

Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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