Clear Spring Health Deluxe Plan (HMO D-SNP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Clear Spring Health Deluxe Plan (HMO D-SNP) by Clear Spring Health (sc), Inc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a South Carolina 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 Clear Spring Health Deluxe Plan (HMO D-SNP)(H9403-001) plan has a $505 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. Clear Spring Health (sc), Inc 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:Clear Spring Health Deluxe Plan (HMO D-SNP)
Plan ID: H9403-001
Provider: Clear Spring Health (sc), Inc
Plan Year:2023
Premium:$0.00
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:South Carolina
Similar Plan:H9403-003


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
3YNA$0NANN
Cabometyx
5NA$0NA30/30YN
Calcipotriene
4YNA$0NA120/30YN
Calcitriol
4YNA$0NANN
Calcium Acetate
3YNA$0NA360/30NN
Calquence
5NA$0NA60/30YN
Camila
2YNANNANN
Camrese Lo
3YNA$0NANN
Candesartan
1YNA$0NANN
Candesartan Cilexetil And Hydrochlorothiazide
1YNA$0NANN
Caplyta
5NA$0NA30/30NN
Caprelsa
5NA$0NA30/30YN
Captopril
1YNA$0NANN
Carbamazepine
4YNA$0NANN
Carbidopa
4YNA$0NANN
Carbidopa And Levodopa
2YNANNANN
Carbidopa, Levodopa, And Entacapone
4YNA$0NANN
Carglumic Acid
5NA$0NAYN
Carteolol Hydrochloride
2YNANNANN
Cartia
2YNANNANN
Caspofungin Acetate
4YNA$0NANN
Cayston
5NA$0NA84/56YN
Caziant
2YNANNANN
Cefaclor
4YNA$0NANN
Cefadroxil
2YNANNANN
Cefazolin
3YNA$0NANN
Cefdinir
2YNANNANN
Cefixime
4YNA$0NANN
Cefoxitin
4YNA$0NAYN
Cefpodoxime Proxetil
4YNA$0NANN
Cefprozil
3YNA$0NANN
Ceftazidime
3YNA$0NAYN
Ceftriaxone Sodium
3YNA$0NANN
Cefuroxime
3YNA$0NAYN
Celecoxib
2YNANNA60/30NN
Celontin
4YNA$0NANN
Cephalexin
3YNA$0NANN
Cerdelga
5NA$0NAYN
Cevimeline
4YNA$0NANN
Chemet
4YNA$0NAYN
Chlorpromazine Hydrochloride
4YNA$0NANN
Chlorthalidone
2YNANNANN
Cholestyramine
3YNA$0NANN
Ciclopirox
3YNA$0NA120/28NN
Ciclopirox Olamine
3YNA$0NA60/28NN
Cilostazol
2YNANNANN
Ciloxan
3YNA$0NANN
Cimduo
5NA$0NANN
Cimetidine
2YNANNANN
Cimetidine Hydrochloride
4YNA$0NANN
Cinacalcet Hydrochloride
5NA$0NA120/30YN
Cipro
4YNA$0NANN
Ciprofloxacin
4YNA$0NANN
Ciprofloxacin And Dexamethasone
2YNANNANN
Citalopram Hydrobromide
3YNA$0NANN
Claravis
4YNA$0NAYN
Clarithromycin
4YNA$0NANN
Clindamycin
3YNA$0NAYN
Clindamycin Hydrochloride
1YNA$0NANN
Clindamycin In 5 Percent Dextrose
4YNA$0NAYN
Clindamycin Palmitate Hydrochloride (pediatric)
4YNA$0NANN
Clindamycin Phosphate
3YNA$0NANN
Clinimix
4YNA$0NAYN
Clobazam
4YNA$0NA480/30YN
Clomipramine Hydrochloride
4YNA$0NAYN
Clonazepam
3YNA$0NA300/30NN
Clonidine Hydrochloride
1YNA$0NANN
Clonidine Transdermal System
4YNA$0NA4/28NN
Clorazepate Dipotassium
4YNA$0NA180/30YN
Clotrimazole
4YNA$0NANN
Clotrimazole Topical Solution Usp, 1%
3YNA$0NA30/28NN
Clozapine
4YNA$0NA135/30NN
Coartem
4YNA$0NANN
Colchicine
3YNA$0NANN
Colesevelam Hydrochloride
4YNA$0NANN
Colestipol Hydrochloride
3YNA$0NANN
Collagenase Santyl
4YNA$0NA180/30NN
Combivent Respimat
4YNA$0NA8/30NN
Complera
5NA$0NANN
Compro
4YNA$0NANN
Copaxone
5NA$0NA30/30YN
Corlanor
4YNA$0NA450/30NN
Cotellic
5NA$0NA63/28YN
Creon
3YNA$0NANN
Cresemba
5NA$0NAYN
Cromolyn Sodium
1YNA$0NANN
Cryselle
2YNANNANN
Cyclobenzaprine Hydrochloride
3YNA$0NAYN
Cyclophosphamide
3YNA$0NAYN
Cyclosporine
4YNA$0NAYN
Cyproheptadine Hydrochloride
3YNA$0NAYN
Cyred Eq
2YNANNANN
Cystagon
4YNA$0NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H9403-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $505. 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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