Clear Spring Health Value Rx (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Clear Spring Health Value Rx (PDP) by Clear Spring Health 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 In Central New England (Connecticut, Massachusetts, Rhode Island, and Vermont). 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 Value Rx (PDP)(S6946-060) 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 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:Clear Spring Health Value Rx (PDP)
Plan ID: S6946-060
Formulary
Provider: Clear Spring Health Insurance Company
Plan Year:2023
Premium:$28.70
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Central New England (Connecticut, Massachusetts, Rhode Island, and Vermont)
Similar Plan:S6946-061


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
4Y36%36%36%NN
Cablivi
525%25%25%32/30YN
Cabometyx
525%25%25%30/30YN
Calcipotriene
4Y36%36%36%120/30NN
Calcitriol
4Y36%36%36%NN
Calcium Acetate
3Y$42$47$42360/30NN
Calquence
525%25%25%60/30YN
Camila
4Y36%36%36%NN
Candesartan
3Y$42$47$4230/30NN
Candesartan Cilexetil And Hydrochlorothiazide
4Y36%36%36%30/30NN
Caplyta
4Y36%36%36%30/30NY
Caprelsa
525%25%25%30/30YN
Captopril
2Y$3$8$3NN
Carbamazepine
4Y36%36%36%NN
Carbidopa
4Y36%36%36%NN
Carbidopa And Levodopa
3Y$42$47$42NN
Carbidopa, Levodopa, And Entacapone
4Y36%36%36%NN
Carglumic Acid
525%25%25%YN
Carteolol Hydrochloride
2Y$3$8$3NN
Cartia
3Y$42$47$42NN
Caspofungin Acetate
4Y36%36%36%NN
Cayston
525%25%25%84/28YN
Caziant
4Y36%36%36%NN
Cefaclor
4Y36%36%36%NN
Cefadroxil
2Y$3$8$3NN
Cefazolin
4Y36%36%36%NN
Cefdinir
4Y36%36%36%NN
Cefoxitin
4Y36%36%36%YN
Cefpodoxime Proxetil
4Y36%36%36%NN
Cefprozil
3Y$42$47$42NN
Ceftazidime
4Y36%36%36%YN
Ceftriaxone Sodium
4Y36%36%36%NN
Cefuroxime
4Y36%36%36%YN
Celecoxib
4Y36%36%36%NN
Celontin
4Y36%36%36%NN
Cephalexin
4Y36%36%36%NN
Chemet
4Y36%36%36%YN
Chlordiazepoxide Hydrochloride
2Y$3$8$3120/30NN
Chlorpromazine Hydrochloride
4Y36%36%36%NN
Chlorthalidone
2Y$3$8$3NN
Cholestyramine
4Y36%36%36%NN
Ciclopirox
4Y36%36%36%120/28NN
Ciclopirox Olamine
4Y36%36%36%60/28NN
Cilostazol
2Y$3$8$3NN
Cimduo
525%25%25%30/30NN
Cinacalcet Hydrochloride
525%25%25%120/30YN
Cinryze
525%25%25%YN
Cipro
4Y36%36%36%NN
Ciprofloxacin
4Y36%36%36%NN
Ciprofloxacin And Dexamethasone
3Y$42$47$42NN
Ciprofloxacin And Fluocinolone Acetonide
4Y36%36%36%14/28NN
Ciprofloxacin Otic
4Y36%36%36%NN
Citalopram Hydrobromide
4Y36%36%36%NN
Claravis
4Y36%36%36%NN
Clarithromycin
4Y36%36%36%NN
Clindamycin
4Y36%36%36%YN
Clindamycin Hydrochloride
2Y$3$8$3NN
Clindamycin In 5 Percent Dextrose
4Y36%36%36%YN
Clindamycin Palmitate Hydrochloride (pediatric)
4Y36%36%36%NN
Clindamycin Phosphate
4Y36%36%36%NN
Clinimix
4Y36%36%36%YN
Clobazam
4Y36%36%36%480/30YN
Clomipramine Hydrochloride
4Y36%36%36%NN
Clonazepam
4Y36%36%36%300/30NN
Clonidine Hydrochloride
1Y$1$6$1NN
Clonidine Transdermal System
4Y36%36%36%4/28NN
Clorazepate Dipotassium
4Y36%36%36%180/30YN
Clotrimazole
4Y36%36%36%NN
Clotrimazole And Betamethasone Dipropionate
4Y36%36%36%60/28NN
Clotrimazole Topical Solution Usp, 1%
3Y$42$47$4230/28NN
Clozapine
4Y36%36%36%120/30NY
Coartem
4Y36%36%36%24/30NN
Colchicine
4Y36%36%36%NN
Colestipol Hydrochloride
4Y36%36%36%NN
Collagenase Santyl
4Y36%36%36%180/30NN
Combivent Respimat
4Y36%36%36%8/30NN
Complera
525%25%25%30/30NN
Compro
4Y36%36%36%NN
Copaxone
525%25%25%30/30YN
Corlanor
3Y$42$47$42450/30NN
Cotellic
525%25%25%63/28YN
Cresemba
525%25%25%YN
Cromolyn Sodium
2Y$3$8$3NN
Cryselle
4Y36%36%36%NN
Cyclobenzaprine Hydrochloride
2Y$3$8$390/30YN
Cyclophosphamide
3Y$42$47$42YN
Cyclosporine
4Y36%36%36%YN
Cyred Eq
4Y36%36%36%NN
Cystagon
4Y36%36%36%YN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S6946-060

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 2022 is $320. 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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