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2021 Medicare Prescription Drug Plan Cost-Sharing Details
| 2021 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
|
Clear Spring Health Value Rx (PDP) (S6946-011-0) Benefit Details 
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| This plan is available in CMS PDP Region 14 Monthly Premium: $24.10 Rx Deductible: $445 Initial Coverage Limit: $4,130 Qualifies for LIS: Yes Click on a letter below to view the Clear Spring Health Value Rx (PDP) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
| This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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| Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
| Initial Deductible Phase Cost Sharing | ||||||
| All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $1.00 | $6.00 | $1.00 | $3.00 | $18.00 | $3.00 |
| Tier 2: Generic: | $3.00 | $8.00 | $3.00 | $9.00 | $24.00 | $9.00 |
| Tier 3: Preferred Brand: | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $126.00 |
| Tier 4: Non-Preferred Drug: | 33% | 33% | 33% | 33% | 33% | 33% |
| Tier 5: Specialty Tier: | 25% | 25% | 25% | 25% | 25% | 25% |
| Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
| All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
| All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
| Catastrophic Coverage Phase Cost Sharing | ||||||
| Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.70 | The greater of 5% or $3.70 | ||||
| Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.20 | The greater of 5% or $9.20 | ||||
| Go to the Clear Spring Health Value Rx (PDP) 2021 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||