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A NEW Rx Plan Designed to Help You Save Money on Prescriptions!

  • Monthly premiums as low as $12.80/month* (View premiums by state)
  • Only $1 co-pay for preferred generic drugs
  • $0 deductible **
  • Save on nearly 2,000 generic prescription drugs
  • Large network of over 57,000 participating local and national pharmacies, including:
  • Costco
  • Albertsons
  • Rite Aid
  • CVS
  • Giant Eagle
  • Safeway
  • Walmart
  • Kroger
  • Walgreens
Plus thousands of local pharmacies
  • Convenient mail order options for certain maintenance medications
  • Friendly customer service representatives who are committed to taking care of our members
*Monthly rates vary from $12.80 to $17.60, depending upon your state. Please check for your state-specific rate.
**Available on Tier 1 and Tier 2 drugs

Clear Spring Health 2020 PDP Plan Documents & Pricing

For your convenience, members and non-members can visit Clear Spring Health's online document library to view and print plan enrollment forms and plan information forms. Click the button found under Enrollment Documents or Member Plan Documents to access materials and information about plan benefits, coverage and enrollment. Click the Member Resources button to access plan-related forms used by members to manage their prescription drug coverage.

Need Help?

1-877-317-6082

TTY: 711

Download our application online
Download our enrollment application below, complete,
sign and return by mail to:
Clear Spring Health
Attn: Enrollment
P.O. Box 3206
Scranton, PA 18505-9877

Or Fax to: (855) 231-8775


Star Ratings
Updated on 11/1/2019
Star Ratings (en Español)
Last Updated: 11/1/2019
Summary of Benefits
Last Updated: 10/03/2019

Evidence of Coverage >
Last Updated: 10/01/2019

Pharmacy Directory
Last Updated: 11/05/2019

Formulary
Last Updated: 11/04/2019
Value Rx Formulary
Last Updated: 11/04/2019
Premier Rx Formulary
Last Updated: 11/04/2019


Prescription Drug Transition Policy
Last Updated: 11/04/2019

Prior Authorization Forms for Physicians and Enrollees
Last Updated: 10/01/2019
COMING SOON!!!

Part D Model Coverage Determination and Redetermination Request Form
Last Updated: 10/01/2019
COMING SOON!!!

Document Premier
Last Updated: 11/07/2019
Prior Authorization Criteria
Last Updated: 11/07/2019
Step Therapy Criteria
Last Updated: 11/07/2019
Quantity Limit Criteria
Last Updated: 11/07/2019

Document Value
Last Updated: 11/07/2019
Prior Authorization Criteria
Last Updated: 11/07/2019
Step Therapy Criteria
Last Updated: 11/07/2019
Quantity Limit Criteria
Last Updated: 11/07/2019
Appointment of Representative
Last Updated: 10/01/2019

Disenrollment Form
Last Updated: 10/01/2019

Member Rights and Responsibilities
Last Updated: 10/01/2019

Appeals and Grievance Process
Last Updated: 10/03/2019

Utilization Management Program
Last Updated: 10/03/2019

Quality Improvement Program
Last Updated: 10/03/2019
Value Plans
Region Description Total Premium
(Basic+Supp)
Download LIS Value
Summary Sheet
04 NJ $31.70 Download
05 DC, DE, MD $26.10 Download
06 PA, WV $33.00 Download
07 VA $27.50 Download
08 NC $25.00 Download
09 SC $21.60 Download
10 GA $22.90 Download
11 FL $26.50 Download
12 AL, TN $27.80 Download
13 MI $29.20 Download
14 OH $30.00 Download
15 IN, KY $29.00 Download
16 WI $32.20 Download
17 IL $24.40 Download
18 MO $29.20 Download
19 AR $23.70 Download
20 MS $23.60 Download
21 LA $29.70 Download
22 TX $21.40 Download
23 OK $27.50 Download
24 KS $28.70 Download
25 IA, MN, MT, ND, NE, SD, WY $32.40 Download
28 AZ $29.50 Download
29 NV $23.60 Download
30 OR, WA $30.50 Download
31 ID, UT $32.70 Download
32 CA $29.70 Download
33 HI $24.80 Download
34 AK $30.20 Download

Premier Plans
Region Description Total Premium
(Basic+Supp)
Download LIS Premier
Summary Sheet
04 NJ $13.20 Download
05 DC, DE, MD $15.60 Download
06 PA, WV $16.30 Download
07 VA $15.80 Download
08 NC $16.10 Download
09 SC $15.70 Download
10 GA $15.60 Download
11 FL $13.80 Download
12 AL, TN $15.00 Download
13 MI $16.00 Download
14 OH $17.00 Download
15 IN, KY $16.00 Download
16 WI $15.10 Download
17 IL $16.20 Download
18 MO $15.60 Download
19 AR $17.10 Download
20 MS $16.90 Download
21 LA $17.10 Download
22 TX $16.20 Download
23 OK $17.60 Download
24 KS $15.60 Download
25 IA, MN, MT, ND, NE, SD, WY $14.40 Download
28 AZ $13.50 Download
29 NV $15.30 Download
30 OR, WA $15.60 Download
31 ID, UT $14.70 Download
32 CA $12.80 Download
33 HI $14.20 Download
34 AK $14.00 Download

Find Your Pharmacy

Our plans provide you the opportunity to save on copays by using a national preferred retail network pharmacy. To view a list of network pharmacies in your area, please select the search below.

Perform Search

Look Up Your Drugs

The Drug Coverage tool reveals which drugs are covered by our plan and provides information on copay Tier.

Perform Value Search Perform Premier Search

Feel Secure with Clear Spring Health Prescription Drug Coverage

Clear Spring Health is a values-based company committed to making a tangible, positive difference in people’s lives. It’s the focus of everything we do.

We’re able to deliver on our mission because we’re backed by two highly experienced, financially strong organizations, Delaware Life Insurance Company and its parent, Group One Thousand One Insurance Holdings.

Enrollment is Easy!

Call 1-877-317-6082 a Member Services Representative will answer any questions you have right over the phone.

Visit ClearSpringHealthRx.com and complete a simple online application.

Enroll October 15 through December 7
1-877-317-6082 (TTY:711)