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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.

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Summary of Benefits
Last Updated: 10/03/2019

Summary of Benefits (en Español)
Last Updated: 11/25/2019

Evidence of Coverage >
Last Updated: 1/31/2020

Pharmacy Directory
Last Updated: 11/05/2019

Formulary
Last Updated: 01/03/2020
Value Rx Formulary
Last Updated: 01/03/2020
Premier Rx Formulary
Last Updated: 01/03/2020

Formulary Changes
Last Updated: 01/03/2020
Value Rx Formulary
Last Updated: 01/03/2020
Premier Rx Formulary
Last Updated: 01/03/2020


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


Part D Model Coverage Determination and Redetermination Request Form
Last Updated: 11/18/2019

Document Premier
Last Updated: 01/03/2020
Prior Authorization Criteria
Last Updated: 01/03/2020
Step Therapy Criteria
Last Updated: 01/03/2020
Quantity Limit Criteria
Last Updated: 01/03/2020

Document Value
Last Updated: 01/03/2020
Prior Authorization Criteria
Last Updated: 01/03/2020
Step Therapy Criteria
Last Updated: 01/03/2020
Quantity Limit Criteria
Last Updated: 01/03/2020

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.

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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.

Important Message

Thank you for your interest in Clear Spring Health. We are taking a hiatus from sales and marketing in order to improve our support and service of our members. For any questions please call Member Services at 877-384-1241