Prescription Drugs for Clarion Health (HMO)

 

See how our prescription drug benefits compare.

View our Formulary:

What is the Clarion Health Formulary?

A formulary is a list of covered drugs selected by Clarion Health in consultation with a team of healthcare providers that represents the prescription therapies believed to be necessary parts of a quality treatment program. Clarion Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Clarion Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (Drug List) Change?

Most changes in drug coverage happen on January 1, but Clarion Health may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.

MEDICARE PART D DRUGS

Four Stages of Drug Coverage

Our plan groups each drug into one of six “tiers” (levels). You will need to use the formulary (list of covered drugs) to locate what tier a drug is on.

Deductible

The deductible is the amount you pay before your plan starts to pay. This deductible is for retail and home delivery. There is no deductible with the Clarion Health (HMO) plan.

Initial Coverage

After you’ve reached the deductible, you’ll enter the initial coverage phase.

In this phase, you and the plan share the costs of some of the covered drugs until your total drug costs, including deductible, reach $4,020. The total drug costs paid by both you and our Part D plan will help you reach the coverage gap.

Coverage Gap

The coverage gap (also called the “donut hole”) starts after the total yearly drug cost (along with what our plan has paid and what you have paid) reaches $4,020.

While in the coverage gap in 2020, you’ll pay 25% of the plan’s cost for brand-name drugs and for generic drugs. You enter the catastrophic coverage phase once your yearly true out-of-pocket cost (Troop) reaches $6,350. The costs paid by you, and the manufacturer discount payment for brand-name drugs count toward your true out-of-pocket costs and help you get out of the coverage gap. Not everyone will reach the coverage gap.

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of: 5% of the cost or you pay $3.60

for generic (including brand-name drugs treated as generic). You pay $8.95 or 5%, whichever is greater for all other drugs.

Clarion Health
hmo plan cost
summary

With our Medicare Advantage plan, you get:

Hospital Coverage

Medical Coverage

Prescription Drug Coverage

And your monthly plan
premium is:

$0
Enroll Now

 

Standard Retail Cost-Sharing

Tier Clarion Health (HMO)
Intial Coverage
$0 - $4,020
30-day supply
Coverage Gap
Over $4,020
Catastrophic
Over $6,350
You Pay You Pay You Pay
Tier 1: Preferred Generic $3 $3 Generic = $3.60 or
5% whichever is greater

Brand = $8.95 or
5% whichever is greater
Tier 2: Generic $10 25%
Tier 3: Preferred Brand $45 25%
Tier 4: Non-Preferred Drug $95 25%
Tier 5: Specialty Tier 33% 25%
Tier 6: Select Care $0 $0

Standard Mail Order Cost-Sharing

Tier Clarion Health (HMO)
Monthly Supply 30 day supply 90 day supply
Tier 1: Preferred Generic $3 $9
Tier 2: Generic $10 $30
Tier 3: Preferred Brand $45 $135
Tier 4: Non-Preferred Brand $95 $285
Tier 5: Specialty Tier 33% N/A
Tier 6: Select Care Drugs $0 $0
If you live in a long-term care facility, you pay the same as at a retail pharmacy.
Qualifying for Extra Help, Low Income Subsidy (LIS)

If you qualify for Extra Help for your Medicare prescription drug plan costs, the amount you pay for insurance every month and cost at the pharmacy will be lower.

The amount of Extra Help, Low Income Subsidy (LIS) level will decide the amount you pay for insurance every month as a member of our plan.

To learn more about available Medicare Part D subsidies (the money granted by the government to help pay for Part D drugs) please call:

Clarion Health at 844-824-8771, (TTY: 711); Seven days a week, 8 am to 8 pm Oct 1 - Mar 31
Monday - Friday 8am to 8pm Apr 1 - Sept 30

Or visit ssa.gov. Social Security can also provide you with an application.

MEDICARE PART B DRUGS

  • Chemotherapy drugs: You pay 20% of the cost
  • Other Part B drugs: You pay 20% of the cost