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Understanding Drug Tiers & Formulary Basics

This article provides a high-level explanation of drug tiers and formulary basics for Clear Spring Health Medicare Advantage Prescription Drug (MAPD) plans. It is intended for agent education only and does not reference specific medications or costs.

 

What Is a Formulary?

A formulary is the official list of medications covered by a MAPD plan. Each  formulary is reviewed and approved by CMS before it is made available to members and agents.

A formulary contains:

  • The medications covered under the plan

  • The tier assignment for each medication

  • Any applicable utilization management rules such as prior authorization, step therapy, or quantity limits

Clear Spring Health updates formularies in accordance with CMS rules and clinical guidance.

What Are Drug Tiers?

Drug tiers are categories within the formulary used to organize medications based on plan design and clinical considerations.

While tier structures can vary by plan, typical tier groupings include:

  • Tier 1 – Preferred Generic: Tier 1 is the lowest-cost tier. Most generic drugs on the
    formulary are included in this tier. Generic drugs contain the same active ingredients as
    brand drugs and are considered equally safe and effective. There are some brand-name
    drugs on this tier.

  • Tier 2 – Generic: Tier 2 is the next-lowest-cost tier. It also includes both generic and
    branded drugs.

  • Tier 3 – Preferred Brand: Tier 3 includes some brand-name drugs and some generic
    drugs.

  • Tier 4 – Non-Preferred Drug: Tier 4 includes non-preferred brand drugs and some
    generic drugs.

  •  Tier 5 – Specialty Tier: Tier 5 is your highest-cost tier. A specialty drug is typically a
    very high-cost drug. It may also require special handling, and or training and close
    monitoring of the patient who takes it. Specialty drugs may be brand or generic.
These tiers help structure how medications are organized, evaluated, and updated within the plan’s formulary.

Why Drug Tiers Matter

Drug tiers are important because they:

  • Provide a structured way to organize medications within the formulary

  • Support safe, consistent, and clinically appropriate medication management

  • Help beneficiaries compare medication coverage within a plan

  • Guide agents when reviewing coverage categories with members

Drug tiers do not indicate cost levels in this article and should not be used to give pricing guidance.

How Clear Spring Health Reviews and Updates Formularies

Clear Spring Health regularly reviews its formularies based on:

  • CMS regulatory requirements

  • Clinical and safety updates

  • Medication availability changes

  • New therapies added to the market

  • Annual plan design adjustments

Beneficiaries receive required notifications if a change affects their current coverage in accordance with CMS rules.

Agents should encourage beneficiaries to review the most current formulary each year, especially during the Annual Election Period (AEP).

How Formularies Work in Clear Spring Health MAPD Plans

Clear Spring Health formularies are designed to:

  • Promote safe and effective medication use

  • Follow clinical best practices

  • Offer a broad range of medication options

  • Support CMS standards for oversight and quality

Formularies may include utilization management tools such as:

  • Prior Authorization: Approval required before certain medications can be covered.

  • Step Therapy: A beneficiary may need to try a clinically appropriate alternative first.

  • Quantity Limits: Restrictions on the amount of medication that can be dispensed.

These practices support medication safety and help ensure appropriate use.

How Agents Should Discuss Formularies

Agents may:

  • Explain what a formulary is

  • Explain how drug tiers are structured

  • Show beneficiaries where to find the Clear Spring Health formulary

  • Demonstrate how to search for medications using Clear Spring Health’s online tools

  • Help beneficiaries understand utilization management categories

Agents may not:

  • Recommend specific medications

  • Provide clinical guidance

  • Discuss drug pricing or cost considerations

  • Suggest changing prescribed medications

  • Interpret provider instructions

All clinical or cost-related questions should be directed to the beneficiary’s prescriber or Clear Spring Health Member Services.

How to Access Clear Spring Health Formularies

Agents can locate the current Clear Spring Health MAPD formulary using the following publicly available resources:

1. Clear Spring Health Website

Visit:
https://clearspringhealthcare.com/

From the homepage, navigate to:

  • Menu → Members →Plan Documents → Select State and Plan → Covered Drug List

    • Provides PDF Documents of that specific plan formulary

  • Menu → Members → Find Drug / Pharmacies & Pricing →Select  State → Go to Search

Provides a search tool to check medication coverage, tier, pharmacy availability, and plan rules. Agents should use this tool only for coverage verification and tier category—not pricing.

Key Takeaways for Agents

  • A formulary is the official list of medications covered by a Clear Spring Health MAPD plan.

  • Drug tiers categorize medications into groups used for plan design and management.

  • Clear Spring Health updates formularies based on CMS rules and clinical guidance.

  • Agents may guide beneficiaries on how to locate and understand the formulary, but must not discuss specific drugs or pricing.

  • Always use the formulary from Clear Spring Health’s official website or broker portal to ensure accuracy.