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2011 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-094-0) Benefit Details
The Community CCRx Basic (PDP) (S5803-094-0) Formulary Drugs Starting with the Letter S in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter S Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter S Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAIZEN 5MG VIAL	4	Specialty Tier	25%	N/A	P Q:11 /28Days
SAIZEN 8.8MG CLICK.EASY CARTG	4	Specialty Tier	25%	N/A	P Q:6 /28Days
SANCTURA TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S Q:60 /30Days
SANCTURA XR 60MG CAPSULE SR 24 HR	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S Q:30 /30Days
SANDIMMUNE 100MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SANDIMMUNE 100MG/ML TUBEX	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SANDIMMUNE 25MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SANDOSTATIN LAR 10MG KIT	4	Specialty Tier	25%	N/A	P Q:1 /28Days
SANDOSTATIN LAR 20MG KIT	4	Specialty Tier	25%	N/A	P Q:2 /28Days
SANDOSTATIN LAR 30MG KIT	4	Specialty Tier	25%	N/A	P Q:1 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SAVELLA TABLETS 100MG 60 COUNT BOT	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SAVELLA TABLETS 12.5MG 60 COUNT BOT	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SAVELLA TABLETS 25MG 60 COUNT BOT	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:55 /365Days
SAVELLA TALBETS 50MG 60 COUNT BOT	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SAXAGLIPTIN 2.5 MG ORAL TABLET [ONGLYZA]	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SAXAGLIPTIN 5 MG ORAL TABLET [ONGLYZA]	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SELEGILINE HCL 5MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
SELEGILINE HCL 5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SELENIUM SULFIDE LOTION USP 2.5% 4 FLOZ-118ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
SELZENTRY 150MG TABLET	4	Specialty Tier	25%	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SELZENTRY 300MG TABLET	4	Specialty Tier	25%	N/A	Q:120 /30Days
SENSIPAR 30MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P Q:60 /30Days
SENSIPAR 60MG TABLET	4	Specialty Tier	25%	N/A	P Q:60 /30Days
SENSIPAR 90MG TABLET	4	Specialty Tier	25%	N/A	P Q:120 /30Days
SEREVENT DIS AER 50MCG	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SEROMYCIN CAPSULES 250MG	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SEROQUEL 100MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
SEROQUEL 200MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
SEROQUEL 25MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
SEROQUEL 300MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
SEROQUEL 400MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SEROQUEL 50MG TABLET (100 CT)	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	Q:90 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 150MG 100 CRTN	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 200MG 100 X 200 MG CRTN	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 400MG 100 X 400 MG CRTN	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SEROQUEL TABLETS EXTENDED RELEASE 50MG 100 TABS CRTN	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SEROQUEL XR 300MG TABLET 60X300MG BOT	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SEROSTIM 4MG VIAL	4	Specialty Tier	25%	N/A	P Q:28 /28Days
SEROSTIM 5MG VIAL	4	Specialty Tier	25%	N/A	P Q:28 /28Days
SEROSTIM 6MG VIAL	4	Specialty Tier	25%	N/A	P Q:28 /28Days
SERTRALINE HCL 100MG TABLET (30 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SERTRALINE HCL 25 MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SERTRALINE HCL 50MG TABLET (30 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:45 /30Days
SERTRALINE HYDROCHLORIDE ORAL CONCENTRATE	1	Generic and Preferred Brand	$2.00	N/A	Q:300 /30Days
SEVELAMER CARBONATE 26.7 MG/ML ORAL SUSPENSION [RENVELA]	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:90 /30Days
SEVELAMER CARBONATE 40 MG/ML ORAL SUSPENSION [RENVELA]	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SILVER SULFADIAZINE 1% CRM	1	Generic and Preferred Brand	$2.00	N/A	None
SIMCOR 1000-20MG TABLET MULTIPHASIC RELEASE 24HR	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SIMCOR 500MG-20MG TABLET MULTIPHASIC RELEASE 24HR	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SIMCOR 750MG-20MG TABLET MULTIPHASIC RELEASE 24HR	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:60 /30Days
SIMCOR TABLETS EXTENDED RELEASE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SIMCOR TABLETS EXTENDED RELEASE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR	4	Specialty Tier	25%	N/A	P Q:1 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SIMVASTATIN 10MG TABLET (30 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
SIMVASTATIN 20MG TABLET 10000 BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
SIMVASTATIN 40MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
SIMVASTATIN 5MG TABLET (90 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
SIMVASTATIN 80MG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
SINGULAIR 10MG TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SINGULAIR 4MG GRANULES	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SINGULAIR 4MG TABLET CHEW	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SINGULAIR 5MG TABLET CHEW	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SODIUM BICARB INJ 7.5%	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM BICARB INJ 8.4%	1	Generic and Preferred Brand	$2.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SODIUM CHLORIDE 0.45% TUBEX	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM CHLORIDE INJECTION 3% 24X500ML BAG	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM CHLORIDE INJECTION USP .9 4X100ML CTR	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM CHLORIDE INJECTION USP 5%	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM CHLORIDE IRRIGATION 0.9% 1000ML CASE	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM CL 2.5 MEQ/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM EDECRIN FOR INJECTION 50MG 1 X 50 MG VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SODIUM FLUORIDE 1MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SODIUM LACTATE 1/6MOLAR INJ	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM LACTATE 5 MEQ/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
SODIUM POLYSTYRENE SULFONATE POWDER	1	Generic and Preferred Brand	$2.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SOLARAZE 3% GEL	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S
SOLIA 0.15-0.03 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
SOLU-MEDROL 2000MG VIAL	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SOMATROPIN INJECTION KIT 5.8MG/1.14ML 1 PKGCOM	4	Specialty Tier	25%	N/A	P Q:5 /28Days
SOMATULINE 60 MG/0.2 ML SYRING	4	Specialty Tier	25%	N/A	P
SOMAVERT 10MG VIAL	4	Specialty Tier	25%	N/A	P Q:90 /30Days
SOMAVERT 15MG VIAL	4	Specialty Tier	25%	N/A	P Q:60 /30Days
SOMAVERT 20MG VIAL	4	Specialty Tier	25%	N/A	P Q:60 /30Days
SORIATANE 17.5 MG CAPSULE	4	Specialty Tier	25%	N/A	S
SORIATANE 22.5 MG CAPSULE	4	Specialty Tier	25%	N/A	S
SORIATANE CAPSULES	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SORIATANE CAPSULES	4	Specialty Tier	25%	N/A	S
SORINE SOLTALOL HCL TABLETS 240MG 100 BOXUD	1	Generic and Preferred Brand	$2.00	N/A	None
SORINE SOTALOL HCL TABLETS 120MG 100 BOXUD	1	Generic and Preferred Brand	$2.00	N/A	None
SORINE SOTALOL HCL TABLETS 160MG 100 BOXUD	1	Generic and Preferred Brand	$2.00	N/A	None
SORINE SOTALOL HCL TABLETS 80MG 100 BOXUD	1	Generic and Preferred Brand	$2.00	N/A	None
SOTALOL HCL 120MG TABLET 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
SOTALOL HCL 160MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SOTALOL HCL 80MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SOTALOL HCL TABLET 240MG	1	Generic and Preferred Brand	$2.00	N/A	None
SOTRET 10MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SOTRET 20MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SOTRET 30MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SOTRET 40MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
SPECTRACEF 400 MG DOSE PACK TB	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SPECTRACEF TABLETS 200 MG	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SPIRIVA 18MCG CP-HANDIHALER 90 (9 X 10) BLPK	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:30 /30Days
SPIRONOLACTONE 100MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SPIRONOLACTONE 25MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SPIRONOLACTONE 50MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SPIRONOLACTONE/HCTZ TABLET 25-25MG (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SPRINTEC 0.25-0.035 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
SPRYCEL 20MG TABLET	4	Specialty Tier	25%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SPRYCEL 50MG TABLET	4	Specialty Tier	25%	N/A	P Q:60 /30Days
SPRYCEL 70MG TABLET	4	Specialty Tier	25%	N/A	P Q:60 /30Days
SPRYCEL TABLETS	4	Specialty Tier	25%	N/A	P Q:30 /30Days
SRONYX 0.1-0.02 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
SSD 1% CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
STAGESIC 5MG-500MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
STALEVO 100 TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
STALEVO 125/200 MG/MG TABLETS	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
STALEVO 150 TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
STALEVO 18.75/75 MG/MG TABLETS	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
STALEVO 200 50-200-200 TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
STALEVO 50 TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
STAVUDINE CAPSULES 15MG 60 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
STAVUDINE CAPSULES 20MG 60 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
STAVUDINE CAPSULES 30MG 60 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
STAVUDINE CAPSULES 40MG 60 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
STAVUDINE FOR ORAL SOLUTION 1MG/ML 200 ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
STERILE VANCOMYCIN HCL INJECTION 10 X 1GM VIAL	1	Generic and Preferred Brand	$2.00	N/A	P
STERILE VANCOMYCIN HYDROCHLORIDE INJECTION	1	Generic and Preferred Brand	$2.00	N/A	P
STERILE WATER FOR IRRIGATION 100 24 X 500ML BAG	1	Generic and Preferred Brand	$2.00	N/A	None
STIMATE 1.5MG/ML NASAL SPRAY	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SUBOXONE 2MG-0.5MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUBOXONE 8MG-2MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P Q:90 /30Days
SUCRALFATE 1GM TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SULFACETAMIDE SODIUM 10% SUSPENSION TOPICAL	1	Generic and Preferred Brand	$2.00	N/A	None
SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
SULFACETAMIDE-PREDNISOLONE 10-0.25% DROPS	1	Generic and Preferred Brand	$2.00	N/A	None
SULFADIAZINE 500MG TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SULFAMETHOXAZOLE W/TMP 800-160MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SULFAMETHOXAZOLE W/TMP VIAL 80MG-16ML 10 X 10ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40MG ORAL SUSPENSION 473ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SULFAMYLON 50G PACKET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SULFAMYLON CREAM 85GM 4 OZ TUBE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SULFASALAZINE 500MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SULFATRIM PEDIATRIC SUSP	1	Generic and Preferred Brand	$2.00	N/A	None
SULFAZINE EC 500MG TABLET DELAYED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	None
SULINDAC 150MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
SULINDAC 200MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
SUMATRIPTAN	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:4 /30Days
SUMATRIPTAN SUCCINATE INJECTION 4MG/0.5ML 0.5 ML VIALSD	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:4 /30Days
SUMATRIPTAN SUCCINATE TABLETS 100MG 9 BOXUD	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:12 /30Days
SUMATRIPTAN SUCCINATE TABLETS 25MG 9 BOX	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:12 /30Days
SUMATRIPTAN SUCCINATE TABLETS 50MG 9 (3 CARDS OF 3) BOX	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:12 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SUPRAX CFIXIME TABLETS USP 400MG 50 TABS BOT	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SURMONTIL 100MG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SURMONTIL 25MG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SURMONTIL 50MG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SUSTIVA 200MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SUSTIVA 50MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SUSTIVA 600MG TABLET	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
SUTENT 12.5MG CAPSULE	4	Specialty Tier	25%	N/A	P Q:112 /28Days
SUTENT 25MG CAPSULE	4	Specialty Tier	25%	N/A	P Q:56 /28Days
SUTENT 50MG CAPSULE	4	Specialty Tier	25%	N/A	P Q:28 /28Days
SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:10 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYMBICORT 80-4.5MCG HFA AEROSOL WITH ADAPTER 60 INHL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	Q:10 /30Days
SYMLIN 0.6MG/ML VIAL	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S Q:20 /30Days
SYMLINPEN 120 1000MCG/ML PEN INJECTOR	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S Q:11 /30Days
SYMLINPEN 60 1000MCG/ML PEN INJECTOR	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	S Q:12 /30Days
SYNAREL 2MG/ML NASAL SPRAY	4	Specialty Tier	25%	N/A	None
SYNERCID 500MG VIAL	4	Specialty Tier	25%	N/A	None
SYNTHROID 100MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 112 MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 125MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 137MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 150MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
SYNTHROID 175MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 200MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 25MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 300MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 50MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 75MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYNTHROID 88 MCG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
SYPRINE 250MG CAPSULE (100 CT)	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Community CCRx Basic (PDP) Plan Formulary.

Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).
Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.
Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $310 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.
Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
- Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
- No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.
Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
- Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
- Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
- Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
- Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
- None - This drug does not fall under any drug utilization management controls.
- P - Prior Authorization -This drug is subject to prior authorization.
- S - Step Therapy -This drug is subject to step therapy.
- Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.

(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2011 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.