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Community CCRx Basic (PDP) (S5803-070-0)
Tier 1 (1490)
Tier 2 (665)
Tier 3 (416)
Tier 4 (275)

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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2011 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-070-0)
Benefit Details           
The Community CCRx Basic (PDP) (S5803-070-0)
Formulary Drugs Starting with the Letter C
in CMS PDP Region 01 which includes: ME NH
Drugs Starting with Letter C

Drug Name		 Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order
CABERGOLINE 0.5 MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CADUET 10MG/10MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 10MG/20MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 10MG/40MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 10MG/80MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 2.5MG/10MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 2.5MG/20MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 2.5MG/40MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 5MG/10MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 5MG/20MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CADUET 5MG/40MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CADUET 5MG/80MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CALCIPOTRIENE OINTMENT   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:120
/30Days
CALCIPOTRIENE TOPICAL SOLUTION   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:120
/30Days
CALCITONIN SALMON NASAL SPRAY 200IU/SPRY   1 Generic and Preferred Brand $2.00N/AQ:4
/30Days
CALCITRIOL 0.25MCG CAPSULE   1 Generic and Preferred Brand $2.00N/AP
CALCITRIOL 0.5MCG CAPSULE   1 Generic and Preferred Brand $2.00N/AP
CALCITRIOL 1MCG/ML SOLUTION ORAL   1 Generic and Preferred Brand $2.00N/AP
CALCITRIOL INJECTION SOLUTION 1MCG 50 X 01ML AMP   1 Generic and Preferred Brand $2.00N/AP
CALCIUM ACETATE CAPSULE 667 MG   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CALCIUM CHLORIDE 0.0014 MEQ/ML / POTASSIUM CHLORIDE 0.004 MEQ/ML / SODIUM CHLORIDE 0.103 MEQ/ML / SO   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAMILA 0.35MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:28
/28Days
CAMPATH 30MG/ML VIAL   4 Specialty Tier 25%N/AP
CAMPRAL 333MG DOSE PAK   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CANASA RECTAL SUPPOSITORIES 1000MG 30 BOX   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CANCIDAS IV 50MG VIAL   4 Specialty Tier 25%N/AP
CANCIDAS IV 70MG VIAL   4 Specialty Tier 25%N/AP
CAPEX SHA 0.01%   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CAPREOMYCIN 500 MG/ML INJECTABLE SOLUTION [CAPASTAT]   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CAPTOPRIL 100MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL 12.5MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL 25MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CAPTOPRIL 50MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL/HCTZ 25/15 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL/HCTZ 25/25 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL/HCTZ 50/15 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CAPTOPRIL/HCTZ 50/25 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CARAC CRE 0.5%   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CARAFATE SUS 1GM/10ML   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CARBAMAZEPINE EXTENDED RELEASE TABLETS 200MG   1 Generic and Preferred Brand $2.00N/ANone
CARBAMAZEPINE EXTENDED RELEASE TABLETS 400MG   1 Generic and Preferred Brand $2.00N/ANone
CARBAMAZEPINE ORAL SUSPENSION 200 MG   1 Generic and Preferred Brand $2.00N/ANone
CARBAMAZEPINE TABLET CHEWABLE 100MG (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARBAMAZEPINE TABLET USP 200MG (1000 CT)   1 Generic and Preferred Brand $2.00N/ANone
CARBIDOPA-LEVODOPA 25MG-100MG TABLET SA   1 Generic and Preferred Brand $2.00N/ANone
CARBIDOPA-LEVODOPA 50MG-200MG TABLET SA   1 Generic and Preferred Brand $2.00N/ANone
CARBIDOPA/LEVO 10/100 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CARBIDOPA/LEVO 25/100 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CARBIDOPA/LEVO 25/250 TABLET   1 Generic and Preferred Brand $2.00N/ANone
CARIMUNE NF 3GM VIAL   4 Specialty Tier 25%N/AP
CARISOPRODOL TABLET USP 350MG (100 CT)   1 Generic and Preferred Brand $2.00N/AQ:120
/30Days
CARTEOLOL HCL OPHTHALMIC SOLUTION USP 1% 15ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CARTIA XT 120MG CAPSULE SA   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
CARTIA XT 180MG CAPSULE SA   1 Generic and Preferred Brand $2.00N/AQ:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CARTIA XT 240MG CAPSULE SA   1 Generic and Preferred Brand $2.00N/AQ:60
/30Days
CARTIA XT 300MG CAPSULE SR 24 HR   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
CARVEDILOL 12.5MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/AQ:90
/30Days
CARVEDILOL 25MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/AQ:120
/30Days
CARVEDILOL 3.125MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/AQ:90
/30Days
CARVEDILOL 6.25MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/AQ:90
/30Days
CEENU 100MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEENU 10MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEENU 40MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFACLOR 250MG/5ML ORAL SUSP   1 Generic and Preferred Brand $2.00N/ANone
CEFACLOR 375MG/5ML ORAL SUSP   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFACLOR CAPSULES   1 Generic and Preferred Brand $2.00N/ANone
CEFACLOR CAPSULES   1 Generic and Preferred Brand $2.00N/ANone
CEFACLOR POWDER FOR ORAL SUSPENSION USP 125MG 75ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CEFADROXIL 1G TABLET   1 Generic and Preferred Brand $2.00N/ANone
CEFADROXIL 500MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
CEFADROXIL 500MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic and Preferred Brand $2.00N/ANone
CEFADROXIL FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CEFAZOLIN 1 GM VIAL   1 Generic and Preferred Brand $2.00N/ANone
CEFAZOLIN 1GM/D5W BAG   1 Generic and Preferred Brand $2.00N/ANone
CEFAZOLIN FOR INJECTION   1 Generic and Preferred Brand $2.00N/ANone
CEFDINIR 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFDINIR CAPSULES 300MG (60 CT)   1 Generic and Preferred Brand $2.00N/ANone
CEFDINIR FOR ORAL SUSPENSION 125MG/5ML (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CEFEPIME HCL 2 GRAM VIAL   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFEPIME INJ 1GM 20ML APX 10x1G VIAL   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFOTAXIME FOR INJECTION   1 Generic and Preferred Brand $2.00N/ANone
CEFOTAXIME FOR INJECTION 1GM 50 BOX VIALGL   1 Generic and Preferred Brand $2.00N/ANone
CEFOTAXIME FOR INJECTION 2GM 25 VIAL   1 Generic and Preferred Brand $2.00N/ANone
CEFOTAXIME FOR INJECTION 500MG 10 VIAL   1 Generic and Preferred Brand $2.00N/ANone
CEFPODOXIME PROXETIL 200MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT)   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 100MG 50ML BOT   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFPODOXIME PROXETIL FOR ORAL SUSPENSION 50MG 50ML BOT   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFPROZIL 250MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CEFPROZIL 250MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic and Preferred Brand $2.00N/ANone
CEFPROZIL FOR ORAL SUSPENSION 125MG/5ML 75ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CEFPROZIL TABLETS 500MG 100 BOT   1 Generic and Preferred Brand $2.00N/ANone
CEFTAZIDIME FOR INJECTION 1GM/VIAL 1 SINGLE VIAL VIAL   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFTAZIDIME FOR INJECTION 2GM/VIAL 10 X 2 CRTN   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFTRIAXONE FOR INJECTION 250MG BOX OF 10 VIALGL   1 Generic and Preferred Brand $2.00N/ANone
CEFTRIAXONE FOR INJECTION 500MG BOX OF 10 VIALGL   1 Generic and Preferred Brand $2.00N/ANone
CEFUROXIME 250MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEFUROXIME AXETIL 125MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Generic and Preferred Brand $2.00N/ANone
CEFUROXIME AXETIL 500MG TABLET (20 CT)   1 Generic and Preferred Brand $2.00N/ANone
CEFUROXIME FOR INJECTION   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFUROXIME FOR INJECTION   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CEFUROXIME FOR INJECTION   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CELEBREX 100MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
CELEBREX 200MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
CELEBREX 400MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AP Q:60
/30Days
CELLCEPT 200MG/ML ORAL SUSP   4 Specialty Tier 25%N/AP
CELONTIN 300MG KAPSEAL   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CEPHALEXIN 250MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CEPHALEXIN 250MG/5ML ORAL SUSP   1 Generic and Preferred Brand $2.00N/ANone
CEPHALEXIN CAPSULES 500MG (500 CT)   1 Generic and Preferred Brand $2.00N/ANone
CEPHALEXIN POWDER FOR SUSPENSION ORAL USP 125MG 200ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CEREDASE 80UNITS/ML VIAL   4 Specialty Tier 25%N/ANone
CEREZYME INJ 200UNIT   4 Specialty Tier 25%N/AP
CESIA 7 DAYS X 3 TABLET   1 Generic and Preferred Brand $2.00N/AQ:28
/28Days
CETIRIZINE HCL 5MG/5ML   1 Generic and Preferred Brand $2.00N/AQ:300
/30Days
CHANTIX 0.5MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:336
/365Days
CHANTIX 1MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:336
/365Days
CHANTIX STARTING MONTH PAK   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:106
/365Days
CHEMET 100MG CAPSULE   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORHEXIDINE GLUCONATE 0.12% MOUTHWASH   1 Generic and Preferred Brand $2.00N/ANone
CHLOROQUINE PH 500MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLOROQUINE PHOSPHATE 250MG TABLET (50 CT)   1 Generic and Preferred Brand $2.00N/ANone
CHLOROTHIAZIDE 250MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLOROTHIAZIDE 500MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE 100MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE 10MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE 25MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE 25MG/ML AMP   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE 50MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHLORPROMAZINE HCL 200MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CHLORTHALIDONE 25MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CHLORTHALIDONE 50MG TABLET (1000 CT)   1 Generic and Preferred Brand $2.00N/ANone
CHLORZOXAZONE 500MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CHOLESTYRAMINE LIGHT POWDER FOR ORAL SUSPENSION   1 Generic and Preferred Brand $2.00N/ANone
CICLOPIROX 0.77% CREAM   1 Generic and Preferred Brand $2.00N/ANone
CICLOPIROX 0.77% TOPICAL SUSPENSION   1 Generic and Preferred Brand $2.00N/ANone
CILOSTAZOL 50MG TABLET (60 CT)   1 Generic and Preferred Brand $2.00N/ANone
CILOSTAZOL TABLET 100MG (60 CT)   1 Generic and Preferred Brand $2.00N/ANone
CILOXAN 0.3% OINTMENT   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:4
/30Days
CIMZIA 200 MG/ML SYRINGE KIT   4 Specialty Tier 25%N/AP Q:1
/28Days
CIMZIA KIT   4 Specialty Tier 25%N/AP Q:1
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CIPRO (10%) SUS 500MG/5   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CIPRO (5%) SUS 250MG/5   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CIPRO HC OTIC SUSPENSION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CIPRODEX OTIC SUSPENSION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:8
/30Days
CIPROFLOXACIN 250MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CIPROFLOXACIN 400 MG/40 ML VL   1 Generic and Preferred Brand $2.00N/ANone
CIPROFLOXACIN 500MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CIPROFLOXACIN HCL 0.3% DROPS   1 Generic and Preferred Brand $2.00N/ANone
CIPROFLOXACIN HCL 100MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CIPROFLOXACIN TABLETS 750MG 100 BOT   1 Generic and Preferred Brand $2.00N/ANone
CITALOPRAM HBR 20 MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:45
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CITALOPRAM HBR ORAL SOLUTION 10MG 240ML BOTPL   1 Generic and Preferred Brand $2.00N/AQ:900
/30Days
CITALOPRAM HYDROBROMIDE TABLETS 40MG 30 BOT   1 Generic and Preferred Brand $2.00N/AQ:45
/30Days
CITOLOPRAM HBR 10MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/AQ:45
/30Days
CLARAVIS 10MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CLARAVIS 20MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CLARAVIS 30MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CLARAVIS 40MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CLARITHROMYCIN 250MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CLARITHROMYCIN 500MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CLARITHROMYCIN ER 500MG TABLET (60 CT)   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CLARITHROMYCIN FOR ORAL SUSPENSION   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLARITHROMYCIN FOR ORAL SUSPENSION   1 Generic and Preferred Brand $2.00N/ANone
CLEMASTINE FUM 2.68MG TABLET   1 Generic and Preferred Brand $2.00N/ANone
CLEMASTINE FUMARATE SYRUP   1 Generic and Preferred Brand $2.00N/ANone
CLEOCIN HCL 75MG CAPSULE   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CLEOCIN PED SOL 75MG/5ML   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CLINDAMYCIN 150MG/ML ADDVAN   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN HCL 150MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN HYDROCHLORIDE CAPSULES   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN PHOSP 1% LOTION   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN PHOSPHATE 1% SOLUTION NON-ORAL   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN PHOSPHATE GEL 1% 30GRAM TUBE   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINDAMYCIN PHOSPHATE TOPICAL SOLUTION USP PLEDGETS 1% 60 BOX   1 Generic and Preferred Brand $2.00N/ANone
CLINDAMYCIN PHOSPHATE VAGINAL CREAM   1 Generic and Preferred Brand $2.00N/ANone
CLINIMIX 2.75%/5% INJECTION 1000ML BAG   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 4.25/10 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 4.25/20 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 4.25/25 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 4.25/5 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 5/15 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 5/20 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX 5/25 SULFITE FREE INJECTIONS 1035MG-420MEQ 1000ML BAG   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 2.75/10 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLINIMIX E 2.75/5 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 4.25/25 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 4.25/5 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 5/20 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 5/25 SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINIMIX E 5%/15% INJECTION 2000ML BAG   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLINISOL 15% SOLUTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP
CLOBETASOL 0.05% OINTMENT   1 Generic and Preferred Brand $2.00N/ANone
CLOBETASOL 0.05% SOLUTION   1 Generic and Preferred Brand $2.00N/ANone
CLOBETASOL E 0.05% CREAM   1 Generic and Preferred Brand $2.00N/ANone
CLOBETASOL PROPIONATE CRM 0.05% 15GM   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOBETASOL PROPIONATE GEL .05% 60 GM TUBE   1 Generic and Preferred Brand $2.00N/ANone
CLOMIPRAMINE HCL 25MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
CLOMIPRAMINE HCL 50MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
CLOMIPRAMINE HCL 75MG CAPSULE   1 Generic and Preferred Brand $2.00N/ANone
CLONIDINE HCL 0.2MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/ANone
CLONIDINE HCL TABLET 0.1MG (500 CT)   1 Generic and Preferred Brand $2.00N/ANone
CLONIDINE HCL TABLET 0.3MG (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CLOTRIMAZOLE 1% CREAM   1 Generic and Preferred Brand $2.00N/ANone
CLOTRIMAZOLE 10MG TROCHE   1 Generic and Preferred Brand $2.00N/ANone
CLOTRIMAZOLE SOLUTION TOPICAL 1% 30ML BOTPL   1 Generic and Preferred Brand $2.00N/ANone
CLOTRIMAZOLE-BETAMETHASONE 1-0.05% LOTION   1 Generic and Preferred Brand $2.00N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREAM USP .5MG-10GM 45GM TUBE   1 Generic and Preferred Brand $2.00N/ANone
CLOZAPINE 100 MG DISINTEGRATING TABLET [FAZACLO]   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:270
/30Days
CLOZAPINE 100 MG ORAL TABLET   1 Generic and Preferred Brand $2.00N/AQ:270
/30Days
CLOZAPINE 12.5 MG DISINTEGRATING TABLET [FAZACLO]   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:120
/30Days
CLOZAPINE 200MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/AQ:135
/30Days
CLOZAPINE 25 MG DISINTEGRATING TABLET [FAZACLO]   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:120
/30Days
CLOZAPINE 25MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/AQ:120
/30Days
CLOZAPINE 50MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/AQ:135
/30Days
CO-GESIC 5/500 TABLET   1 Generic and Preferred Brand $2.00N/AQ:240
/30Days
COARTEM 20MG-120MG   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:24
/30Days
CODEINE 60 MG ORAL TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:180
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CODEINE SULFATE 30 MG TABLET 3100   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:180
/30Days
CODEINE SULFATE TABLETS   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:180
/30Days
COLCHICINE 0.6 MG ORAL TABLET [COLCRYS]   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
COLESTIPOL HCL 1G TABLET   1 Generic and Preferred Brand $2.00N/ANone
COLESTIPOL HCL 5G GRANULES   1 Generic and Preferred Brand $2.00N/ANone
COLISTIMETHATE 150MG VIAL   4 Specialty Tier 25%N/ANone
COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COLOCORT 100MG ENEMA   1 Generic and Preferred Brand $2.00N/ANone
COLY MYCIN S OTIC SUSPENSION 3;3.3;10MG/ML;MG/ 5 ML BOTDR   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COMBIGAN 0.2%-0.5% DROPS   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:10
/30Days
COMBIPATCH 0.05/0.14MG PTCH   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:8
/28Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COMBIPATCH 0.05/0.25MG PTCH   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:8
/28Days
COMBIVENT INHALER   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:29
/30Days
COMBIVIR TABLETS   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
COMPRO 25MG SUPPOSITORY   1 Generic and Preferred Brand $2.00N/ANone
COMTAN 200MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AQ:240
/30Days
COMVAX VACCINE VIAL   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CONDYLOX GEL 0.5% 3.5 GM CRTN   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CONSTULOSE 10GM/15ML SYRUP   1 Generic and Preferred Brand $2.00N/ANone
COPAXONE 20MG/ML 30 BLISTER PACK IN 1 CRTN   4 Specialty Tier 25%N/AP Q:30
/30Days
CORDRAN 0.05% LOTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CORDRAN SP 0.05% CREAM   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COREG CR 10MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
COREG CR 20MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
COREG CR 40MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
COREG CR 80MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:30
/30Days
CORTISONE ACETATE 25MG TABLET (100 CT)   1 Generic and Preferred Brand $2.00N/ANone
CORTISPORIN CRE 0.5%   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CORTISPORIN OINTMENT   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CORTOMYCIN EAR SOLUTION   1 Generic and Preferred Brand $2.00N/ANone
CORTOMYCIN EAR SUSPENSION   1 Generic and Preferred Brand $2.00N/ANone
COUMADIN 10MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 1MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
COUMADIN 2.5MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 2MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 3MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 4MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 5MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 6MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
COUMADIN 7.5MG TABLET   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CREON DELAYED RELEASE CAPSULES 12000MG 100 BOT   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CREON DELAYED RELEASE CAPSULES 24000MG 100 BOT   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CREON DELAYED RELEASE CAPSULES 6000MG 100 BOT   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CRESTOR 10MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CRESTOR 20MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
CRESTOR 40MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
CRESTOR 5MG TABLET   1 Generic and Preferred Brand $2.00N/AQ:30
/30Days
CRIXIVAN 100MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CRIXIVAN 200MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CRIXIVAN 333MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CRIXIVAN 400MG CAPSULE (120 CT)   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
CROMOLYN NEBULIZER SOLUTION   1 Generic and Preferred Brand $2.00N/AP
CROMOLYN SODIUM 4% 40MG 10ML BOT   1 Generic and Preferred Brand $2.00N/ANone
CUBICIN 500MG VIAL   4 Specialty Tier 25%N/AP
CUPRIMINE CAPSULES 250MG (100 CT)   2 Non-Preferred Generic/Preferred Brand 32%N/ANone
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYCLOBENZAPRINE HCL 10MG TABLET (1000 CT)   1 Generic and Preferred Brand $2.00N/AQ:90
/30Days
CYCLOBENZAPRINE HCL 5MG TABLET (500 CT)   1 Generic and Preferred Brand $2.00N/AQ:90
/30Days
CYCLOPHOSPHAMIDE 25MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CYCLOPHOSPHAMIDE 50MG TABLET   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CYCLOSPORINE 100MG CAPSULE   1 Generic and Preferred Brand $2.00N/AP
CYCLOSPORINE 100MG CAPSULE   1 Generic and Preferred Brand $2.00N/AP
CYCLOSPORINE 25MG CAPSULE   1 Generic and Preferred Brand $2.00N/AP
CYCLOSPORINE ORAL SOLUTION 100MG 50ML BOT   1 Generic and Preferred Brand $2.00N/AP
CYKLOKAPRON 100MG/ML AMPUL   2 Non-Preferred Generic/Preferred Brand 32%N/AP
CYMBALTA 20MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
CYMBALTA 60MG CAPSULE   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
Drug Name Tier
Nbr.		 Tier
Description		 30-Day
Preferred
Pharm		 90-Day
Mail
Order		 Drug
Usage
Mgmt
CYMBALTA CAPSULES DELAYED RELEASE 30MG (30 CT)   2 Non-Preferred Generic/Preferred Brand 32%N/AQ:60
/30Days
CYPROHEPTADINE HCL 4 MG   1 Generic and Preferred Brand $2.00N/ANone
CYPROHEPTADINE HYDROCHLORIDE SOLUTION USP SYRUP 2MG 473 ML BOTGL   1 Generic and Preferred Brand $2.00N/ANone
CYSTADANE POWDER FOR ORAL SOLUTION 180GM   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CYSTAGON 150MG CAPSULE   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CYSTAGON 50MG CAPSULE   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/ANone
CYTOVENE IV INJECTION   3 Non-Preferred Generic/ Non-Preferred Brand 58%N/AP

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.