Q1Medicare.com 2011 Medicare Part D or Medicare Advantage Plan Formulary Browser

2011 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-077-0) Benefit Details
The Community CCRx Basic (PDP) (S5803-077-0) Formulary Drugs Starting with the Letter D in CMS PDP Region 8 which includes: NC
Drugs Starting with Letter D Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter D Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
D5W/KCL 20MEQ/L IV SOLUTION	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
D5W/KCL 30MEQ/L IV SOLUTION	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DANAZOL 100MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DANAZOL 50MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DANAZOL CAPSULES USP 200MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DANTROLENE SODIUM 100MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DANTROLENE SODIUM 25MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DANTROLENE SODIUM 50MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DAPSONE TABLETS 100MG 30 BLPK	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DAPSONE TABLETS 25MG 30 BLPK	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DAPTACEL VACCINE 15;5;5;3; LF/.5ML	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DARAPRIM 25MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DECAVAC VACCINE 2;5 UNT/0.5 ML	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEMECLOCYCLINE HCL 150MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	P
DEMECLOCYCLINE HCL 300MG TABLET	4	Specialty Tier	25%	N/A	P
DENAVIR 1% CREAM	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:2 /30Days
DEPADE 50MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEPEN 250MG TITRATAB	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEPO-MEDROL 20MG/ML VIAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEPO-PROVERA 400MG/ML VIAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DERMA-SMOOTHE/FS 0.01% BODY OIL	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DESIPRAMINE 25MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DESIPRAMINE 50MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DESIPRAMINE HCL 75MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DESIPRAMINE HYDROCHLORIDE TABLETS	1	Generic and Preferred Brand	$2.00	N/A	None
DESIPRAMINE HYDROCHLORIDE TABLETS 10MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DESIPRAMINE HYDROCHLORIDE TABLETS USP 100MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DESMOPRESSIN 0.1MG/ML SOL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DESMOPRESSIN ACETATE 0.1MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DESMOPRESSIN ACETATE NASAL SOLUTION 0.1% 5 ML BOTSPR	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DESMOPRESSIN ACETATE TABLET 0.2MG (100 CT)	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DESONIDE 0.05% CREAM	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
DESONIDE 0.05% LOTION	1	Generic and Preferred Brand	$2.00	N/A	None
DESONIDE 0.05% OINTMENT 60GM TUBE	1	Generic and Preferred Brand	$2.00	N/A	None
DETROL 1MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:60 /30Days
DETROL 2MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:60 /30Days
DETROL LA 2MG CAPSULE SA	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DETROL LA 4MG CAPSULE SA	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DEXAMETHASONE 0.5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 0.5MG/0.5ML DROP	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 0.5MG/5ML ELX	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 0.75MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 1.5MG TABLET	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
DEXAMETHASONE 1MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 2MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 4MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE 6MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE SODIUM PHOSPHATE 0.1% DROPS	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE SODIUM PHOSPHATE INJECTION 4MG 30ML VIALMD	1	Generic and Preferred Brand	$2.00	N/A	None
DEXAMETHASONE TABLETS	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEXASPORIN EYE DROPS	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROAMPHETAMINE 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROAMPHETAMINE 5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROAMPHETAMINE SACCHARATE AND SULFATE AMPHETAMINE ASPARTATE 10MG TABLET (100 CT)	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
DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASE 5MG 100 CAPSULES BOT	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEXTROAMPHETAMINE SULFATE CAPSULES SUSTAINED RELEASED 10MG 100 CAPSULES BOT	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEXTROSE 10%-1/4NS IV TUBEX	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DEXTROSE 2.5%-1/2NS IV SOLUTION	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE 5% AND 0.9% NACL INJECTION 5-900 24 X 500ML BAG	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE 5%-1/4NS IV SOLUTION	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE AND ELECTROLYTE NO 48 INJECTION 5% 500ML BAG	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE IN SODIUM CHLORIDE INJECTION 1000ML X 12 CASE	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DEXTROSE IN SODIUM CHLORIDE INJECTION 500ML X 24 BAG	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE INJECTION 10 250ML X 24 BOTPL	1	Generic and Preferred Brand	$2.00	N/A	None
DEXTROSE INJECTION USP 5 4 X 100ML CTR	1	Generic and Preferred Brand	$2.00	N/A	None
DIBENZYLINE 10MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DICLOFENAC 25MG TABLET EC	1	Generic and Preferred Brand	$2.00	N/A	None
DICLOFENAC POTASSIUM 50MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DICLOFENAC SOD 100MG TABLET SA	1	Generic and Preferred Brand	$2.00	N/A	None
DICLOFENAC SODIUM 0.1% DROPS	1	Generic and Preferred Brand	$2.00	N/A	Q:5 /30Days
DICLOFENAC SODIUM 50MG TABLET DELAYED RELEASE (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DICLOFENAC SODIUM 75MG TABLET DELAYED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	None
DICLOXACILLIN 250MG CAPSULE	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
DICLOXACILLIN SODIUM 500MG CAP	1	Generic and Preferred Brand	$2.00	N/A	None
DICYCLOMINE 10MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DICYCLOMINE 10MG/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
DICYCLOMINE HCL 10MG/5ML SYRUP	1	Generic and Preferred Brand	$2.00	N/A	None
DICYCLOMINE HCL 20MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DIDANOSINE 200MG CAPSULE DELAYED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	None
DIDANOSINE 250MG CAPSULE DELAYED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	None
DIDANOSINE 400MG CAPSULE DELAYED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	None
DIDANOSINE DELAYED RELEASE CAPSULES 125MG 30 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DIFLORASONE 0.05% CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
DIFLORASONE 0.05% OINTMENT	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
DIFLUNISAL 500MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DIGOXIN 125MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DIGOXIN 250MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DIGOXIN 50MCG/ML SOLUTION ORAL	1	Generic and Preferred Brand	$2.00	N/A	None
DIGOXIN INJECTION 500MCG 25 X 2ML AMP	1	Generic and Preferred Brand	$2.00	N/A	None
DIHYDROERGOTAMINE 1MG/ML AM	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DILANTIN 50MG INFATAB	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DILANTIN CAPSULES EXTENDED RELEASE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DILANTIN EXTENDED ORAL CAPSULE 100MG (100 CT)	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DILANTIN-125 SUS 125/5ML	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DILAUDID HYDROMORPHONE HCL ORAL LIQUID 1MG/ML 1 PINT BOTGL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:2400 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DILT-CD 120MG CAPSULE SR 24 HR	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILT-CD DILTIAZEM HCL ER CAPSULES 300MG	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILT-XR 180MG CAPSULE DEGRADABLE CONTROLLED-RELEASE	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DILTIAZEM 30MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DILTIAZEM 90MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DILTIAZEM CD CAPSULES 120MG (90 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTIAZEM CD CAPSULES 240MG (90 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DILTIAZEM CD CAPSULES 300MG (90 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTIAZEM ER 240MG CAPSULE SA	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DILTIAZEM ER 420MG CAPSULE SA	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTIAZEM HCL 120MG ER CAPSULE	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
DILTIAZEM HCL 120MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DILTIAZEM HCL 60MG ER CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DILTIAZEM HCL 60MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DILTIAZEM HYDROCHLORIDE CAPSULES EXTENDED RELEASE	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES USP 90MG 1 BLPK	1	Generic and Preferred Brand	$2.00	N/A	None
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 120MG	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 180MG	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 240MG	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DILTZAC DILTIAZEM HYDROCHLORIDE EXTENDED RELEASE CAPSULES 300MG	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DILTZAC ER CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DIOVAN 160MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIOVAN 320MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN 40MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN 80MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN HCT 160/12.5MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN HCT 160/25MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN HCT 320/12.5MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN HCT 320/25MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIOVAN HCT 80/12.5MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
DIPHENHYDRAMINE HCL INJECTION 50MG 1 VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
DIPHENOXYLATE/ATROPINE LIQ	1	Generic and Preferred Brand	$2.00	N/A	None
DIPHTHERIA-TETANUS TOX-PED .17;6.7;5 MG/5ML;LF	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DIPYRIDAMOLE TABETS 25MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DIPYRIDAMOLE TABLETS 50MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DIPYRIDAMOLE TABLETS 75MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DISOPYRAMIDE PHOSPHATE 150MG CAPSULE USP (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DISOPYRAMIDE PHOSPHATE CAPSULES 100MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DIURIL 250MG/5ML SUSPENSION ORAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DIVALPROEX SODIUM 125MG TBEC	1	Generic and Preferred Brand	$2.00	N/A	None
DIVALPROEX SODIUM 250MG TBEC	1	Generic and Preferred Brand	$2.00	N/A	None
DIVALPROEX SODIUM 500MG TBEC	1	Generic and Preferred Brand	$2.00	N/A	None
DIVALPROEX SODIUM COATED PARTICLES IN CAPSULES 125MG 100 BOT	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DIVALPROEX SODIUM EXTENDED RELEASE TABLETS 250MG 100 BOT	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
DIVALPROEX SODIUM TABLETS EXTENDED RELEASE 500MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DONEPEZIL HYDROCHLORIDE TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:30 /30Days
DONEPEZIL HYDROCHLORIDE TABLETS	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:30 /30Days
DORIBAX FOR INJECTION 500MG/VIAL	4	Specialty Tier	25%	N/A	None
DORZOLAMIDE HCL OPHTHALMIC 2% 10 ML BOTDR	1	Generic and Preferred Brand	$2.00	N/A	Q:10 /30Days
DORZOLAMIDE HCL TIMOLOL MALEATE OPHTHALMIC SOLUTION 22.3;6.8MG/ML;	1	Generic and Preferred Brand	$2.00	N/A	Q:10 /30Days
DOVONEX CREAM	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:120 /30Days
DOXAZOSIN MESYLATE 4MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DOXAZOSIN MESYLATE TABLET 2MG (500 CT)	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
DOXAZOSIN MESYLATE TABLET 8MG (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
DOXAZOSIN TABLET 1MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
DOXEPIN 10MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DOXEPIN 10MG/ML ORAL CONC	1	Generic and Preferred Brand	$2.00	N/A	None
DOXEPIN 50 MG ORAL CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DOXEPIN 75MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DOXEPIN HCL 25MG CAPSULE (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DOXEPIN HYDROCHLORIDE CAPSULES 100MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
DOXERCALCIFEROL 0.001 MG ORAL CAPSULE [HECTOROL]	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	P S
DOXYCYCLINE 100MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DOXYCYCLINE 100MG VIAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DOXYCYCLINE 50MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
DOXYCYCLINE FOR INJECTION 100MG/VIAL 10 X 1 VIAL CRTN	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DOXYCYCLINE HYCLATE 100MG TABLET USP (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DOXYCYCLINE HYCLATE 20MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
DOXYCYCLINE MONOHYDRATE 75MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
DRONABINOL CAPS 10MG	4	Specialty Tier	25%	N/A	P Q:60 /30Days
DRONABINOL CAPS 2.5MG	2	Non-Preferred Generic/Preferred Brand	31%	N/A	P Q:90 /30Days
DRONABINOL CAPS 5MG	4	Specialty Tier	25%	N/A	P Q:90 /30Days
DROXIA 200MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DROXIA 300MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
DROXIA 400MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
DUETACT 30MG-2MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	S Q:30 /30Days
DUETACT 30MG-4MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	S Q:30 /30Days
DULERA INHALATION AEROSOL	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:13 /30Days
DULERA INHALATION AEROSOL	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	Q:13 /30Days
DYRENIUM 100MG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	61%	N/A	None
DYRENIUM 50MG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	61%	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.