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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 H in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY
Drugs Starting with Letter H Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter H Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HALOBETASOL 0.5 MG/ML TOPICAL CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
HALOBETASOL PROPIONATE 0.05% OINTMENT	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 0.5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 10MG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 1MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 20MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 2MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL 5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL DEC 100MG/ML VL	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL DEC 50MG 10 X 1ML PKG	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
HALOPERIDOL LAC 2MG/ML CONC	1	Generic and Preferred Brand	$2.00	N/A	None
HALOPERIDOL LAC 5MG/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
HAVRIX HEPATITIS A VACCINE INACTIVATED INJECTION SOLUTION 1440UNITS 10 X 1ML VIALSD	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
HAVRIX HEPATITIS A VACCINE INJECTION	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
HECTOROL 0.5MCG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P S
HECTOROL 2.5MCG CAPSULE	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P S
HELIDAC THERAPY	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	None
HEPARIN 25000U-1/2NS 250ML	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HEPARIN 25000U-1/2NS 500ML	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HEPARIN NA 2000UNITS/ML VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HEPARIN NA 2500UNITS/ML VIAL	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
HEPARIN SODIUM IN 5% DEXTROSE INJECTION SOLUTION 4000UNITS 24 X 500ML CTR	1	Generic and Preferred Brand	$2.00	N/A	None
HEPARIN SODIUM INJECTION	1	Generic and Preferred Brand	$2.00	N/A	None
HEPARIN SODIUM INJECTION	1	Generic and Preferred Brand	$2.00	N/A	None
HEPARIN SODIUM INJECTION	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HEPARIN SODIUM INJECTION	1	Generic and Preferred Brand	$2.00	N/A	None
HEPARIN SODIUM INJECTION SOLUTION 200UNITS 12 X 1000ML CTR	1	Generic and Preferred Brand	$2.00	N/A	None
HEPATAMINE INJECTION 8%	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P
HEPATASOL INJECTION 8% 500ML BAG	3	Non-Preferred Generic/ Non-Preferred Brand	55%	N/A	P
HEPATITIS B VACCINE RECOMBIANT ADULT FORMULATION INJECTION 10MCG 1ML VIALSD	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
HEPSERA 10MG TABLET	4	Specialty Tier	25%	N/A	S Q:30 /30Days
HEXALEN CAPSULES	4	Specialty Tier	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMALOG 100U/ML VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMALOG KWIKPEN INJECTION	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMALOG MIX 50/50 VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMALOG MIX 75/25 VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMALOG MIX KWIKPEN INJECTION	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMALOG MIX KWIKPEN INJECTION SUSPENSION	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMATROPE 12MG CARTRIDGE	4	Specialty Tier	25%	N/A	P Q:4 /28Days
HUMATROPE 24MG CARTRIDGE	4	Specialty Tier	25%	N/A	P Q:4 /28Days
HUMATROPE 6MG CARTRIDGE	4	Specialty Tier	25%	N/A	P Q:4 /28Days
HUMATROPE FOR INJECTION 5MG 6 X 5ML VIAL	4	Specialty Tier	25%	N/A	P Q:18 /28Days
HUMIRA 40MG/0.8ML SYRINGE	4	Specialty Tier	25%	N/A	P Q:4 /28Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HUMIRA PEN KIT 40MG-70% 1 PKGCOM	4	Specialty Tier	25%	N/A	P Q:6 /365Days
HUMULIN 70/30 PEN INJECTION 100UNT 1 X 3.0ML(PEN) CTG	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMULIN 70/30 VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMULIN N 100U/ML VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMULIN N PEN INJECTION 100UNT 1 X 3.0ML (PEN) CTG	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMULIN R 100U/ML VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	None
HUMULIN R 500U/ML VIAL	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
HYDRALAZINE 100MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDRALAZINE 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDRALAZINE 25MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDRALAZINE 50MG 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
HYDROCHLORIDE 50MG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCHLOROTHIAZIDE 12.5MG CAPSULE (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCHLOROTHIAZIDE 12.5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCHLOROTHIAZIDE 25 MG / TRIAMTERENE 50 MG ORAL CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCHLOROTHIAZIDE TABLETS 25MG	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCODONE BITARTRATE AND ACETAMINOPHEN ORAL SOLUTION 500;7;7.5MG/15ML;% 4 FLO BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:3600 /30Days
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 500-7.5MG (120 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROCODONE BITARTRATE AND ACETAMINOPHEN TABLET 7.5-650MG (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:185 /30Days
HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:150 /30Days
HYDROCODONE-ACETAMINOPHEN 10-750MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:160 /30Days
HYDROCODONE-ACETAMINOPHEN 10MG-500MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
HYDROCODONE-ACETAMINOPHEN 10MG-650MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:185 /30Days
HYDROCODONE-ACETAMINOPHEN 5MG-325MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:360 /30Days
HYDROCODONE-ACETAMINOPHEN 7.5-325MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:360 /30Days
HYDROCODONE/APAP 10/325 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:360 /30Days
HYDROCODONE/APAP 10/660 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:181 /30Days
HYDROCODONE/APAP 2.5/500 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROCODONE/APAP 5/500 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROCODONE/APAP 7.5/750 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:160 /30Days
HYDROCORTISONE 0.2% CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE 0.2% OINTMENT	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE 1% LOTION 118ML	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
HYDROCORTISONE 100MG ENEMA	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE 20MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE 5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE BUTYRATE 0.1% CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE BUTYRATE 0.1% OINTMENT	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE BUTYRATE 0.1% SOLUTION NON-ORAL	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE CREAM 1% 1 LB JAR	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE CREAM USP 2.5% 20GM TUBE	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE LOTION 2.5% 2 OZ BOT	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROCORTISONE OINTMENT 1% 1 LB JAR	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
HYDROCORTISONE OINTMENT USP 2.5% 20GM TUBE BOX	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROMORPHON INJ 10MG/ML	2	Non-Preferred Generic/Preferred Brand	30%	N/A	P
HYDROMORPHONE HCL 8MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROMORPHONE HYDROCHLORIDE TABLETS	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROMORPHONE HYDROCHLORIDE TABLETS	1	Generic and Preferred Brand	$2.00	N/A	Q:240 /30Days
HYDROXYCHLOROQUINE 200MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYUREA 500MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE 25MG/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE 50MG/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE HCL 10MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE HCL 10MG/5ML ORAL SOLUTION 1 PT 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
HYDROXYZINE HCL 25MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE HCL TABLETS 50MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE PAM 100MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE PAM 50MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
HYDROXYZINE PAMOATE 25MG CAPSULE	1	Generic and Preferred Brand	$2.00	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.