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

2011 Medicare Part D Plan Formulary Information
Community CCRx Basic (PDP) (S5803-101-0) Benefit Details
The Community CCRx Basic (PDP) (S5803-101-0) Formulary Drugs Starting with the Letter L in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter L Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter L Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
LABETALOL HCL 100MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LABETALOL HCL 200MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LABETALOL HCL 300MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LACLOTION 12% LOTION	1	Generic and Preferred Brand	$2.00	N/A	None
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
LACTATED RINGERS IRRIGATION 20-30-600MG 3000ML BAG	1	Generic and Preferred Brand	$2.00	N/A	None
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LAMICTAL ODT 100MG TABLET 30 EA	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LAMICTAL ODT 200MG TABLET 30 EA	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P
LAMICTAL ODT 25MG TABLET 30 EA	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P
LAMICTAL ODT 50MG TABLET 30 EA	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P
LAMOTRIGINE 150MG TABLET (60 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LAMOTRIGINE 200MG TABLET (60 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LAMOTRIGINE 25MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LAMOTRIGINE 25MG TABLET DISPERSIBLE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LAMOTRIGINE 5MG TABLET DISPERSIBLE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LAMOTRIGINE TABLET 100MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LANOXIN 0.125MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LANOXIN 0.25MG TABLET	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
LANOXIN 0.25MG/ML AMPUL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LANOXIN PED 0.1MG/ML AMPUL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE]	4	Specialty Tier	25%	N/A	P
LANREOTIDE INJECTION 30MG	4	Specialty Tier	25%	N/A	P
LANTUS 100U/ML VIAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LANTUS SOLOSTAR INJECTION	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEENA 7-9-5 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
LEFLUNOMIDE 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEFLUNOMIDE TABLETS	1	Generic and Preferred Brand	$2.00	N/A	None
LESSINA 0.1-0.02 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
LETAIRIS 10MG TABLET	4	Specialty Tier	25%	N/A	S Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LETAIRIS 5MG TABLET	4	Specialty Tier	25%	N/A	S Q:30 /30Days
LEUCOVORIN CALCIUM 100MG VL	1	Generic and Preferred Brand	$2.00	N/A	None
LEUCOVORIN CALCIUM 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEUCOVORIN CALCIUM 15MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEUCOVORIN CALCIUM 25MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEUCOVORIN CALCIUM 350MG VL	1	Generic and Preferred Brand	$2.00	N/A	None
LEUCOVORIN CALCIUM 5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEUKERAN 2MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEUKINE 250MCG VIAL	4	Specialty Tier	25%	N/A	P
LEUKINE LIQUID INJECTION 500MCG/VIAL 500 MCG X 5 VILMD CRTN	4	Specialty Tier	25%	N/A	P
LEUPROLIDE 11.25 MG/ML PREFILLED SYRINGE [LUPRON]	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
LEUPROLIDE 15 MG/ML PREFILLED SYRINGE [LUPRON]	4	Specialty Tier	25%	N/A	P Q:1 /28Days
LEUPROLIDE 3.75 MG/ML PREFILLED SYRINGE [LUPRON]	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P Q:1 /30Days
LEUPROLIDE ACETATE INJECTION	2	Non-Preferred Generic/Preferred Brand	31%	N/A	P
LEUPROLIDE7.5 MG/ML PREFILLED SYRINGE [LUPRON]	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	P Q:1 /84Days
LEVAQUIN 750 MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LEVAQUIN INJECTION 25 MG/ML	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
LEVAQUIN INJECTION 5 MG/ML	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
LEVEMIR 100UNITS/ML VIAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEVEMIR FLEXPEN 100UNITS/ML	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:900 /30Days
LEVETIRACETAM 500 MG TABLET 120 BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:180 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LEVETIRACETAM INJECTION	4	Specialty Tier	25%	N/A	None
LEVETIRACETAM TABLETS 1000MG 60 BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:90 /30Days
LEVETIRACETAM TABLETS 250MG 500 BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:90 /30Days
LEVETIRACETAM TABLETS 750MG 500 BOT	1	Generic and Preferred Brand	$2.00	N/A	Q:120 /30Days
LEVOBUNOLOL 0.25% EYE DROPS	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOCARNITINE 100MG/ML SOLUTION ORAL	1	Generic and Preferred Brand	$2.00	N/A	P
LEVOCARNITINE 200MG/ML VIAL	1	Generic and Preferred Brand	$2.00	N/A	P
LEVOCARNITINE TABLET 330MG 90 BLPK	1	Generic and Preferred Brand	$2.00	N/A	P
LEVOFLOXACIN 25 MG/ML ORAL SOLUTION [LEVAQUIN]	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEVOFLOXACIN 250 MG ORAL TABLET [LEVAQUIN]	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
LEVOFLOXACIN 500 MG ORAL TABLET [LEVAQUIN]	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LEVORA-28 TABLET 0.15/30	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
LEVOTHROID 100MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 112MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 125MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 137MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 150MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 175MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 200MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 25MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 300MCG 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
LEVOTHROID 50MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 75MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHROID 88MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 100MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 112MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 125MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 137MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 175MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 200MCG 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
LEVOTHYROXINE SODIUM 25MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 300MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 50MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOTHYROXINE SODIUM 88MCG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 100MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 112MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 125MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 137MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 150MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 175MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 200MCG TABLET (1000 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
LEVOXYL 25MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 50MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 75MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEVOXYL 88MCG TABLET (1000 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LEXAPRO 10MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:45 /30Days
LEXAPRO 20MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LEXAPRO 5MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LEXAPRO 5MG/5ML SOLUTION	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:600 /30Days
LEXIVA 50MG/ML SUSPENSION ORAL	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LEXIVA TABLETS	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LIDOCAINE 5% 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
LIDOCAINE HCL 0.5% VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE HCL 1% VIAL	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE HCL 2% JELLY	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE HCL 2% JELLY 30ML TUBE	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM	1	Generic and Preferred Brand	$2.00	N/A	None
LIDODERM 5% PATCH	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:3 /1Days
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS 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
LIPITOR 10MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LIPITOR 20MG TABLET (5000 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LIPITOR 40MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LIPITOR 80MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LISINOPRIL 10MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL 2.5MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL 20MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL 30MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL 40MG TABLET (500 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL TABLETS 5 MG	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL-HCTZ 10/12.5 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
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LISINOPRIL-HCTZ 20/12.5 TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CARBONATE 150MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CARBONATE 300MG CAPSULE (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CARBONATE 300MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CARBONATE CAPSULES	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CARBONATE ER TABLET 300MG (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM CIT 8MEQ/5ML SYRUP	1	Generic and Preferred Brand	$2.00	N/A	None
LITHIUM ER 450 MG TABLET	1	Generic and Preferred Brand	$2.00	N/A	None
LODOSYN 25MG TABLET	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	None
LOKARA 0.05% LOTION	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
LOPERAMIDE HCL 2MG CAPSULE	1	Generic and Preferred Brand	$2.00	N/A	None
LOSARTAN POTASSIUM 100 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOSARTAN POTASSIUM 25 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOSARTAN POTASSIUM 50 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOSARTAN-HCTZ 100-12.5 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOSARTAN-HCTZ 100-25 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOSARTAN-HCTZ 50-12.5 MG TAB	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOTEMAX 0.5% EYE DROPS	2	Non-Preferred Generic/Preferred Brand	31%	N/A	None
LOTREL 10/20MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LOTREL 10/40MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LOTREL 2.5/10MG CAPSULE	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
LOTREL 5/10MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LOTREL 5/20MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LOTREL 5/40MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LOTRONEX TABLETS .5MG 30 BOTPL	4	Specialty Tier	25%	N/A	P Q:60 /30Days
LOTRONEX TABLETS 1MG 30 BOTPL	4	Specialty Tier	25%	N/A	P Q:60 /30Days
LOVASTATIN 10MG TABLET (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	Q:30 /30Days
LOVASTATIN 20 MG ORAL TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
LOVASTATIN 40 MG ORAL TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:60 /30Days
LOVAZA CAPSULES 1GM 120 BOT	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	Q:120 /30Days
LOVENOX 100MG PREFILLED SYR	4	Specialty Tier	25%	N/A	Q:30 /30Days
LOVENOX 120MG PREFILLED SYR	4	Specialty Tier	25%	N/A	Q:24 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LOVENOX 150MG PREFILLED SYR	4	Specialty Tier	25%	N/A	Q:30 /30Days
LOVENOX 300MG VIAL	4	Specialty Tier	25%	N/A	Q:30 /30Days
LOVENOX 30MG PREFILLED SYRN	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	Q:9 /30Days
LOVENOX 40MG PREFILLED SYRN	3	Non-Preferred Generic/ Non-Preferred Brand	63%	N/A	Q:12 /30Days
LOVENOX 60MG PREFILLED SYRN	4	Specialty Tier	25%	N/A	Q:18 /30Days
LOVENOX 80MG PREFILLED SYRN	4	Specialty Tier	25%	N/A	Q:24 /30Days
LOW-OGESTREL-28 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
LOXAPINE 25MG CAPSULE (100 CT)	1	Generic and Preferred Brand	$2.00	N/A	None
LOXAPINE CAPSULES 10MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LOXAPINE CAPSULES 50MG 100 BOT	1	Generic and Preferred Brand	$2.00	N/A	None
LOXAPINE CAPSULES 5MG 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
LUNESTA 2MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LUNESTA 3MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LUNESTA TABLETS 1MG 30 BOT	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:30 /30Days
LUTERA 0.1-0.02 TABLET	1	Generic and Preferred Brand	$2.00	N/A	Q:28 /28Days
LYRICA 100MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 150MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 200MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 225MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 25MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 300MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYRICA 50MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
LYRICA 75MG CAPSULE	2	Non-Preferred Generic/Preferred Brand	31%	N/A	Q:90 /30Days
LYSODREN 500MG TABLET	2	Non-Preferred Generic/Preferred Brand	31%	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.