MedicarePartD.guide

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2026 HealthSpring Assurance Rx (PDP) formulary (drug list)

Contract S5617, plan 221 · Michigan · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 13 plan.

Hide drugs on tiers

86 drugs starting with G.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
GABAPENTIN 100 mg Capsule2Generic10%10%
  • QL 36 per 30 days
GABAPENTIN 250 mg/5mL Solution4Non-Preferred Drug30%30%
  • QL 216 per 30 days
GABAPENTIN 300 mg Capsule2Generic10%10%
  • QL 36 per 30 days
GABAPENTIN 400 mg Capsule2Generic10%10%
  • QL 27 per 30 days
GABAPENTIN 600 mg Tablet2Generic10%10%
  • QL 18 per 30 days
GABAPENTIN 800 mg Tablet2Generic10%10%
  • QL 12 per 30 days
GALANTAMINE 12 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 6 per 30 days
GALANTAMINE 16 mg Capsule, Extended Release4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GALANTAMINE 24 mg Capsule, Extended Release4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GALANTAMINE 4 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 6 per 30 days
GALANTAMINE 8 mg Capsule, Extended Release4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GALANTAMINE 8 mg Tablet, Film Coated3Preferred Brand25%25%
  • QL 6 per 30 days
GALANTAMINE HYDROBROMIDE 4 mg/mL Solution4Non-Preferred Drug30%30%
  • QL 2 per 30 days
GALLIFREY 5 mg TabletNorethindrone Acetate4Non-Preferred Drug30%30%None
GARDASIL 9 30/40/60/40/20/20/20/20/20 ug/.5mL Injection, SuspensionHuman Papillomavirus 9-Valent Vaccine, Recombinant4Non-Preferred Drug30%30%None
GARDASIL 9 30/40/60/40/20/20/20/20/20 ug/.5mL Injection, SuspensionHuman Papillomavirus 9-Valent Vaccine, Recombinant4Non-Preferred Drug30%30%None
GATTEX KitTeduglutide5Specialty Tier25%N/A
  • PA
GAVILYTE - C TM 240/5.84/2.98/6.72/22.72 g/278.26g Powder, For SolutionPolyethylene Glycol-3350 And Electrolytes With Flavor Pack2Generic10%10%None
GAVRETO 100 mg CapsulePralsetinib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
GEFITINIB 250 mg Tablet, Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GEMFIBROZIL 600 mg Tablet2Generic10%10%None
GEMMILY KitNorethindrone Acetate And Ethinyl Estradiol, And Ferrous Fumarate4Non-Preferred Drug30%30%None
GENERLAC 10 g/15mL SolutionLactulose2Generic10%10%None
GENGRAF 100 mg CapsuleCyclosporine4Non-Preferred Drug30%30%
  • PA
GENGRAF 25 mg CapsuleCyclosporine4Non-Preferred Drug30%30%
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin4Non-Preferred Drug30%30%
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENOTROPIN KitSomatropin5Specialty Tier25%N/A
  • PA
GENTAMICIN SULFATE 1 mg/g Cream4Non-Preferred Drug30%30%
  • QL 6 per 30 days
GENTAMICIN SULFATE 1 mg/g Ointment3Preferred Brand25%25%None
GENTAMICIN SULFATE 3 mg/mL Solution3Preferred Brand25%25%None
GENTAMICIN SULFATE 40 mg/mL Injection, Solution4Non-Preferred Drug30%30%
  • PA
GENTAMICIN SULFATE IN SODIUM CHLORIDE 100 mg/100mL Injection, SolutionGentamicin Sulfate4Non-Preferred Drug30%30%
  • PA
GENTAMICIN SULFATE IN SODIUM CHLORIDE 60 mg/50mL Injection, SolutionGentamicin Sulfate4Non-Preferred Drug30%30%
  • PA
GENTAMICIN SULFATE IN SODIUM CHLORIDE 80 mg/100mL Injection, SolutionGentamicin Sulfate4Non-Preferred Drug30%30%
  • PA
GENTAMICIN SULFATE IN SODIUM CHLORIDE 80 mg/50mL Injection, SolutionGentamicin Sulfate4Non-Preferred Drug30%30%
  • PA
GENVOYA 150/150/200/10 mg TabletElvitegravir, Cobicistat, Emtricitabine, And Tenofovir Alafenamide5Specialty Tier25%N/A
  • QL 3 per 30 days
GILOTRIF 20 mg Tablet, Film CoatedAfatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GILOTRIF 30 mg Tablet, Film CoatedAfatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GILOTRIF 40 mg Tablet, Film CoatedAfatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GLASSIA 1 g/50mL Injection, SolutionAlpha.1-Proteinase Inhibitor Human5Specialty Tier25%N/A
  • PA
GLATIRAMER ACETATE 20 mg/mL Injection, Solution5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GLATIRAMER ACETATE 40 mg/mL Injection, SolutionGlatiramer5Specialty Tier25%N/A
  • PA
  • QL 12 per 28 days
GLATOPA 20 mg/mL Injection, SolutionGlatiramer Acetate5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
GLATOPA 40 mg/mL Injection, SolutionGlatiramer Acetate5Specialty Tier25%N/A
  • PA
  • QL 12 per 28 days
GLEOSTINE 10 mg Capsule, Gelatin CoatedLomustine4Non-Preferred Drug30%30%None
GLEOSTINE 100 mg Capsule, Gelatin CoatedLomustine4Non-Preferred Drug30%30%None
GLEOSTINE 40 mg Capsule, Gelatin CoatedLomustine4Non-Preferred Drug30%30%None
GLIMEPIRIDE 1 mg Tablet1Preferred Generic5%5%
  • QL 24 per 30 days
GLIMEPIRIDE 2 mg Tablet1Preferred Generic5%5%
  • QL 12 per 30 days
GLIMEPIRIDE 4 mg Tablet1Preferred Generic5%5%
  • QL 6 per 30 days
GLIPIZIDE 10 mg Tablet1Preferred Generic5%5%
  • QL 12 per 30 days
GLIPIZIDE 10 mg Tablet, Film Coated, Extended Release1Preferred Generic5%5%
  • QL 6 per 30 days
GLIPIZIDE 2.5 mg Tablet3Preferred Brand25%25%
  • QL 3 per 30 days
GLIPIZIDE 2.5 mg Tablet, Film Coated, Extended Release1Preferred Generic5%5%
  • QL 24 per 30 days
GLIPIZIDE 5 mg Tablet1Preferred Generic5%5%
  • QL 24 per 30 days
GLIPIZIDE 5 mg Tablet, Film Coated, Extended Release1Preferred Generic5%5%
  • QL 12 per 30 days
GLIPIZIDE AND METFORMIN HYDROCHLORIDE 2.5/250 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 24 per 30 days
GLIPIZIDE AND METFORMIN HYDROCHLORIDE 2.5/500 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 12 per 30 days
GLIPIZIDE AND METFORMIN HYDROCHLORIDE 5/500 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 12 per 30 days
GLUCAGON Kit3Preferred Brand25%25%None
GLYCOPYRROLATE 1 mg Tablet4Non-Preferred Drug30%30%None
GLYCOPYRROLATE 2 mg Tablet4Non-Preferred Drug30%30%None
GOMEKLI 1 mg CapsuleMirdametinib5Specialty Tier25%N/A
  • PA
  • QL 126 per 28 days
GOMEKLI 1 mg Tablet, For SuspensionMirdametinib5Specialty Tier25%N/A
  • PA
  • QL 168 per 28 days
GOMEKLI 2 mg CapsuleMirdametinib5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
GRANISETRON HYDROCHLORIDE 1 mg Tablet3Preferred Brand25%25%
  • PA
GRISEOFULVIN 500 mg Tablet4Non-Preferred Drug30%30%None
GRISOFULVIN 125 mg/5mL Suspension4Non-Preferred Drug30%30%None
GUANFACINE EXTENDED-RELEASE 1 mg Tablet, Extended ReleaseGuanfacine4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GUANFACINE EXTENDED-RELEASE 2 mg Tablet, Extended ReleaseGuanfacine4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GUANFACINE EXTENDED-RELEASE 3 mg Tablet, Extended ReleaseGuanfacine4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GUANFACINE EXTENDED-RELEASE 4 mg Tablet, Extended ReleaseGuanfacine4Non-Preferred Drug30%30%
  • QL 3 per 30 days
GVOKE HYPOPEN 0.5 MG AUTO-INJECTOR .5 mg/.1mL Injection, SolutionGlucagon Injection, Solution3Preferred Brand25%25%
  • QL 0.8 per 30 days
GVOKE HYPOPEN 1 MG AUTO-INJECTOR 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution3Preferred Brand25%25%
  • QL 0.8 per 30 days
GVOKE KIT 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution3Preferred Brand25%25%
  • QL 0.8 per 30 days
GVOKE PFS 1 MG PRE-FILLED SYRINGE 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution3Preferred Brand25%25%
  • QL 0.8 per 30 days

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.