2026 BlueCross Rx Value (PDP) formulary (drug list)
Contract S5953, plan 001 · South Carolina · 3,082 drugs on file · formulary ID 00026220. Each drug links to its cost in every CMS PDP Region 09 plan.
87 drugs starting with G.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| GABAPENTIN 100 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| GABAPENTIN 250 mg/5mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| GABAPENTIN 300 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| GABAPENTIN 400 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| GABAPENTIN 600 mg Tablet | 2Generic | $17.00 | $42.50 |
|
| GABAPENTIN 800 mg Tablet | 2Generic | $17.00 | $42.50 |
|
| GALANTAMINE 12 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| GALANTAMINE 16 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| GALANTAMINE 24 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| GALANTAMINE 4 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| GALANTAMINE 8 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| GALANTAMINE 8 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| GALANTAMINE HYDROBROMIDE 4 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| GALLIFREY 5 mg TabletNorethindrone Acetate | 2Generic | $17.00 | $42.50 | None |
| GARDASIL 9 30/40/60/40/20/20/20/20/20 ug/.5mL Injection, SuspensionHuman Papillomavirus 9-Valent Vaccine, Recombinant | 1Preferred Generic | $12.00 | $30.00 | None |
| GARDASIL 9 30/40/60/40/20/20/20/20/20 ug/.5mL Injection, SuspensionHuman Papillomavirus 9-Valent Vaccine, Recombinant | 1Preferred Generic | $12.00 | $30.00 | None |
| GATIFLOXACIN 5 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| GAVILYTE - C TM 240/5.84/2.98/6.72/22.72 g/278.26g Powder, For SolutionPolyethylene Glycol-3350 And Electrolytes With Flavor Pack | 2Generic | $17.00 | $42.50 | None |
| GAVILYTE G TM 236/22.74/6.74/5.86/2.97 g/274.31g Powder, For SolutionPolyethylene Glycol-3350 And Electrolytes | 2Generic | $17.00 | $42.50 | None |
| GAVRETO 100 mg CapsulePralsetinib | 5Specialty Tier | 25% | N/A |
|
| GEFITINIB 250 mg Tablet, Coated | 5Specialty Tier | 25% | N/A |
|
| GEMFIBROZIL 600 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| GEMTESA 75 mg Tablet, Film CoatedVibegron | 4Non-Preferred Drug | 50% | 50% | None |
| GENERLAC 10 g/15mL SolutionLactulose | 2Generic | $17.00 | $42.50 | None |
| GENGRAF 100 mg CapsuleCyclosporine | 4Non-Preferred Drug | 50% | 50% |
|
| GENGRAF 25 mg CapsuleCyclosporine | 4Non-Preferred Drug | 50% | 50% |
|
| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
|
| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
|
| GENOTROPIN KitSomatropin | 4Non-Preferred Drug | 50% | 50% |
|
| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
|
| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
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| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
|
| GENOTROPIN KitSomatropin | 5Specialty Tier | 25% | N/A |
|
| GENTAMICIN SULFATE 1 mg/g Cream | 3Preferred Brand | 17% | 17% | None |
| GENTAMICIN SULFATE 1 mg/g Ointment | 3Preferred Brand | 17% | 17% | None |
| GENTAMICIN SULFATE 3 mg/mL Solution | 2Generic | $17.00 | $42.50 | None |
| GENTAMICIN SULFATE 40 mg/mL Injection, Solution | 4Non-Preferred Drug | 50% | 50% | None |
| GENVOYA 150/150/200/10 mg TabletElvitegravir, Cobicistat, Emtricitabine, And Tenofovir Alafenamide | 5Specialty Tier | 25% | N/A |
|
| GILOTRIF 20 mg Tablet, Film CoatedAfatinib | 5Specialty Tier | 25% | N/A |
|
| GILOTRIF 30 mg Tablet, Film CoatedAfatinib | 5Specialty Tier | 25% | N/A |
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| GILOTRIF 40 mg Tablet, Film CoatedAfatinib | 5Specialty Tier | 25% | N/A |
|
| GLATIRAMER ACETATE 20 mg/mL Injection, Solution | 5Specialty Tier | 25% | N/A |
|
| GLATIRAMER ACETATE 40 mg/mL Injection, SolutionGlatiramer | 5Specialty Tier | 25% | N/A |
|
| GLEOSTINE 10 mg Capsule, Gelatin CoatedLomustine | 4Non-Preferred Drug | 50% | 50% | None |
| GLEOSTINE 100 mg Capsule, Gelatin CoatedLomustine | 4Non-Preferred Drug | 50% | 50% | None |
| GLEOSTINE 40 mg Capsule, Gelatin CoatedLomustine | 4Non-Preferred Drug | 50% | 50% | None |
| GLIMEPIRIDE 1 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIMEPIRIDE 2 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIMEPIRIDE 4 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 10 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 10 mg Tablet, Film Coated, Extended Release | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 2.5 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 2.5 mg Tablet, Film Coated, Extended Release | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 5 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE 5 mg Tablet, Film Coated, Extended Release | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE AND METFORMIN HYDROCHLORIDE 2.5/250 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE AND METFORMIN HYDROCHLORIDE 2.5/500 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLIPIZIDE AND METFORMIN HYDROCHLORIDE 5/500 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLUCAGON Kit | 3Preferred Brand | 17% | 17% | None |
| GLYBURIDE 1.25 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYBURIDE 2.5 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYBURIDE 5 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYBURIDE AND METFORMIN HYDROCHLORIDE 1.25/250 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYBURIDE AND METFORMIN HYDROCHLORIDE 2.5/500 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYBURIDE AND METFORMIN HYDROCHLORIDE 5/500 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| GLYCOPYRROLATE 1 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| GLYCOPYRROLATE 2 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| GLYXAMBI 10/5 mg Tablet, Film CoatedEmpagliflozin And Linagliptin | 3Preferred Brand | 17% | 17% | None |
| GLYXAMBI 25/5 mg Tablet, Film CoatedEmpagliflozin And Linagliptin | 3Preferred Brand | 17% | 17% | None |
| GOMEKLI 1 mg CapsuleMirdametinib | 5Specialty Tier | 25% | N/A |
|
| GOMEKLI 1 mg Tablet, For SuspensionMirdametinib | 5Specialty Tier | 25% | N/A |
|
| GOMEKLI 2 mg CapsuleMirdametinib | 5Specialty Tier | 25% | N/A |
|
| GRISEOFULVIN 500 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| GRISOFULVIN 125 mg/5mL Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| GUANFACINE EXTENDED-RELEASE 1 mg Tablet, Extended ReleaseGuanfacine | 3Preferred Brand | 17% | 17% | None |
| GUANFACINE EXTENDED-RELEASE 2 mg Tablet, Extended ReleaseGuanfacine | 3Preferred Brand | 17% | 17% | None |
| GUANFACINE EXTENDED-RELEASE 3 mg Tablet, Extended ReleaseGuanfacine | 3Preferred Brand | 17% | 17% | None |
| GUANFACINE EXTENDED-RELEASE 4 mg Tablet, Extended ReleaseGuanfacine | 3Preferred Brand | 17% | 17% | None |
| GVOKE HYPOPEN 0.5 MG AUTO-INJECTOR .5 mg/.1mL Injection, SolutionGlucagon Injection, Solution | 3Preferred Brand | 17% | 17% | None |
| GVOKE HYPOPEN 1 MG AUTO-INJECTOR 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution | 3Preferred Brand | 17% | 17% | None |
| GVOKE KIT 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution | 3Preferred Brand | 17% | 17% | None |
| GVOKE PFS 1 MG PRE-FILLED SYRINGE 1 mg/.2mL Injection, SolutionGlucagon Injection, Solution | 3Preferred Brand | 17% | 17% | None |
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.