2009 Medicare Part D Plan Formulary Information |
Blue MedicareRx Value (S5596-009-0)
Sanctioned Plan
|
The Blue MedicareRx Value (S5596-009-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 10 which includes: GA
|
Drugs Starting with Letter G
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
GABAPENTIN 100MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABAPENTIN 100MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABAPENTIN 400MG CAPSULE (10 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:270 /30Days |
GABAPENTIN 400MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABAPENTIN 600MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABAPENTIN CAPSULES 300MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABAPENTIN TABLET 800MG |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:180 /30Days |
GABITRIL 12MG FILMTAB |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GABITRIL 16MG FILMTAB |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GABITRIL 2MG FILMTAB |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GABITRIL 4MG FILMTAB |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GALANTAMINE HBR 12MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
GALANTAMINE HBR 4MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
GALANTAMINE HBR 8MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL |
5 |
Tier 5. |
29% | N/A | P |
GAMMAGARD LIQUID 10% VIAL |
5 |
Tier 5. |
29% | N/A | P |
GAMMAGARD LIQUID 10% VIAL |
5 |
Tier 5. |
29% | N/A | P |
GAMMAGARD LIQUID 10% VIAL |
5 |
Tier 5. |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAMMAGARD LIQUID 10% VIAL |
5 |
Tier 5. |
29% | N/A | P |
GAMMAGARD LIQUID 10% VIAL |
5 |
Tier 5. |
29% | N/A | P |
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL |
5 |
Tier 5. |
29% | N/A | P |
GANCICLOVIR 250MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GANCICLOVIR 500MG CAPSULE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GANTRISIN PED 500MG/5ML SUSPENSION |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GARDASIL VIAL |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GASTROCROM 100MG/5ML CONC |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GEMFIBROZIL TABLET 600MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GEMZAR 1GRAM VIAL |
5 |
Tier 5. |
29% | N/A | None |
GEMZAR 200MG VIAL |
5 |
Tier 5. |
29% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GENGRAF 100MG CAPSULE U.D. |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | P |
GENGRAF 100MG/ML SOLUTION |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | P |
GENGRAF 25MG CAPSULE U.D. |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | P |
GENOPTIC SOL 0.3% OP |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GENOTROPIN 5.8MG CARTRIDGE |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.4MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.6MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.8MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.2MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 1.4MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.6MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.8MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN MINIQUICK 2MG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENOTROPIN POWDER FOR INJECTION 13.8MG 5 X 13.8MG CTG |
5 |
Tier 5. |
29% | N/A | P Q:28 /28Days |
GENTAK 3MG/GM EYE OINTMENT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:8 /30Days |
GENTAK 3MG/ML EYE DROPS |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GENTAMICIN 100MG/NS 100ML |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 10MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 60MG/NS 50ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAMICIN 60MG/NS 50ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 70MG/NS 50ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 80MG/NS 100ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 80MG/NS 100ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 80MG/NS 50ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 80MG/NS 50ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN 90MG/NS 100ML PB |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN INJECTION PEDIATRIC 20MG 25 X 2ML VIALSD |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN SULFATE 0.3% OINTMENT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:8 /30Days |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION 1 MG/ML |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GENTASOL 3MG/ML EYE DROPS |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:30 /30Days |
GEODON 20MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | Q:60 /30Days |
GEODON 20MG VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GEODON 40MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | Q:60 /30Days |
GEODON 60MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | Q:90 /30Days |
GEODON 80MG CAPSULE |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | Q:90 /30Days |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Tier 5. |
29% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLEEVEC 400MG TABLET |
5 |
Tier 5. |
29% | N/A | P |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE ER 10MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE ER 5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIPIZIDE XL 10MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE XL 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE XL 5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLUCAGEN 1MG HYPOKIT |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GLUCAGON 1MG EMERGENCY KIT |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GLYBURIDE 2.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE 5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE TABLET 1.25MG (50 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE TABLET MICRONIZED 6MG (500 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYCOPYRROLATE 0.2MG/ML VL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYCRON 1.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYCRON 3MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GLYCRON 6MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GRANISETRON HCL 0.1MG/ML VIAL INJECTION SOLUTION |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GRANISETRON HCL 1MG TABLET (20 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | P Q:30 /30Days |
GRANISETRON HCL 1MG/ML VIAL |
4 |
Tier 4 Non-Specialty Injectable |
29% | 29% | None |
GRIS-PEG 125MG TABLET |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GRIS-PEG 250MG TABLET |
2 |
Tier 2 Preferred Brand |
$38.00 | $95.00 | None |
GRISEOFULVIN 125MG/5ML SUSPENSION ORAL |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GUANABENZ ACETATE 4MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GUANABENZ ACETATE 8MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GUANFACINE 1MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:90 /30Days |
GUANFACINE 2MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | Q:60 /30Days |
GUANIDINE HCL 125MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GYNODIOL 0.5MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GYNODIOL 1MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |
GYNODIOL 2MG TABLET |
1 |
Tier 1 Preferred Generic |
$10.00 | $15.00 | None |