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2009 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (S5678-016-0) Benefit Details
The Health Net Orange Option 1 (S5678-016-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 5 which includes: DC DE MD
Drugs Starting with Letter G Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter G Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GABAPENTIN 100MG CAPSULE	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN 100MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN 400MG CAPSULE (10 CT)	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN 400MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN 600MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN CAPSULES 300MG (500 CT)	1	Preferred Generic	$2.00	$4.00	None
GABAPENTIN TABLET 800MG	1	Preferred Generic	$2.00	$4.00	None
GABITRIL 12MG FILMTAB	2	Preferred Brand	$45.00	$90.00	None
GABITRIL 16MG FILMTAB	2	Preferred Brand	$45.00	$90.00	None
GABITRIL 2MG FILMTAB	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GABITRIL 4MG FILMTAB	2	Preferred Brand	$45.00	$90.00	None
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL	5	Specialty	25%	N/A	P
GAMMAGARD LIQUID 10% VIAL	5	Specialty	25%	N/A	P
GAMMAGARD LIQUID 10% VIAL	5	Specialty	25%	N/A	P
GAMMAGARD LIQUID 10% VIAL	5	Specialty	25%	N/A	P
GAMMAGARD LIQUID 10% VIAL	5	Specialty	25%	N/A	P
GAMMAGARD LIQUID 10% VIAL	5	Specialty	25%	N/A	P
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL	5	Specialty	25%	N/A	P
GANCICLOVIR 250MG CAPSULE	1	Preferred Generic	$2.00	$4.00	None
GANCICLOVIR 500MG CAPSULE	1	Preferred Generic	$2.00	$4.00	None
GANTRISIN PED 500MG/5ML SUSPENSION	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GARDASIL VIAL	4	Injectable	25%	N/A	None
GEMFIBROZIL TABLET 600MG (500 CT)	1	Preferred Generic	$2.00	$4.00	None
GEMZAR 1GRAM VIAL	5	Specialty	25%	N/A	None
GEMZAR 200MG VIAL	5	Specialty	25%	N/A	None
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL	1	Preferred Generic	$2.00	$4.00	None
GENGRAF 100MG CAPSULE U.D.	1	Preferred Generic	$2.00	$4.00	P
GENGRAF 100MG/ML SOLUTION	1	Preferred Generic	$2.00	$4.00	P
GENGRAF 25MG CAPSULE U.D.	1	Preferred Generic	$2.00	$4.00	P
GENOPTIC SOL 0.3% OP	1	Preferred Generic	$2.00	$4.00	None
GENOTROPIN 5.8MG CARTRIDGE	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 0.2MG	4	Injectable	25%	N/A	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENOTROPIN MINIQUICK 0.4MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 0.6MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 0.8MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 1.2MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 1.4MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 1.6MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 1.8MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 1MG	4	Injectable	25%	N/A	P
GENOTROPIN MINIQUICK 2MG	4	Injectable	25%	N/A	P
GENOTROPIN POWDER FOR INJECTION 13.8MG 5 X 13.8MG CTG	4	Injectable	25%	N/A	P
GENTAK 3MG/GM EYE OINTMENT	1	Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENTAK 3MG/ML EYE DROPS	1	Preferred Generic	$2.00	$4.00	None
GENTAMICIN 100MG/NS 100ML	4	Injectable	25%	N/A	None
GENTAMICIN 10MG/ML VIAL	4	Injectable	25%	N/A	None
GENTAMICIN 60MG/NS 50ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 60MG/NS 50ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 70MG/NS 50ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 80MG/NS 100ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 80MG/NS 100ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 80MG/NS 50ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 80MG/NS 50ML PB	4	Injectable	25%	N/A	None
GENTAMICIN 90MG/NS 100ML PB	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENTAMICIN INJECTION PEDIATRIC 20MG 25 X 2ML VIALSD	4	Injectable	25%	N/A	None
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD	4	Injectable	25%	N/A	None
GENTAMICIN SULFATE 0.3% OINTMENT	1	Preferred Generic	$2.00	$4.00	None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE	1	Preferred Generic	$2.00	$4.00	None
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION	4	Injectable	25%	N/A	None
GENTAMICIN SULFATE IN NACL SOLUTION FOR INJECTION 1 MG/ML	4	Injectable	25%	N/A	None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE	1	Preferred Generic	$2.00	$4.00	None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT	1	Preferred Generic	$2.00	$4.00	None
GENTASOL 3MG/ML EYE DROPS	1	Preferred Generic	$2.00	$4.00	None
GEODON 20MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
GEODON 20MG VIAL	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GEODON 40MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
GEODON 60MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
GEODON 80MG CAPSULE	2	Preferred Brand	$45.00	$90.00	Q:2 /1Days
GLEEVEC 100MG TABLET (90 CT)	5	Specialty	25%	N/A	P
GLEEVEC 400MG TABLET	5	Specialty	25%	N/A	P
GLIMEPIRIDE 1MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLIMEPIRIDE 2MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLIMEPIRIDE 4MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE 10MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE 5MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE ER 10MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE ER 5MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE XL 10MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE XL 2.5MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE XL 5MG TABLET SR OSMOTIC PUSH 24HR	1	Preferred Generic	$2.00	$4.00	None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLUCAGEN 1MG HYPOKIT	2	Preferred Brand	$45.00	$90.00	Q:1 /30Days
GLUCAGON 1MG EMERGENCY KIT	2	Preferred Brand	$45.00	$90.00	Q:2 /30Days
GLUCOPHAGE 1000MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLUCOPHAGE 500MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLUCOPHAGE 850MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLUCOPHAGE XR 500MG TABLET SA	2	Preferred Brand	$45.00	$90.00	None
GLUCOPHAGE XR 750MG TABLET SA	2	Preferred Brand	$45.00	$90.00	None
GLUCOTROL 10MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLUCOTROL 5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLUCOTROL XL 10MG TABLET SA	2	Preferred Brand	$45.00	$90.00	None
GLUCOTROL XL 2.5MG TABLET SA	2	Preferred Brand	$45.00	$90.00	None
GLUCOTROL XL 5MG TABLET SA	2	Preferred Brand	$45.00	$90.00	None
GLUCOVANCE 1.25/250MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLUCOVANCE 2.5/500MG TABLET	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLUCOVANCE 5/500MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLYBURIDE 2.5MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE 5MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE MICRO 3MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE TABLET 1.25MG (50 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE TABLET MICRONIZED 6MG (500 CT)	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYCOPYRROLATE 0.2MG/ML VL	4	Injectable	25%	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLYCRON 1.5MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYCRON 3MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYCRON 4.5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLYCRON 6MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GLYNASE 1.5MG PRESTAB	2	Preferred Brand	$45.00	$90.00	None
GLYNASE PRESTAB TABLET 3MG (100 CT)	2	Preferred Brand	$45.00	$90.00	None
GLYNASE PRESTAB TABLET 6MG (100 CT)	2	Preferred Brand	$45.00	$90.00	None
GLYSET 100MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLYSET 25MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GLYSET 50MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GOLYTELY PACKET 227.1 GM/2.82 GM	2	Preferred Brand	$45.00	$90.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM	2	Preferred Brand	$45.00	$90.00	None
GRANISETRON HCL 0.1MG/ML VIAL INJECTION SOLUTION	4	Injectable	25%	N/A	P
GRANISETRON HCL 1MG/ML VIAL	4	Injectable	25%	N/A	P
GRIFULVIN V 125MG/5ML SUSP	2	Preferred Brand	$45.00	$90.00	None
GRIFULVIN V 500MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GRIS-PEG 125MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GRIS-PEG 250MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GRISEOFULVIN 125MG/5ML SUSPENSION ORAL	1	Preferred Generic	$2.00	$4.00	None
GUANABENZ ACETATE 4MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GUANABENZ ACETATE 8MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GUANFACINE 1MG TABLET	1	Preferred Generic	$2.00	$4.00	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GUANFACINE 2MG TABLET (100 CT)	1	Preferred Generic	$2.00	$4.00	None
GUANIDINE HCL 125MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GYNAZOLE-1 CRE 2%	3	Non-Preferred Brand	$90.00	$225.00	None
GYNODIOL 0.5MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GYNODIOL 1.5MG TABLET	2	Preferred Brand	$45.00	$90.00	None
GYNODIOL 1MG TABLET	1	Preferred Generic	$2.00	$4.00	None
GYNODIOL 2MG TABLET	1	Preferred Generic	$2.00	$4.00	None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Health Net Orange Option 1 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 $295 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 initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing 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 2009 )

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.