2011 Medicare Part D Plan Formulary Information |
AARP MedicareRx Enhanced (PDP) (S5921-273-0)
Benefit Details
|
The AARP MedicareRx Enhanced (PDP) (S5921-273-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 29 which includes: NV
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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 400 MG CAPSULE |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GABAPENTIN 600MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GABAPENTIN CAPSULES 100MG 100 BOT |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GABAPENTIN CAPSULES 300MG |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GABAPENTIN TABLET 800MG |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GABITRIL 12MG FILMTAB |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | Q:124 /31Days |
GABITRIL 16MG FILMTAB |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | Q:93 /31Days |
GABITRIL 2MG FILMTAB |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | Q:124 /31Days |
GABITRIL 4MG FILMTAB |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GALANTAMINE HBR 12MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GALANTAMINE HBR 4MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GALANTAMINE HBR 8MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GALANTAMINE HYDROBROMIDE 4 MG/ML ORAL SOLUTION |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | Q:31 /31Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | Q:31 /31Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | Q:31 /31Days |
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P |
GAMMAGARD LIQUID 10% VIAL |
4 |
Tier 4 Specialty |
33% | 33% | P |
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL |
4 |
Tier 4 Specialty |
33% | 33% | P |
GANCICLOVIR 250MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
GANCICLOVIR 500MG CAPSULE |
4 |
Tier 4 Specialty |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GANCICLOVIR FOR INJECTION |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P |
GARDASIL VIAL |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GASTROCROM 100MG/5ML CONC |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GELNIQUE GEL 100MG/ML 30 PACKET IN 1 CRTN |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | Q:31 /31Days |
GEMFIBROZIL TABLET 600MG (500 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GEMZAR 1GRAM VIAL |
4 |
Tier 4 Specialty |
33% | 33% | None |
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GENGRAF 100MG CAPSULE U.D. |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P |
GENGRAF 100MG/ML SOLUTION |
4 |
Tier 4 Specialty |
33% | 33% | P |
GENGRAF 25MG CAPSULE U.D. |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P |
GENOTROPIN 13.8MG CARTRIDGE |
4 |
Tier 4 Specialty |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 0.2MG |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.4MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.6MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.8MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.2MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.4MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.6MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.8MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 2MG |
4 |
Tier 4 Specialty |
33% | 33% | P Q:28 /28Days |
GENTAK 3MG/GM EYE OINTMENT |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAK 3MG/ML EYE DROPS |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GENTAMICIN 100MG/NS 100ML |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN 10MG/ML VIAL |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN 60MG/NS 50ML PB |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN 70MG/NS 50ML PB |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN 80MG/NS 50ML PB |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN 90MG/NS 100ML PB |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTASOL 3MG/ML EYE DROPS |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GEODON 20MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GEODON 20MG VIAL |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GEODON 40MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GEODON 60MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GEODON 80MG CAPSULE |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GIANVI TABLETS |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLEEVEC 100MG TABLET (90 CT) |
4 |
Tier 4 Specialty |
33% | 33% | P |
GLEEVEC 400MG TABLET |
4 |
Tier 4 Specialty |
33% | 33% | P |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE 5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE TABLETS EXTENDED RELEASE |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE TABLETS EXTENDED RELEASE |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOPHAGE 1000MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOPHAGE 500MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOPHAGE 850MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOPHAGE XR 500MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOPHAGE XR 750MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOTROL 10MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOTROL 5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOTROL XL 10MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOTROL XL 2.5MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOTROL XL 5MG TABLET SA |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOVANCE 1.25/250MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOVANCE 2.5/500MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUCOVANCE 5/500MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLUMETZA ER 500MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYBURIDE 2.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE TABLET MICRONIZED 6MG (500 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE TABLETS |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE TABLETS |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYCOPYRROLATE 0.2MG/ML VL |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GLYCRON 1.5MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYCRON 3MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYCRON 4.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYCRON 6MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GLYNASE 1.5MG PRESTAB |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYNASE PRESTAB TABLET 3MG (100 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYNASE PRESTAB TABLET 6MG (100 CT) |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYSET 100MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYSET 25MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GLYSET 50MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GOLYTELY PACKET 227.1 GM/2.82 GM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | Q:4000 /31Days |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | Q:4000 /31Days |
GRANISETRON 1 MG/ML INJECTABLE SOLUTION |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GRANISETRON HCL 1MG TABLET (20 CT) |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P Q:6 /3Days |
GRANISETRON HYDROCHLORIDE INJECTION |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GRANISOL 1MG/5ML SOLUTION ORAL |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | P Q:30 /3Days |
GRIFULVIN V 500MG TABLET |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GRIS-PEG 125MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GRIS-PEG 250 MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GRISEOFULVIN ORAL SUSPENSION 125MG/5ML 4 FLOZ CTR |
2 |
Tier 2 Generic Preferred Brand |
$40.00 | $105.00 | None |
GUANABENZ ACETATE 4MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GUANABENZ ACETATE 8MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GUANFACINE 1MG TABLET |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GUANFACINE 2MG TABLET (100 CT) |
1 |
Tier 1 Preferred Generic Brand |
$5.00 | $10.00 | None |
GUANIDINE HCL 125MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GYNAZOLE-1 CRE 2% |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |
GYNODIOL 1.5MG TABLET |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None |