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Blue MedicareRx Premier (PDP) (S5596-003-0)
Tier 1 (1617)
Tier 2 (563)
Tier 3 (1426)
Tier 4 (554)
Tier 5 (339)
Requires Prior Authorization:
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Uses Step Therapy:
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2011 Medicare Part D Plan Formulary Information
Blue MedicareRx Premier (PDP) (S5596-003-0)
Benefit Details           
The Blue MedicareRx Premier (PDP) (S5596-003-0)
Formulary Drugs Starting with the Letter G

in CMS PDP Region 01 which includes: ME NH
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 $6.00$9.00Q:270
/30Days
GABAPENTIN 600MG TABLET   1 Tier 1 $6.00$9.00Q:180
/30Days
GABAPENTIN CAPSULES 100MG 100 BOT   1 Tier 1 $6.00$9.00Q:180
/30Days
GABAPENTIN CAPSULES 300MG   1 Tier 1 $6.00$9.00Q:180
/30Days
GABAPENTIN TABLET 800MG   1 Tier 1 $6.00$9.00Q:180
/30Days
GABITRIL 12MG FILMTAB   2 Tier 2 $43.00$107.50None
GABITRIL 16MG FILMTAB   2 Tier 2 $43.00$107.50None
GABITRIL 2MG FILMTAB   2 Tier 2 $43.00$107.50None
GABITRIL 4MG FILMTAB   2 Tier 2 $43.00$107.50None
GALANTAMINE HBR 12MG TABLET   1 Tier 1 $6.00$9.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GALANTAMINE HBR 4MG TABLET   1 Tier 1 $6.00$9.00Q:60
/30Days
GALANTAMINE HBR 8MG TABLET   1 Tier 1 $6.00$9.00Q:60
/30Days
GALANTAMINE HYDROBROMIDE 4 MG/ML ORAL SOLUTION   1 Tier 1 $6.00$9.00Q:180
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT   1 Tier 1 $6.00$9.00Q:30
/30Days
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL   4 Tier 4 33%33%P
GAMMAGARD LIQUID 10% VIAL   5 Tier 5 33%N/AP
GAMUNEX FOR SOLUTION 10GM/25ML VIALGL   5 Tier 5 33%N/AP
GANCICLOVIR 250MG CAPSULE   1 Tier 1 $6.00$9.00None
GANCICLOVIR 500MG CAPSULE   1 Tier 1 $6.00$9.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GANCICLOVIR FOR INJECTION   4 Tier 4 33%33%None
GARDASIL VIAL   2 Tier 2 $43.00$107.50None
GASTROCROM 100MG/5ML CONC   2 Tier 2 $43.00$107.50None
GELNIQUE GEL 100MG/ML 30 PACKET IN 1 CRTN   3 Tier 3 $85.00$212.50None
GEMFIBROZIL TABLET 600MG (500 CT)   1 Tier 1 $6.00$9.00None
GEMZAR 1GRAM VIAL   5 Tier 5 33%N/AP
GENERLAC SOLUTION 10G/15 ML 473 ML BOTPL   1 Tier 1 $6.00$9.00None
GENGRAF 100MG CAPSULE U.D.   1 Tier 1 $6.00$9.00P
GENGRAF 100MG/ML SOLUTION   1 Tier 1 $6.00$9.00P
GENGRAF 25MG CAPSULE U.D.   1 Tier 1 $6.00$9.00P
GENOTROPIN 13.8MG CARTRIDGE   5 Tier 5 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENOTROPIN MINIQUICK 0.2MG   4 Tier 4 33%33%P
GENOTROPIN MINIQUICK 0.4MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 0.6MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 0.8MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 1.2MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 1.4MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 1.6MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 1.8MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 1MG   5 Tier 5 33%N/AP
GENOTROPIN MINIQUICK 2MG   5 Tier 5 33%N/AP
GENTAK 3MG/GM EYE OINTMENT   1 Tier 1 $6.00$9.00None
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 $6.00$9.00None
GENTAMICIN 100MG/NS 100ML   4 Tier 4 33%33%None
GENTAMICIN 10MG/ML VIAL   4 Tier 4 33%33%None
GENTAMICIN 60MG/NS 50ML PB   4 Tier 4 33%33%None
GENTAMICIN 70MG/NS 50ML PB   4 Tier 4 33%33%None
GENTAMICIN 80MG/NS 50ML PB   4 Tier 4 33%33%None
GENTAMICIN 90MG/NS 100ML PB   4 Tier 4 33%33%None
GENTAMICIN INJECTION USP 40MG 25 X 20ML VIALMD   4 Tier 4 33%33%None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   1 Tier 1 $6.00$9.00None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   1 Tier 1 $6.00$9.00None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT   1 Tier 1 $6.00$9.00None
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 $6.00$9.00None
GEODON 20MG CAPSULE   2 Tier 2 $43.00$107.50Q:60
/30Days
GEODON 20MG VIAL   4 Tier 4 33%33%None
GEODON 40MG CAPSULE   2 Tier 2 $43.00$107.50Q:60
/30Days
GEODON 60MG CAPSULE   2 Tier 2 $43.00$107.50Q:90
/30Days
GEODON 80MG CAPSULE   2 Tier 2 $43.00$107.50Q:90
/30Days
GIANVI TABLETS   3 Tier 3 $85.00$212.50Q:28
/28Days
GLEEVEC 100MG TABLET (90 CT)   5 Tier 5 33%N/AP
GLEEVEC 400MG TABLET   5 Tier 5 33%N/AP
GLIMEPIRIDE 1MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLIMEPIRIDE 2MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
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 $6.00$9.00None
GLIPIZIDE 10MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLIPIZIDE 5MG TABLET   1 Tier 1 $6.00$9.00None
GLIPIZIDE AND METFORMIN HCL 2.5-250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLIPIZIDE AND METFORMIN HCL 5-500MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   1 Tier 1 $6.00$9.00None
GLIPIZIDE TABLETS EXTENDED RELEASE   1 Tier 1 $6.00$9.00None
GLIPIZIDE TABLETS EXTENDED RELEASE   1 Tier 1 $6.00$9.00None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET   1 Tier 1 $6.00$9.00None
GLUCAGEN 1MG HYPOKIT   4 Tier 4 33%33%None
GLUCAGON 1MG EMERGENCY KIT   4 Tier 4 33%33%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLUCOPHAGE 1000MG TABLET   3 Tier 3 $85.00$212.50None
GLUCOPHAGE 500MG TABLET   3 Tier 3 $85.00$212.50None
GLUCOPHAGE 850MG TABLET   3 Tier 3 $85.00$212.50None
GLUCOPHAGE XR 500MG TABLET SA   3 Tier 3 $85.00$212.50None
GLUCOPHAGE XR 750MG TABLET SA   3 Tier 3 $85.00$212.50None
GLUCOTROL 10MG TABLET   3 Tier 3 $85.00$212.50None
GLUCOTROL 5MG TABLET   3 Tier 3 $85.00$212.50None
GLUCOTROL XL 10MG TABLET SA   3 Tier 3 $85.00$212.50None
GLUCOTROL XL 2.5MG TABLET SA   3 Tier 3 $85.00$212.50None
GLUCOTROL XL 5MG TABLET SA   3 Tier 3 $85.00$212.50None
GLUCOVANCE 1.25/250MG TABLET   3 Tier 3 $85.00$212.50None
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 $85.00$212.50None
GLUCOVANCE 5/500MG TABLET   3 Tier 3 $85.00$212.50None
GLUMETZA ER 500MG TABLET   3 Tier 3 $85.00$212.50None
GLYBURIDE 2.5MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLYBURIDE MICRO 3MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GLYBURIDE TABLET MICRONIZED 6MG (500 CT)   1 Tier 1 $6.00$9.00None
GLYBURIDE TABLETS   1 Tier 1 $6.00$9.00None
GLYBURIDE TABLETS   1 Tier 1 $6.00$9.00None
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET   1 Tier 1 $6.00$9.00None
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 $6.00$9.00None
GLYCOPYRROLATE 0.2MG/ML VL   4 Tier 4 33%33%None
GLYCOPYRROLATE TABLET 1MG (100 CT)   1 Tier 1 $6.00$9.00None
GLYCOPYRROLATE TABLET 2MG (100 CT)   1 Tier 1 $6.00$9.00None
GLYCRON 1.5MG TABLET   1 Tier 1 $6.00$9.00None
GLYCRON 3MG TABLET   1 Tier 1 $6.00$9.00None
GLYCRON 4.5MG TABLET   1 Tier 1 $6.00$9.00None
GLYCRON 6MG TABLET   1 Tier 1 $6.00$9.00None
GLYNASE 1.5MG PRESTAB   3 Tier 3 $85.00$212.50None
GLYNASE PRESTAB TABLET 3MG (100 CT)   3 Tier 3 $85.00$212.50None
GLYNASE PRESTAB TABLET 6MG (100 CT)   3 Tier 3 $85.00$212.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYSET 100MG TABLET   3 Tier 3 $85.00$212.50None
GLYSET 25MG TABLET   3 Tier 3 $85.00$212.50None
GLYSET 50MG TABLET   3 Tier 3 $85.00$212.50None
GOLYTELY PACKET 227.1 GM/2.82 GM   3 Tier 3 $85.00$212.50None
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM   3 Tier 3 $85.00$212.50None
GRANISETRON 1 MG/ML INJECTABLE SOLUTION   4 Tier 4 33%33%None
GRANISETRON HCL 1MG TABLET (20 CT)   1 Tier 1 $6.00$9.00P Q:30
/30Days
GRANISETRON HYDROCHLORIDE INJECTION   4 Tier 4 33%33%None
GRIFULVIN V 500MG TABLET   3 Tier 3 $85.00$212.50None
GRIS-PEG 125MG TABLET   2 Tier 2 $43.00$107.50None
GRIS-PEG 250 MG TABLET   2 Tier 2 $43.00$107.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GRISEOFULVIN ORAL SUSPENSION 125MG/5ML 4 FLOZ CTR   1 Tier 1 $6.00$9.00None
GUANABENZ ACETATE 4MG TABLET   1 Tier 1 $6.00$9.00None
GUANABENZ ACETATE 8MG TABLET   1 Tier 1 $6.00$9.00None
GUANFACINE 1MG TABLET   1 Tier 1 $6.00$9.00None
GUANFACINE 2MG TABLET (100 CT)   1 Tier 1 $6.00$9.00None
GUANIDINE HCL 125MG TABLET   1 Tier 1 $6.00$9.00None
GYNAZOLE-1 CRE 2%   3 Tier 3 $85.00$212.50None
GYNODIOL 1.5MG TABLET   3 Tier 3 $85.00$212.50None

Chart Legend:

Below are a few notes to help you understand the above 2011 Medicare Part D Blue MedicareRx Premier (PDP) 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 $310 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 intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $(2840)) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, on the 2011 Humana Walmart-Preferred Rx Plan the pricing 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 2011 )

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.





 
 

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Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.