2012 Medicare Part D Plan Formulary Information |
Medica Prime Solution Enhanced w/Part D Option 3 (Cost) (H2450-006-0)
Benefit Details
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The Medica Prime Solution Enhanced w/Part D Option 3 (Cost) (H2450-006-0) Formulary Drugs Starting with the Letter G in WASHBURN County, WI: CMS MA Region 14 which includes: WI
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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 100mg/1 |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GABAPENTIN 400 MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GABAPENTIN 600MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GABAPENTIN CAPSULES 300MG |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GABAPENTIN TABLET 800MG |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GABITRIL 12MG FILMTAB |
2 |
Tier 2 |
$34.00 | $68.00 | None |
GABITRIL 16mg/1 |
2 |
Tier 2 |
$34.00 | $68.00 | None |
GABITRIL 2mg/1 |
2 |
Tier 2 |
$34.00 | $68.00 | None |
GABITRIL 4mg/1 |
2 |
Tier 2 |
$34.00 | $68.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Galantamine 12mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
Galantamine 4mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
Galantamine 8mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:200 /30Days |
GAMASTAN S/D INJECTION 16.5GM/2ML VIALGL |
2 |
Tier 2 |
$34.00 | $68.00 | P |
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS in 1 CARTON / 25 mL in 1 BOTTLE, GLASS |
4 |
Tier 4 |
25% | 25% | P |
GAMMAPLEX INJECTION 5 GM/100 ML |
4 |
Tier 4 |
25% | 25% | P |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
4 |
Tier 4 |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GANCICLOVIR 250MG CAPSULE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GANCICLOVIR 500MG CAPSULE |
4 |
Tier 4 |
25% | 25% | None |
GANCICLOVIR FOR INJECTION |
1 |
Tier 1 |
$10.00 | $20.00 | P |
GARDASIL VIAL |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GASTROCROM 100MG/5ML CONC |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GaviLyte - C TM 240; 2.98; 6.72; 5.84; 22.72g/278.26g; g/278.26g; g/278.26g; g/278.26g; g/278.26g 27 |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GaviLyte - N 420; 1.48; 5.72; 11.2g/438.4g; g/438.4g; g/438.4g; g/438.4g 438.4 g in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GaviLyte G TM 236; 2.97; 6.74; 5.86; 22.74g/274.31g; g/274.31g; g/274.31g; g/274.31g; g/274.31g 274. |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GELNIQUE 100mg/g 30 PACKET in 1 CARTON / 1 g in 1 PACKET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
Gemcitabine 38mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 26.3 mL in 1 VIAL, SINGLE-USE |
4 |
Tier 4 |
25% | 25% | None |
Gemcitabine Hydrochloride 1g/25mL |
4 |
Tier 4 |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GEMFIBROZIL TABLET 600MG (500 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GEMZAR 1GRAM VIAL |
4 |
Tier 4 |
25% | 25% | None |
GENGRAF 100MG CAPSULE U.D. |
1 |
Tier 1 |
$10.00 | $20.00 | P |
GENGRAF 100MG/ML SOLUTION |
1 |
Tier 1 |
$10.00 | $20.00 | P |
GENGRAF 25MG CAPSULE U.D. |
1 |
Tier 1 |
$10.00 | $20.00 | P |
GENOTROPIN 13.8MG CARTRIDGE |
4 |
Tier 4 |
25% | 25% | P Q:5 /28Days |
GENOTROPIN 5 MG CARTRIDGE |
4 |
Tier 4 |
25% | 25% | P Q:5 /28Days |
GENOTROPIN MINIQUICK 0.2MG |
2 |
Tier 2 |
$34.00 | $68.00 | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.4MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.6MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 0.8MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 1.2MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.4MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.6MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1.8MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 1MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENOTROPIN MINIQUICK 2MG |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GENTAK 3MG/GM EYE OINTMENT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN 100MG/NS 100ML |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN 10MG/ML VIAL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN 60MG/NS 50ML PB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN 70MG/NS 50ML PB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAMICIN 80MG/NS 50ML PB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN 90MG/NS 100ML PB |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GENTASOL 3MG/ML EYE DROPS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GEODON 20MG CAPSULE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:62 /31Days |
GEODON 20MG VIAL |
3 |
Tier 3 |
$74.00 | $148.00 | Q:6 /28Days |
GEODON 40MG CAPSULE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:62 /31Days |
GEODON 60MG CAPSULE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:62 /31Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GEODON 80MG CAPSULE |
3 |
Tier 3 |
$74.00 | $148.00 | Q:62 /31Days |
GIANVI 3 MG-0.02 MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Gilenya 0.5mg/1 28 CAPSULE in 1 CARTON |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days |
GLASSIA 1g/50mL 1 VIAL, GLASS in 1 CARTON / 50 mL in 1 VIAL, GLASS |
4 |
Tier 4 |
25% | 25% | S |
GLEEVEC 100MG TABLET (90 CT) |
4 |
Tier 4 |
25% | 25% | None |
GLEEVEC 400MG TABLET |
4 |
Tier 4 |
25% | 25% | None |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLIPIZIDE 5MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
Glipizide and Metformin Hydrochloride 5; 500mg/1; mg/1 100 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLIPIZIDE TABLETS EXTENDED RELEASE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
GLIPIZIDE TABLETS EXTENDED RELEASE |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLUCAGEN 1MG HYPOKIT |
2 |
Tier 2 |
$34.00 | $68.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
2 |
Tier 2 |
$34.00 | $68.00 | None |
GLUCOPHAGE 1000MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:60 /30Days |
GLUCOPHAGE 500MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:120 /30Days |
GLUCOPHAGE 850MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOPHAGE XR 500MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | Q:120 /30Days |
GLUCOPHAGE XR 750MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | Q:60 /30Days |
GLUCOTROL 10MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:120 /30Days |
GLUCOTROL 5MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
GLUCOTROL XL 10MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | Q:60 /30Days |
GLUCOTROL XL 2.5MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
GLUCOTROL XL 5MG TABLET SA |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
GLUCOVANCE 2.5/500MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:120 /30Days |
GLUCOVANCE 5/500MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:120 /30Days |
GLUMETZA ER 500 MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:60 /30Days |
GLYBURIDE 2.5MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Glyburide 6mg/1 500 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:60 /30Days |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLYBURIDE TABLETS |
1 |
Tier 1 |
$10.00 | $20.00 | Q:30 /30Days |
GLYBURIDE TABLETS |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | Q:120 /30Days |
GLYCOPYRROLATE 0.2MG/ML VL |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYNASE 1.5MG PRESTAB |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
GLYNASE PRESTAB TABLET 3MG (100 CT) |
3 |
Tier 3 |
$74.00 | $148.00 | Q:30 /30Days |
GLYNASE PRESTAB TABLET 6MG (100 CT) |
3 |
Tier 3 |
$74.00 | $148.00 | Q:60 /30Days |
GLYSET 100MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:90 /30Days |
GLYSET 25MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:90 /30Days |
GLYSET 50MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | Q:90 /30Days |
GOLYTELY PACKET 227.1 GM/2.82 GM |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
3 |
Tier 3 |
$74.00 | $148.00 | None |
Gralise 300mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | S Q:90 /30Days |
Gralise 600mg/1 90 TABLET, FILM COATED in 1 BOTTLE |
3 |
Tier 3 |
$74.00 | $148.00 | S Q:90 /30Days |
Gralise Starter Pack 1 KIT in 1 BLISTER PACK |
3 |
Tier 3 |
$74.00 | $148.00 | S Q:78 /30Days |
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 |
$10.00 | $20.00 | P |
Granisetron Hydrochloride 0.1mg/mL 10 VIAL, GLASS in 1 CARTON / 1 mL in 1 VIAL, GLASS |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Granisetron Hydrochloride 1mg/mL 10 VIAL, SINGLE-USE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-USE |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Granisol 2mg/10mL 1 BOTTLE, GLASS in 1 CARTON / 30 mL in 1 BOTTLE, GLASS |
1 |
Tier 1 |
$10.00 | $20.00 | P |
GRIFULVIN V 500MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GRIS-PEG 125MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GRIS-PEG 250 MG TABLET |
3 |
Tier 3 |
$74.00 | $148.00 | None |
GRISEOFULVIN ORAL SUSPENSION 125MG/5ML 4 FLOZ CTR |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GUANABENZ ACETATE 4MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GUANFACINE 1MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |
GUANFACINE 2MG TABLET (100 CT) |
1 |
Tier 1 |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GUANIDINE HCL 125MG TABLET |
1 |
Tier 1 |
$10.00 | $20.00 | None |