2013 Medicare Part D Plan Formulary Information |
Health Net Violet Option 1 (PPO) (H5520-004-0)
Benefit Details
|
The Health Net Violet Option 1 (PPO) (H5520-004-0) Formulary Drugs Starting with the Letter G in DOUGLAS County, OR: CMS MA Region 23 which includes: OR
|
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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GABAPENTIN 400 MG CAPSULE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GABAPENTIN 600MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GABAPENTIN CAPSULES 300MG |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GABAPENTIN TABLET 800MG |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GABITRIL 2mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GABITRIL 4mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Galantamine 12mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GamaSTAN S/D 0.165g/mL |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | P |
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS in 1 CARTON / 25 mL in 1 BOTTLE, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
GAMMAPLEX INJECTION 5 GM/100 ML |
5 |
Specialty Tier |
33% | 33% | P |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GANCICLOVIR FOR INJECTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GARDASIL VIAL |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | 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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | 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 |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | 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. |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GELNIQUE 100mg/g 30 PACKET in 1 CARTON / 1 g in 1 PACKET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GELNIQUE 3% GEL |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Gemcitabine Hydrochloride 1g/25mL 1 VIAL in 1 CARTON / 25 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GEMFIBROZIL TABLET 600MG (500 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
GEMZAR 1GRAM VIAL |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GENERESS FE CHEWABLE TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENERLAC 10 GM/15 ML SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENGRAF 100MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
GENGRAF 100MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
GENGRAF 25MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
GENOTROPIN 13.8MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN 5 MG CARTRIDGE |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GENOTROPIN MINIQUICK 0.4MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 0.6MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 0.8MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 1.2MG |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 1.4MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 1.6MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 1.8MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 1MG |
5 |
Specialty Tier |
33% | 33% | None |
GENOTROPIN MINIQUICK 2MG |
5 |
Specialty Tier |
33% | 33% | None |
GENTAK 3MG/GM EYE OINTMENT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENTAMICIN 100MG/NS 100ML |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENTAMICIN 10MG/ML VIAL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENTAMICIN 80MG/NS 50ML PB |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GEODON 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GEODON 20MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GEODON 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GEODON 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GEODON 80MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Gianvi 3 BLISTER PACK in 1 PACKAGE / 1 KIT in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
gildagia 0.4 mg-0.035 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Gilenya 0.5mg/1 28 CAPSULE in 1 CARTON |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLASSIA 1g/50mL 1 VIAL, GLASS in 1 CARTON / 50 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Specialty Tier |
33% | 33% | None |
GLEEVEC 400MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:2 /1Days |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:2 /1Days |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:2 /1Days |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | None |
GLIPIZIDE 5MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | Q:4 /1Days |
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Glipizide and Metformin Hydrochloride 5; 500mg/1; mg/1 100 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:2 /1Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIPIZIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLIPIZIDE TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:2 /1Days |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOPHAGE 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOPHAGE XR 750MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:4 /1Days |
GLUCOTROL XL 10MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUCOTROL XL 2.5MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:2 /1Days |
GLUCOTROL XL 5MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:2 /1Days |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | P |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | P |
GLUMETZA ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLUMETZA ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLYBURIDE 2.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GLYBURIDE TABLETS |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GLYBURIDE TABLETS |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
GLYCOPYRROLATE 0.2MG/ML VL |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GLYNASE 1.5MG PRESTAB |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLYNASE PRESTAB TABLET 3MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYNASE PRESTAB TABLET 6MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GLYSET 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:3 /1Days |
GLYSET 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:3 /1Days |
GLYSET 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:3 /1Days |
GOLYTELY PACKET 227.1 GM/2.82 GM |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Gralise 300mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Gralise 600mg/1 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
Gralise Starter Pack 1 KIT in 1 BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None |
GRANISETRON HCL 1MG TABLET (20 CT) |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P |
granisetron hydrochloride 0.1mg/mL 1 VIAL, SINGLE-USE in 1 CARTON / 1 mL in 1 VIAL, SINGLE-USE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Granisetron Hydrochloride 1mg/mL 10 VIAL, SINGLE-USE in 1 TRAY / 1 mL in 1 VIAL, SINGLE-USE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Grifulvin V 500mg/1 100 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GRIS-PEG 125MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
GRIS-PEG 250 MG TABLET |
3 |
Preferred Brand |
$42.00 | $84.00 | None |
Griseofulvin 125mg/5mL 120 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
griseofulvin micro 500 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
griseofulvin ultra 125 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
griseofulvin ultra 250 mg tab |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |
GUANFACINE 1MG TABLET |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
GUANFACINE 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$3.00 | $6.00 | P |
guanidine hcl 125 mg tablet |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None |