2014 Medicare Part D Plan Formulary Information |
Kaiser Permanente Senior Advantage Essential (HMO) (H1230-005-0)
Benefit Details
|
The Kaiser Permanente Senior Advantage Essential (HMO) (H1230-005-0) Formulary Drugs Starting with the Letter G in HAWAII County, HI: CMS MA Region 25 which includes: HI Plan Monthly Premium: $33.00 Deductible: $0 |
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 |
$33.00 | $66.00 | None |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GABAPENTIN 400 MG CAPSULE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GABAPENTIN 600MG TABLET |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GABAPENTIN CAPSULES 300MG |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GABAPENTIN TABLET 800MG |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GABITRIL 2mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GABITRIL 4mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gablofen 2000ug/mL 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gablofen 500ug/mL 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gablofen 50ug/mL 1 mL in 1 SYRINGE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Galantamine 12mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GamaSTAN S/D 0.165g/mL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS per CARTON / 25 mL in 1 BOTTLE, GLASS |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
GAMMAPLEX INJECTION 5 GM/100 ML |
3 |
Preferred Brand |
$45.00 | $90.00 | P |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
GANCICLOVIR 500MG VIAL FOR INJECTION |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GARDASIL VIAL |
6 |
Vaccines |
$0.00 | N/A | None |
GASTROCROM 100MG/5ML CONC |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid] |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GATTEX 5 MG ONE-VIAL KIT |
5 |
Specialty Tier |
25% | 25% | 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 |
$33.00 | $66.00 | 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 |
$33.00 | $66.00 | 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 |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GELNIQUE 100mg/g 30 PACKET per CARTON / 1 g in 1 PACKET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GELNIQUE 3% GEL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gemcitabine Hydrochloride 1g/25mL 1 VIAL per CARTON / 25 mL in 1 VIAL |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GEMFIBROZIL TABLET 600MG (500 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GEMZAR 1GRAM VIAL |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENERESS FE CHEWABLE TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENERLAC 10 GM/15 ML SOLUTION |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENGRAF 100MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | P |
GENGRAF 100MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | P |
GENGRAF 25MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | P |
GENOTROPIN 13.8MG CARTRIDGE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN 5 MG CARTRIDGE |
5 |
Specialty Tier |
25% | 25% | None |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 0.4MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 0.6MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 0.8MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 1.2MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 1.4MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 1.6MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 1.8MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 1MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GENOTROPIN MINIQUICK 2MG |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAK 3MG/GM EYE OINTMENT |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN 100MG/NS 100ML |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN 10MG/ML VIAL |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Gentamicin 3 mg/gm eye oint |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN 70MG/NS 50ML PB |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN 80MG/NS 50ML PB |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN 90MG/NS 100ML PB |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GEODON 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GEODON 20MG VIAL |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
GEODON 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GEODON 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GEODON 80MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gianvi 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GIAZO 180 GM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
gildagia 0.4 mg-0.035 mg tab |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Gilenya 0.5mg/1 28 CAPSULE per CARTON |
5 |
Specialty Tier |
25% | 25% | None |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
GLASSIA 1g/50mL 1 VIAL, GLASS per CARTON / 50 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
25% | 25% | None |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Specialty Tier |
25% | 25% | None |
GLEEVEC 400MG TABLET |
5 |
Specialty Tier |
25% | 25% | None |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLIPIZIDE 5 MG TABLET |
1 |
Preferred Generic |
$10.00 | $20.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLIPIZIDE-METFORMIN 5-500 MG |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOPHAGE 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOPHAGE XR 750MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOTROL XL 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOTROL XL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOTROL XL 5MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUMETZA ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLUMETZA ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYBURIDE 1.25MG TABLETS |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE 2.5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE 5MG TABLETS |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYCOPYRROLATE 0.2MG/ML VL |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYNASE 1.5MG PRESTAB |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYNASE PRESTAB TABLET 3MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYNASE PRESTAB TABLET 6MG (100 CT) |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYSET 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYSET 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GLYSET 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GOLYTELY PACKET 227.1 GM/2.82 GM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gralise 300mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gralise 600mg/1 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Gralise Starter Pack 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Granisetron HCl 0.1 mg/ml vial |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GRANISETRON HCL 1MG TABLET (20 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | P |
Granisetron Hydrochloride 1mg/mL 10 VIAL, SINGLE-USE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-USE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Granisol 2mg/10mL 1 BOTTLE, GLASS per CARTON / 30 mL in 1 BOTTLE, GLASS |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | P |
GRANIX 300 MCG/0.5 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | None |
GRANIX 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
25% | 25% | None |
GRASTEK 2;800 BAU SL TABLET |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GRIS-PEG 125MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
GRIS-PEG 250 MG TABLET |
3 |
Preferred Brand |
$45.00 | $90.00 | None |
Griseofulvin 125mg/5mL 120 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
griseofulvin micro 500 mg tab |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
griseofulvin ultra 125 mg tab |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
griseofulvin ultra 250 mg tab |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GUANFACINE 1MG TABLET |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
GUANFACINE 2MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |
guanidine hcl 125 mg tablet |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None |
GYNAZOLE-1 2% CREAM |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None |