2015 Medicare Part D Plan Formulary Information |
Advocare Essence Rx (HMO-POS) (H5211-002-0)
Benefit Details
|
The Advocare Essence Rx (HMO-POS) (H5211-002-0) Formulary Drugs Starting with the Letter G in LANGLADE County, WI: CMS MA Region 14 which includes: WI Plan Monthly Premium: $77.00 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 |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GABAPENTIN 400 MG CAPSULE |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GABAPENTIN 600MG TABLET |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GABAPENTIN CAPSULES 300MG |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GABAPENTIN TABLET 800MG |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GABITRIL 2mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GABITRIL 4mg/1 |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 |
$19.00 | $57.00 | None |
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GamaSTAN S/D 0.165g/mL |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS per CARTON / 25 mL in 1 BOTTLE, GLASS |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAPLEX INJECTION 5 GM/100 ML |
5 |
Specialty Tier |
33% | N/A | P |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
3 |
Preferred Brand |
$45.00 | $135.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GANCICLOVIR 500MG VIAL FOR INJECTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Garamycin 0.3% eye drops |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GARDASIL VIAL |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GASTROCROM 100MG/5ML CONC |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid] |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GATTEX 5 MG ONE-VIAL KIT |
5 |
Specialty Tier |
33% | N/A | P |
GAVILYTE-C SOLUTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GAVILYTE-G SOLUTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GAVILYTE-N SOLUTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GELNIQUE 100mg/g 30 PACKET per CARTON / 1 g in 1 PACKET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GELNIQUE 3% GEL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GEMFIBROZIL TABLET 600MG (500 CT) |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENERESS FE CHEWABLE TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GENERLAC 10 GM/15 ML SOLUTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENGRAF 100MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | P |
GENGRAF 100MG/ML SOLUTION |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | P |
GENGRAF 25MG CAPSULE U.D. |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | P |
GENTAK 3MG/GM EYE OINTMENT |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN 100MG/NS 100ML |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN 10MG/ML VIAL |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gentamicin 3 mg/gm eye oint |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN 70MG/NS 50ML PB |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENTAMICIN 80MG/NS 50ML PB |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN 90MG/NS 100ML PB |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GEODON 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GEODON 20MG VIAL |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GEODON 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GEODON 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GEODON 80MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Gianvi 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GIAZO 180 GM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
gildagia 0.4 mg-0.035 mg tab |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gildess 1.5 mg-30 mcg tablet |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gildess 24 fe 1-20 Tablet |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Gilenya 0.5mg/1 28 CAPSULE per CARTON |
5 |
Specialty Tier |
33% | N/A | P |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
Glatopa 20 mg/ml syringe |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Specialty Tier |
33% | N/A | P |
GLEEVEC 400MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GLEOSTINE 10 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
GLEOSTINE 100 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
GLEOSTINE 40 MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Glipizide 5mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLIPIZIDE-METFORMIN 5-500 MG |
1 |
Preferred Generic |
$6.00 | $18.00 | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOPHAGE 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | 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 | $285.00 | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOTROL XL 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOTROL XL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOTROL XL 5MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUMETZA ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLUMETZA ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GLYNASE 1.5MG PRESTAB |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Glynase 3mg/1 1000 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Glynase 6mg/1 500 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYSET 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYSET 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYSET 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYXAMBI 10 MG-5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GLYXAMBI 25 MG-5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
GOLYTELY PACKET 227.1 GM/2.82 GM |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gralise 300mg/1 30 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Gralise 600mg/1 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Gralise Starter Pack 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | None |
Granisetron Hydrochloride 1mg/1 2 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | P |
GRIS-PEG 125MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
GRIS-PEG 250 MG TABLET |
3 |
Preferred Brand |
$45.00 | $135.00 | None |
Griseofulvin 125mg/5mL 120 mL in 1 BOTTLE |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
griseofulvin micro 500 mg tab |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
griseofulvin ultra 125 mg tab |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
griseofulvin ultra 250 mg tab |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
GUANFACINE 1MG TABLET |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GUANFACINE 2MG TABLET (100 CT) |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None |
guanidine hcl 125 mg tablet |
3 |
Preferred Brand |
$45.00 | $135.00 | None |