Q1Medicare.com 2015 Medicare Part D or Medicare Advantage Plan Formulary Browser

2015 Medicare Part D Plan Formulary Information
Humana Preferred Rx Plan (PDP) (S5884-134-0) Benefit Details
The Humana Preferred Rx Plan (PDP) (S5884-134-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 9 which includes: SC Plan Monthly Premium: $29.00 Deductible: $320 Qualifies for LIS: Yes
Drugs Starting with Letter G Drug Name	Drug Tier Information		Cost-Sharing		Drug Usage Mgmt
Drugs Starting with Letter G Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GABAPENTIN 100mg/1	2	Non-Preferred Generic	$2.00	$0.00	Q:270 /30Days
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE	3	Preferred Brand	20%	17%	None
GABAPENTIN 400 MG CAPSULE	2	Non-Preferred Generic	$2.00	$0.00	Q:270 /30Days
GABAPENTIN 600MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	Q:180 /30Days
GABAPENTIN CAPSULES 300MG	2	Non-Preferred Generic	$2.00	$0.00	Q:270 /30Days
GABAPENTIN TABLET 800MG	2	Non-Preferred Generic	$2.00	$0.00	Q:180 /30Days
Galantamine 12mg/1 60 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE	4	Non-Preferred Brand	35%	35%	Q:60 /30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT	4	Non-Preferred Brand	35%	35%	Q:30 /30Days
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE	4	Non-Preferred Brand	35%	35%	Q:200 /30Days
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS per CARTON / 25 mL in 1 BOTTLE, GLASS	5	Specialty Tier	25%	N/A	P
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS	4	Non-Preferred Brand	35%	35%	P
GANCICLOVIR 500MG VIAL FOR INJECTION	3	Preferred Brand	20%	17%	None
Garamycin 0.3% eye drops	3	Preferred Brand	20%	17%	None
GARDASIL 9 SYRINGE	4	Non-Preferred Brand	35%	35%	Q:2 /365Days
GARDASIL 9 VIAL	4	Non-Preferred Brand	35%	35%	Q:2 /365Days
GARDASIL SYRINGE	4	Non-Preferred Brand	35%	35%	Q:3 /365Days
GARDASIL VIAL	4	Non-Preferred Brand	35%	35%	Q:3 /365Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid]	4	Non-Preferred Brand	35%	35%	Q:3 /25Days
GATTEX 5 MG ONE-VIAL KIT	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GAVILYTE-C SOLUTION	2	Non-Preferred Generic	$2.00	$0.00	None
GAVILYTE-G SOLUTION	2	Non-Preferred Generic	$2.00	$0.00	None
GAVILYTE-N SOLUTION	2	Non-Preferred Generic	$2.00	$0.00	None
Gemcitabine Hydrochloride 1g/25mL 1 VIAL per CARTON / 25 mL in 1 VIAL	5	Specialty Tier	25%	N/A	None
GEMFIBROZIL TABLET 600MG (500 CT)	2	Non-Preferred Generic	$2.00	$0.00	Q:60 /30Days
GENERLAC 10 GM/15 ML SOLUTION	2	Non-Preferred Generic	$2.00	$0.00	None
GENGRAF 100MG CAPSULE U.D.	4	Non-Preferred Brand	35%	35%	P
GENGRAF 100MG/ML SOLUTION	4	Non-Preferred Brand	35%	35%	P
GENGRAF 25MG CAPSULE U.D.	4	Non-Preferred Brand	35%	35%	P
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	$2.00	$0.00	None
GENTAMICIN 100MG/NS 100ML	3	Preferred Brand	20%	17%	None
GENTAMICIN 10MG/ML VIAL	3	Preferred Brand	20%	17%	None
Gentamicin 3 mg/gm eye oint	3	Preferred Brand	20%	17%	None
GENTAMICIN 70MG/NS 50ML PB	3	Preferred Brand	20%	17%	None
GENTAMICIN 80MG/NS 50ML PB	3	Preferred Brand	20%	17%	None
GENTAMICIN 90MG/NS 100ML PB	3	Preferred Brand	20%	17%	None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE	3	Preferred Brand	20%	17%	None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE	1	Preferred Generic	$1.00	$0.00	None
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG	3	Preferred Brand	20%	17%	None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE	1	Preferred Generic	$1.00	$0.00	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	1	Preferred Generic	$1.00	$0.00	None
GEODON 20MG VIAL	4	Non-Preferred Brand	35%	35%	None
Gianvi 3 BLISTER PACK in 1 PACKAGE / 1 KIT per BLISTER PACK	4	Non-Preferred Brand	35%	35%	None
Gildess 1.5 mg-30 mcg tablet	4	Non-Preferred Brand	35%	35%	None
Gilenya 0.5mg/1 28 CAPSULE per CARTON	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GILOTRIF 20 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GILOTRIF 30 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GILOTRIF 40 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GLASSIA 1g/50mL 1 VIAL, GLASS per CARTON / 50 mL in 1 VIAL, GLASS	5	Specialty Tier	25%	N/A	P
GLEEVEC 100MG TABLET (90 CT)	5	Specialty Tier	25%	N/A	P Q:180 /30Days
GLEEVEC 400MG TABLET	5	Specialty Tier	25%	N/A	P Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLEOSTINE 10 MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
GLEOSTINE 100 MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
GLEOSTINE 40 MG CAPSULE	4	Non-Preferred Brand	35%	35%	None
GLIMEPIRIDE 1MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	None
GLIMEPIRIDE 2MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	None
GLIMEPIRIDE 4MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	None
GLIPIZIDE 10MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	None
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE	2	Non-Preferred Generic	$2.00	$0.00	None
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE	2	Non-Preferred Generic	$2.00	$0.00	None
Glipizide 5mg/1 500 TABLET BOTTLE	1	Preferred Generic	$1.00	$0.00	None
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC /	3	Preferred Brand	20%	17%	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR	2	Non-Preferred Generic	$2.00	$0.00	None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET	3	Preferred Brand	20%	17%	None
GLIPIZIDE-METFORMIN 5-500 MG	3	Preferred Brand	20%	17%	None
GLUCAGEN 1MG HYPOKIT	4	Non-Preferred Brand	35%	35%	None
GLUCAGON 1MG EMERGENCY KIT	3	Preferred Brand	20%	17%	None
GLYBURIDE 1.25MG TABLETS	2	Non-Preferred Generic	$2.00	$0.00	P
GLYBURIDE 2.5MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	P
GLYBURIDE 5MG TABLETS	1	Preferred Generic	$1.00	$0.00	P
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC	1	Preferred Generic	$1.00	$0.00	P
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)	2	Non-Preferred Generic	$2.00	$0.00	P
GLYBURIDE MICRO 3MG TABLET (100 CT)	1	Preferred Generic	$1.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)	2	Non-Preferred Generic	$2.00	$0.00	P
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
GLYCOPYRROLATE 0.2MG/ML VL	3	Preferred Brand	20%	17%	None
GLYCOPYRROLATE TABLET 1MG (100 CT)	3	Preferred Brand	20%	17%	None
GLYCOPYRROLATE TABLET 2MG (100 CT)	3	Preferred Brand	20%	17%	None
GLYSET 100MG TABLET	4	Non-Preferred Brand	35%	35%	None
GLYSET 25MG TABLET	4	Non-Preferred Brand	35%	35%	None
GLYSET 50MG TABLET	4	Non-Preferred Brand	35%	35%	None
GOLYTELY PACKET 227.1 GM/2.82 GM	3	Preferred Brand	20%	17%	None
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM	3	Preferred Brand	20%	17%	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	4	Non-Preferred Brand	35%	35%	None
Granisetron Hydrochloride 1mg/1 2 TABLET BOTTLE	4	Non-Preferred Brand	35%	35%	P Q:28 /28Days
Granisetron Hydrochloride 1mg/mL 10 VIAL, SINGLE-USE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-USE	4	Non-Preferred Brand	35%	35%	Q:4 /28Days
GRANIX 300 MCG/0.5 ML SYRINGE	5	Specialty Tier	25%	N/A	P Q:14 /28Days
GRANIX 480 MCG/0.8 ML SYRINGE	5	Specialty Tier	25%	N/A	P Q:14 /28Days
GRIS-PEG 125MG TABLET	4	Non-Preferred Brand	35%	35%	None
GRIS-PEG 250 MG TABLET	4	Non-Preferred Brand	35%	35%	None
griseofulvin ultra 125 mg tab	4	Non-Preferred Brand	35%	35%	None
griseofulvin ultra 250 mg tab	4	Non-Preferred Brand	35%	35%	None
GUANFACINE 1MG TABLET	2	Non-Preferred Generic	$2.00	$0.00	P
GUANFACINE 2MG TABLET (100 CT)	2	Non-Preferred Generic	$2.00	$0.00	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
guanidine hcl 125 mg tablet	3	Preferred Brand	20%	17%	None

Chart Legend:

Below are a few notes to help you understand the above 2015 Medicare Part D Humana Preferred Rx Plan (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 $320 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 $2960) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2016 Humana Walmart-Preferred Rx Plan the cost-sharing 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 September 2015 )

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.