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EnvisionRxPlus Silver (PDP) (S7694-002-0)
Tier 1 (1093)
Tier 2 (448)
Tier 3 (1101)
Tier 4 (432)

Requires Prior Authorization:
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Uses Step Therapy:
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Has Quantity Limits:
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Cick on the first letter of your drug name to browse the formulary:

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2016 Medicare Part D Plan Formulary Information
EnvisionRxPlus Silver (PDP) (S7694-002-0)
Benefit Details           
The EnvisionRxPlus Silver (PDP) (S7694-002-0)
Formulary Drugs Starting with the Letter G

in CMS PDP Region 2 which includes: CT MA RI VT
Plan Monthly Premium: $33.30 Deductible: $360 Qualifies for LIS: No
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   3 Non-Preferred Brand 40%40%Q:270
/30Days
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
GABAPENTIN 400 MG CAPSULE   3 Non-Preferred Brand 40%40%Q:270
/30Days
GABAPENTIN 600MG TABLET   3 Non-Preferred Brand 40%40%Q:180
/30Days
GABAPENTIN CAPSULES 300MG   3 Non-Preferred Brand 40%40%Q:270
/30Days
GABAPENTIN TABLET 800MG   3 Non-Preferred Brand 40%40%Q:180
/30Days
GABITRIL 12 MG TABLET   3 Non-Preferred Brand 40%40%S
GABITRIL 16mg/1   3 Non-Preferred Brand 40%40%S
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT   1 Generic $2.00$6.00None
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT   1 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 8MG 30 BOT   1 Generic $2.00$6.00None
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE   3 Non-Preferred Brand 40%40%None
GamaSTAN S/D 0.165g/mL   3 Non-Preferred Brand 40%40%P
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS per CARTON / 25 mL in 1 BOTTLE, GLASS   4 Specialty Tier 25%N/AP
GANCICLOVIR 500MG VIAL FOR INJECTION   4 Specialty Tier 25%N/AP
GARDASIL 9 SYRINGE   3 Non-Preferred Brand 40%40%None
GARDASIL 9 VIAL   3 Non-Preferred Brand 40%40%None
GARDASIL SYRINGE   3 Non-Preferred Brand 40%40%None
GARDASIL VIAL   3 Non-Preferred Brand 40%40%Q:3
/365Days
GATTEX 5 MG ONE-VIAL KIT   4 Specialty Tier 25%N/ANone
GAVILYTE-C SOLUTION   3 Non-Preferred Brand 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GAVILYTE-G SOLUTION   1 Generic $2.00$6.00None
GAVILYTE-N SOLUTION   1 Generic $2.00$6.00None
Gemcitabine Hydrochloride 1g/25mL 1 VIAL per CARTON / 25 mL in 1 VIAL   2 Preferred Brand 12%12%None
GEMFIBROZIL TABLET 600MG (500 CT)   1 Generic $2.00$6.00Q:60
/30Days
GENERLAC 10 GM/15 ML SOLUTION   1 Generic $2.00$6.00None
GENGRAF 100 MG CAPSULE   2 Preferred Brand 12%12%P
GENGRAF 100MG/ML SOLUTION   2 Preferred Brand 12%12%P
GENGRAF 25 MG CAPSULE   1 Generic $2.00$6.00P
GENTAK 3MG/GM EYE OINTMENT   1 Generic $2.00$6.00None
GENTAMICIN 100MG/NS 100ML   1 Generic $2.00$6.00None
GENTAMICIN 10MG/ML VIAL   1 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GENTAMICIN 70MG/NS 50ML PB   1 Generic $2.00$6.00None
GENTAMICIN 80MG/NS 50ML PB   1 Generic $2.00$6.00None
GENTAMICIN 90MG/NS 100ML PB   1 Generic $2.00$6.00None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE   1 Generic $2.00$6.00None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   1 Generic $2.00$6.00None
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG   1 Generic $2.00$6.00None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   3 Non-Preferred Brand 40%40%None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT   3 Non-Preferred Brand 40%40%None
GENVOYA TABLET   4 Specialty Tier 25%N/ANone
GEODON 20MG VIAL   3 Non-Preferred Brand 40%40%S
GILENYA 0.5 MG CAPSULE   4 Specialty Tier 25%N/AQ:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GILOTRIF 20 MG TABLET   4 Specialty Tier 25%N/AP Q:30
/30Days
GILOTRIF 30 MG TABLET   4 Specialty Tier 25%N/AP Q:30
/30Days
GILOTRIF 40 MG TABLET   4 Specialty Tier 25%N/AP Q:30
/30Days
GLEEVEC 100MG TABLET (90 CT)   4 Specialty Tier 25%N/AP Q:180
/30Days
GLEEVEC 400 MG TABLET   4 Specialty Tier 25%N/AP Q:60
/30Days
GLEOSTINE 5 MG CAPSULE   3 Non-Preferred Brand 40%40%P
GLIMEPIRIDE 1MG TABLET (100 CT)   1 Generic $2.00$6.00None
GLIMEPIRIDE 2MG TABLET (100 CT)   1 Generic $2.00$6.00None
GLIMEPIRIDE 4MG TABLET (100 CT)   1 Generic $2.00$6.00None
GLIPIZIDE 10MG TABLET (100 CT)   1 Generic $2.00$6.00None
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE   1 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE   1 Generic $2.00$6.00None
Glipizide 5mg/1 500 TABLET BOTTLE   1 Generic $2.00$6.00None
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC /   1 Generic $2.00$6.00None
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   1 Generic $2.00$6.00None
GLIPIZIDE-METFORMIN 2.5-500MG TABLET   1 Generic $2.00$6.00None
GLIPIZIDE-METFORMIN 5-500 MG   1 Generic $2.00$6.00None
GLUCAGEN 1MG HYPOKIT   2 Preferred Brand 12%12%None
GLYBURIDE 1.25MG TABLETS   3 Non-Preferred Brand 40%40%P
GLYBURIDE 2.5MG TABLET (100 CT)   3 Non-Preferred Brand 40%40%P
GLYBURIDE 5MG TABLETS   3 Non-Preferred Brand 40%40%P
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC   1 Generic $2.00$6.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYBURIDE AND METFORMIN HCL 1.25-250MG TABLET (100 CT)   1 Generic $2.00$6.00P
GLYBURIDE MICRO 3MG TABLET (100 CT)   1 Generic $2.00$6.00P
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)   1 Generic $2.00$6.00P
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET   3 Non-Preferred Brand 40%40%P
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET   3 Non-Preferred Brand 40%40%P
Granisetron HCl 0.1 mg/ml vial   1 Generic $2.00$6.00P Q:60
/30Days
Granisetron Hydrochloride 1mg/1 2 TABLET BOTTLE   2 Preferred Brand 12%12%Q:60
/30Days
Granisetron Hydrochloride 1mg/mL 10 VIAL, SINGLE-USE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-USE   1 Generic $2.00$6.00P Q:60
/30Days
GUANFACINE 1MG TABLET   1 Generic $2.00$6.00None
GUANFACINE 2MG TABLET (100 CT)   1 Generic $2.00$6.00None
Guanfacine hcl er 1 mg tablet   1 Generic $2.00$6.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Guanfacine hcl er 2 mg tablet   1 Generic $2.00$6.00None
Guanfacine hcl er 3 mg tablet   1 Generic $2.00$6.00None
Guanfacine hcl er 4 mg tablet   1 Generic $2.00$6.00None
guanidine hcl 125 mg tablet   3 Non-Preferred Brand 40%40%None

Chart Legend:

Below are a few notes to help you understand the above 2016 Medicare Part D EnvisionRxPlus Silver (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 $360 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 $3310) 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 2016 )

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.