2017 Medicare Part D Plan Formulary Information |
Group Health Cooperative Essential (HMO) (H5050-009-0)
Benefit Details
|
The Group Health Cooperative Essential (HMO) (H5050-009-0) Formulary Drugs Starting with the Letter G in Grays Harbor County, WA: CMS MA Region 23 which includes: WA Plan Monthly Premium: $129.00 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 |
$4.00 | N/A | None |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
2 |
Generic |
$20.00 | N/A | None |
GABAPENTIN 400 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GABAPENTIN 600MG TABLET |
1 |
Preferred Generic |
$4.00 | N/A | None |
GABAPENTIN CAPSULES 300MG |
1 |
Preferred Generic |
$4.00 | N/A | None |
GABAPENTIN TABLET 800MG |
1 |
Preferred Generic |
$4.00 | N/A | None |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GABITRIL 2mg/1 |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GABITRIL 4mg/1 |
4 |
Non-Preferred Brand |
$95.00 | N/A | 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 | N/A | P |
Gablofen 500ug/mL 20 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Gablofen 50ug/mL 1 mL in 1 SYRINGE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
Galantamine 12mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GALANTAMINE ER 8 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GAMASTAN S-D 10 ML |
3 |
Preferred Brand |
$45.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAMASTAN S-D 2 ML |
3 |
Preferred Brand |
$45.00 | N/A | P |
GamaSTAN S/D 0.165g/mL |
3 |
Preferred Brand |
$45.00 | N/A | P |
GAMMAGARD LIQUID 100mg/mL 1 BOTTLE, GLASS per CARTON / 25 mL in 1 BOTTLE, GLASS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GAMMAGARD S-D 10 G (IGA<1) SOL |
3 |
Preferred Brand |
$45.00 | N/A | None |
GAMMAGARD S-D 5 G (IGA<1) SOLN |
3 |
Preferred Brand |
$45.00 | N/A | None |
GAMMAKED 1 GRAM/10 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GAMMAPLEX 10 GRAM/100 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
GAMMAPLEX 20 GRAM/200 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
GAMMAPLEX 5 GRAM/50 ML VIAL |
4 |
Non-Preferred Brand |
$95.00 | 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 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GANCICLOVIR 500MG VIAL FOR INJECTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
GARDASIL 9 SYRINGE |
3 |
Preferred Brand |
$45.00 | N/A | None |
GARDASIL 9 VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
GASTROCROM 100 MG/5 ML CONC |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid] |
1 |
Preferred Generic |
$4.00 | N/A | None |
GATTEX 5 MG ONE-VIAL KIT |
5 |
Specialty Tier |
33% | N/A | P Q:30 /30Days |
GAVILYTE-C SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
GAVILYTE-G SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
GAVILYTE-H AND BISACODYL KIT |
2 |
Generic |
$20.00 | N/A | None |
GAVILYTE-N SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
GELNIQUE 100mg/g 30 PACKET per CARTON / 1 g in 1 PACKET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gemcitabine Hydrochloride 1g/25mL 1 VIAL per CARTON / 25 mL in 1 VIAL |
1 |
Preferred Generic |
$4.00 | N/A | None |
GEMFIBROZIL TABLET 600MG (500 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GEMZAR 1GRAM VIAL |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GENERESS FE CHEWABLE TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GENERLAC 10 GM/15 ML SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | None |
GENGRAF 100 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | P |
GENGRAF 100MG/ML SOLUTION |
1 |
Preferred Generic |
$4.00 | N/A | P |
GENGRAF 25 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | P |
GENGRAF 50 MG CAPSULE |
1 |
Preferred Generic |
$4.00 | N/A | P |
GENOTROPIN 13.8MG CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN 5 MG CARTRIDGE |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Non-Preferred Brand |
$95.00 | N/A | P |
GENOTROPIN MINIQUICK 0.4MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 0.6MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 0.8MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 1.2MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 1.4MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 1.6MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 1.8MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 1MG |
5 |
Specialty Tier |
33% | N/A | P |
GENOTROPIN MINIQUICK 2MG |
5 |
Specialty Tier |
33% | N/A | P |
GENTAK 3MG/GM EYE OINTMENT |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gentamicin 10 mg/ml vial |
1 |
Preferred Generic |
$4.00 | N/A | None |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
1 |
Preferred Generic |
$4.00 | N/A | None |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
1 |
Preferred Generic |
$4.00 | N/A | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT |
1 |
Preferred Generic |
$4.00 | N/A | None |
GENVOYA TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GEODON 20MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GEODON 20MG VIAL |
3 |
Preferred Brand |
$45.00 | N/A | None |
GEODON 40MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GEODON 60MG CAPSULE |
4 |
Non-Preferred Brand |
$95.00 | N/A | 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 | N/A | None |
Gianvi 3 mg-0.02 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
GIAZO 180 GM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
gildagia 0.4 mg-0.035 mg tab |
1 |
Preferred Generic |
$4.00 | N/A | None |
GILENYA 0.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | Q:30 /30Days |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GLASSIA 1g/50mL 1 VIAL, GLASS per CARTON / 50 mL in 1 VIAL, GLASS |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Glatopa 20 mg/ml syringe |
5 |
Specialty Tier |
33% | N/A | None |
GLEEVEC 100MG TABLET (90 CT) |
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 400 MG TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GLEOSTINE 10 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLEOSTINE 100 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLEOSTINE 40 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLEOSTINE 5 MG CAPSULE |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLIMEPIRIDE 1MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIMEPIRIDE 2MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIMEPIRIDE 4MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIPIZIDE 10MG TABLET (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$4.00 | N/A | 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 |
$4.00 | N/A | None |
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / |
2 |
Generic |
$20.00 | N/A | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
GLIPIZIDE-METFORMIN 5-500 MG |
2 |
Generic |
$20.00 | N/A | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLUCAGON 1MG EMERGENCY KIT |
3 |
Preferred Brand |
$45.00 | N/A | None |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOPHAGE 500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Brand |
$95.00 | N/A | 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 | N/A | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOTROL XL 10 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOTROL XL 2.5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOTROL XL 5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | S |
GLUMETZA ER 1,000 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLUMETZA ER 500 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet [Glucovance] |
2 |
Generic |
$20.00 | N/A | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE 1.25MG TABLETS |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE 2.5MG TABLET (100 CT) |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE 5MG TABLETS |
2 |
Generic |
$20.00 | N/A | S |
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT) |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET [Glucovance] |
2 |
Generic |
$20.00 | N/A | S |
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET [Glucovance] |
2 |
Generic |
$20.00 | N/A | S |
GLYCOPYRROLATE 0.2MG/ML VL |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
1 |
Preferred Generic |
$4.00 | N/A | 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 | N/A | S |
Glynase 3mg/1 1000 TABLET BOTTLE, PLASTIC |
4 |
Non-Preferred Brand |
$95.00 | N/A | S |
GLYNASE 6 MG PRESTAB |
4 |
Non-Preferred Brand |
$95.00 | N/A | S |
GLYSET 100MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLYSET 25MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLYSET 50MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLYXAMBI 10 MG-5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GLYXAMBI 25 MG-5 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GOLYTELY PACKET 227.1 GM/2.82 GM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GONITRO 0.4 MG SUBLINGUAL PWD |
1 |
Preferred Generic |
$4.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gralise 600 MG 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GRALISE ER 300 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Gralise Starter Pack 1 KIT per BLISTER PACK |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Granisetron HCl 0.1 mg/ml vial |
2 |
Generic |
$20.00 | N/A | None |
Granisetron hcl 1 mg/ml vial |
2 |
Generic |
$20.00 | N/A | None |
Granisetron hcl 1 mg/ml vial |
2 |
Generic |
$20.00 | N/A | None |
Granisetron Hydrochloride 1mg/1 2 TABLET BOTTLE |
2 |
Generic |
$20.00 | N/A | P |
GRANIX 300 MCG/0.5 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
GRANIX 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | None |
GRASTEK 2;800 BAU SL TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GRIS-PEG 125MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GRIS-PEG 250 MG TABLET |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |
GRISEOFULVIN 125 MG/5 ML SUSP |
1 |
Preferred Generic |
$4.00 | N/A | None |
griseofulvin micro 500 mg tab |
1 |
Preferred Generic |
$4.00 | N/A | None |
griseofulvin ultra 125 mg tab |
1 |
Preferred Generic |
$4.00 | N/A | None |
griseofulvin ultra 250 mg tab |
1 |
Preferred Generic |
$4.00 | N/A | None |
GUANFACINE 1MG TABLET |
2 |
Generic |
$20.00 | N/A | None |
GUANFACINE 2MG TABLET (100 CT) |
2 |
Generic |
$20.00 | N/A | None |
Guanfacine hcl er 1 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
Guanfacine hcl er 2 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
Guanfacine hcl er 3 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
Guanfacine hcl er 4 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
guanidine hcl 125 mg tablet |
2 |
Generic |
$20.00 | N/A | None |
GYNAZOLE-1 2% CREAM |
4 |
Non-Preferred Brand |
$95.00 | N/A | None |