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2017 Medicare Part D Plan Formulary Information
Anthem Blue MedicareRx Standard (PDP) (S5596-017-0) Benefit Details
The Anthem Blue MedicareRx Standard (PDP) (S5596-017-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 15 which includes: IN KY Plan Monthly Premium: $65.00 Deductible: $400 Qualifies for LIS: No
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	Generic	$5.00	N/A	Q:1080 /30Days
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE	4	Non-Preferred Drug	40%	N/A	Q:2160 /30Days
GABAPENTIN 400 MG CAPSULE	2	Generic	$5.00	N/A	Q:270 /30Days
GABAPENTIN 600MG TABLET	2	Generic	$5.00	N/A	Q:180 /30Days
GABAPENTIN CAPSULES 300MG	2	Generic	$5.00	N/A	Q:360 /30Days
GABAPENTIN TABLET 800MG	2	Generic	$5.00	N/A	Q:120 /30Days
GABITRIL 12 MG TABLET	4	Non-Preferred Drug	40%	N/A	None
GABITRIL 16mg/1	5	Specialty Tier	25%	N/A	None
Galantamine 12mg/1 60 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$32.00	N/A	Q:60 /30Days
Galantamine 4mg/1 60 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$32.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Galantamine 8mg/1 60 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	$32.00	N/A	Q:60 /30Days
GALANTAMINE ER 8 MG CAPSULE	3	Preferred Brand	$32.00	N/A	Q:30 /30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 16MG 30 BOT	3	Preferred Brand	$32.00	N/A	Q:30 /30Days
GALANTAMINE HYDROBROMIDE CAPSULES EXTENDED RELEASE 24MG 30 BOT	3	Preferred Brand	$32.00	N/A	Q:30 /30Days
Galantamine Hydrobromide Oral Solution 4mg/mL 100 mL in 1 BOTTLE	4	Non-Preferred Drug	40%	N/A	Q:180 /30Days
GamaSTAN S/D 0.165g/mL	3	Preferred Brand	$32.00	N/A	P
GANCICLOVIR 500MG VIAL FOR INJECTION	3	Preferred Brand	$32.00	N/A	P
GARDASIL 9 SYRINGE	3	Preferred Brand	$32.00	N/A	None
GARDASIL 9 VIAL	3	Preferred Brand	$32.00	N/A	None
GATTEX 5 MG ONE-VIAL KIT	5	Specialty Tier	25%	N/A	None
GAVILYTE-C SOLUTION	1*	Preferred Generic	$1.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GAVILYTE-G SOLUTION	2	Generic	$5.00	N/A	None
GAVILYTE-H AND BISACODYL KIT	3	Preferred Brand	$32.00	N/A	None
GAVILYTE-N SOLUTION	2	Generic	$5.00	N/A	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	Generic	$5.00	N/A	None
GENERLAC 10 GM/15 ML SOLUTION	2	Generic	$5.00	N/A	None
GENGRAF 100 MG CAPSULE	3	Preferred Brand	$32.00	N/A	P
GENGRAF 100MG/ML SOLUTION	3	Preferred Brand	$32.00	N/A	P
GENGRAF 25 MG CAPSULE	3	Preferred Brand	$32.00	N/A	P
GENGRAF 50 MG CAPSULE	3	Preferred Brand	$32.00	N/A	P
GENTAK 3MG/GM EYE OINTMENT	2	Generic	$5.00	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	4	Non-Preferred Drug	40%	N/A	None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE	4	Non-Preferred Drug	40%	N/A	None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE	2	Generic	$5.00	N/A	None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE	2	Generic	$5.00	N/A	None
GENTAMICIN SULFATE OPHTHALMIC SOLUTION 0.3% 5ML BOT	1*	Preferred Generic	$1.00	N/A	None
GENVOYA TABLET	5	Specialty Tier	25%	N/A	Q:30 /30Days
GEODON 20MG VIAL	4	Non-Preferred Drug	40%	N/A	None
gildagia 0.4 mg-0.035 mg tab	3	Preferred Brand	$32.00	N/A	None
GILENYA 0.5 MG CAPSULE	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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GILOTRIF 40 MG TABLET	5	Specialty Tier	25%	N/A	P Q:30 /30Days
Glatopa 20 mg/ml syringe	5	Specialty Tier	25%	N/A	P Q:30 /30Days
GLEOSTINE 10 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	P
GLEOSTINE 100 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	P
GLEOSTINE 40 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	P
GLEOSTINE 5 MG CAPSULE	4	Non-Preferred Drug	40%	N/A	P
GLIMEPIRIDE 1MG TABLET (100 CT)	6*	Select Care Drugs	$0.00	N/A	Q:240 /30Days
GLIMEPIRIDE 2MG TABLET (100 CT)	6*	Select Care Drugs	$0.00	N/A	Q:120 /30Days
GLIMEPIRIDE 4MG TABLET (100 CT)	6*	Select Care Drugs	$0.00	N/A	Q:60 /30Days
GLIPIZIDE 10MG TABLET (100 CT)	6*	Select Care Drugs	$0.00	N/A	Q:120 /30Days
GLIPIZIDE 10MG TABLETS EXTENDED RELEASE	6*	Select Care Drugs	$0.00	N/A	Q:60 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE	6*	Select Care Drugs	$0.00	N/A	Q:120 /30Days
Glipizide 5mg/1 500 TABLET BOTTLE	6*	Select Care Drugs	$0.00	N/A	Q:240 /30Days
Glipizide and Metformin Hydrochloride 2.5; 250mg/1; mg/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC /	2	Generic	$5.00	N/A	Q:240 /30Days
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR	6*	Select Care Drugs	$0.00	N/A	Q:240 /30Days
GLIPIZIDE-METFORMIN 2.5-500MG TABLET	2	Generic	$5.00	N/A	Q:120 /30Days
GLIPIZIDE-METFORMIN 5-500 MG	2	Generic	$5.00	N/A	Q:120 /30Days
GLUCAGEN 1MG HYPOKIT	3	Preferred Brand	$32.00	N/A	None
GLUCAGON 1MG EMERGENCY KIT	4	Non-Preferred Drug	40%	N/A	None
Glyburide 1.25 MG / Metformin hydrochloride 250 MG Oral Tablet [Glucovance]	2	Generic	$5.00	N/A	P Q:240 /30Days
GLYBURIDE 1.25MG TABLETS	4	Non-Preferred Drug	40%	N/A	P Q:480 /30Days
GLYBURIDE 2.5MG TABLET (100 CT)	4	Non-Preferred Drug	40%	N/A	P Q:240 /30Days
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GLYBURIDE 5MG TABLETS	4	Non-Preferred Drug	40%	N/A	P Q:120 /30Days
Glyburide 6mg/1 500 TABLET BOTTLE, PLASTIC	4	Non-Preferred Drug	40%	N/A	P Q:60 /30Days
GLYBURIDE MICRO 3MG TABLET (100 CT)	4	Non-Preferred Drug	40%	N/A	P Q:120 /30Days
GLYBURIDE MICRONIZED 1.5MG TABLET (100 CT)	2	Generic	$5.00	N/A	P Q:240 /30Days
GLYBURIDE-METFORMIN HCL 2.5-500MG TABLET [Glucovance]	4	Non-Preferred Drug	40%	N/A	P Q:120 /30Days
GLYBURIDE-METFORMIN HCL 5MG-500MG TABLET [Glucovance]	4	Non-Preferred Drug	40%	N/A	P Q:120 /30Days
Granisetron HCl 0.1 mg/ml vial	4	Non-Preferred Drug	40%	N/A	None
Granisetron hcl 1 mg/ml vial	4	Non-Preferred Drug	40%	N/A	None
Granisetron hcl 1 mg/ml vial	4	Non-Preferred Drug	40%	N/A	None
Granisetron Hydrochloride 1mg/1 2 TABLET BOTTLE	3	Preferred Brand	$32.00	N/A	P Q:30 /30Days
GRISEOFULVIN 125 MG/5 ML SUSP	2	Generic	$5.00	N/A	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
griseofulvin ultra 125 mg tab	3	Preferred Brand	$32.00	N/A	None
griseofulvin ultra 250 mg tab	3	Preferred Brand	$32.00	N/A	None
GUANFACINE 1MG TABLET	4	Non-Preferred Drug	40%	N/A	P
GUANFACINE 2MG TABLET (100 CT)	4	Non-Preferred Drug	40%	N/A	P
Guanfacine hcl er 1 mg tablet	3	Preferred Brand	$32.00	N/A	P Q:30 /30Days
Guanfacine hcl er 2 mg tablet	3	Preferred Brand	$32.00	N/A	P Q:30 /30Days
Guanfacine hcl er 3 mg tablet	3	Preferred Brand	$32.00	N/A	P Q:30 /30Days
Guanfacine hcl er 4 mg tablet	3	Preferred Brand	$32.00	N/A	P Q:30 /30Days
guanidine hcl 125 mg tablet	3	Preferred Brand	$32.00	N/A	None

Chart Legend:

Below are a few notes to help you understand the above 2017 Medicare Part D Anthem Blue MedicareRx Standard (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 $400 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 $3700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2017 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 2017 )

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.