2018 Medicare Part D Plan Formulary Information |
Anthem MediBlue Access Basic (Regional PPO) (R5941-015-0)
Benefit Details
|
The Anthem MediBlue Access Basic (Regional PPO) (R5941-015-0) Formulary Drugs Starting with the Letter G in Statewide County, KY: CMS MA Region 13 which includes: IN KY Plan Monthly Premium: $61.40 Deductible: $100 |
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 100 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | Q:1080 /30Days |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
4 |
Non-Preferred Drug |
46% | N/A | Q:2160 /30Days |
GABAPENTIN 300 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | Q:360 /30Days |
GABAPENTIN 400 MG CAPSULE |
2* |
Generic |
$15.00 | N/A | Q:270 /30Days |
GABAPENTIN 600 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:180 /30Days |
GABAPENTIN 800 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:120 /30Days |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | None |
GABITRIL 16mg/1 |
5 |
Specialty Tier |
31% | N/A | None |
GALANTAMINE 4 MG/ML ORAL SOLN |
3 |
Preferred Brand |
$42.00 | N/A | Q:180 /30Days |
GALANTAMINE ER 16 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GALANTAMINE ER 24 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
GALANTAMINE ER 8 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | Q:30 /30Days |
GALANTAMINE HBR 12 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
GALANTAMINE HBR 4 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
GALANTAMINE HBR 8 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
31% | N/A | P |
GANCICLOVIR 500MG VIAL FOR INJECTION |
3 |
Preferred Brand |
$42.00 | N/A | P |
GARDASIL 9 SYRINGE |
3 |
Preferred Brand |
$42.00 | N/A | None |
GARDASIL 9 VIAL |
3 |
Preferred Brand |
$42.00 | N/A | None |
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid] |
4 |
Non-Preferred Drug |
46% | N/A | None |
GATTEX 5 MG 30-VIAL KIT |
5 |
Specialty Tier |
31% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAVILYTE-C SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
GAVILYTE-G SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
GAVILYTE-N SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
GEMCITABINE HCL 1 GRAM VIAL |
5 |
Specialty Tier |
31% | N/A | P |
GEMFIBROZIL 600 MG TABLET |
2* |
Generic |
$15.00 | N/A | None |
GENERLAC 10 GM/15 ML SOLUTION |
2* |
Generic |
$15.00 | N/A | None |
GENGRAF 100 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | P |
GENGRAF 100MG/ML SOLUTION |
4 |
Non-Preferred Drug |
46% | N/A | P |
GENGRAF 25 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | P |
GENTAK 3MG/GM EYE OINTMENT |
2* |
Generic |
$15.00 | N/A | None |
GENTAMICIN 3 MG/ML EYE DROPS |
2* |
Generic |
$15.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE |
3 |
Preferred Brand |
$42.00 | N/A | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
3 |
Preferred Brand |
$42.00 | N/A | None |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
3 |
Preferred Brand |
$42.00 | N/A | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
3 |
Preferred Brand |
$42.00 | N/A | None |
GENVOYA TABLET |
5 |
Specialty Tier |
31% | N/A | Q:30 /30Days |
GEODON 20MG VIAL |
4 |
Non-Preferred Drug |
46% | N/A | Q:6 /28Days |
GIANVI 3 MG-0.02 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | None |
GILENYA 0.5 MG CAPSULE |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLATIRAMER 20 MG/ML SYRINGE [Copaxone] |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
GLATIRAMER 40 MG/ML SYRINGE [Copaxone] |
5 |
Specialty Tier |
31% | N/A | P Q:12 /28Days |
Glatopa 20 mg/ml syringe |
5 |
Specialty Tier |
31% | N/A | P Q:30 /30Days |
GLATOPA 40 MG/ML SYRINGE [Glatopa] |
5 |
Specialty Tier |
31% | N/A | P Q:12 /28Days |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Specialty Tier |
31% | N/A | P Q:240 /30Days |
GLEEVEC 400 MG TABLET |
5 |
Specialty Tier |
31% | N/A | P Q:60 /30Days |
GLEOSTINE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | P |
GLEOSTINE 100 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | P |
GLEOSTINE 40 MG CAPSULE |
4 |
Non-Preferred Drug |
46% | N/A | P |
GLIMEPIRIDE 1 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:240 /30Days |
GLIMEPIRIDE 2 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:120 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIMEPIRIDE 4 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:60 /30Days |
GLIPIZIDE 10 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:120 /30Days |
GLIPIZIDE 5 MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:240 /30Days |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
6* |
Select Care Drugs |
$0.00 | N/A | Q:120 /30Days |
GLIPIZIDE ER 10 MG TABLET ER 24 [Glucotrol XL] |
6* |
Select Care Drugs |
$0.00 | N/A | Q:60 /30Days |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
6* |
Select Care Drugs |
$0.00 | N/A | Q:240 /30Days |
GLIPIZIDE-METFORMIN 2.5-250 MG |
6* |
Select Care Drugs |
$0.00 | N/A | Q:240 /30Days |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
6* |
Select Care Drugs |
$0.00 | N/A | Q:120 /30Days |
GLIPIZIDE-METFORMIN 5-500 MG |
6* |
Select Care Drugs |
$0.00 | N/A | Q:120 /30Days |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$42.00 | N/A | None |
GLUCAGON 1MG EMERGENCY KIT |
4 |
Non-Preferred Drug |
46% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
GLUCOPHAGE 500 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:150 /30Days |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:90 /30Days |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Drug |
46% | N/A | Q:120 /30Days |
GLUCOPHAGE XR 750MG TABLET SA |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
Glucose 50 MG/ML / Potassium Chloride 0.01 MEQ/ML / Sodium Chloride 0.0769 MEQ/ML Injectable Solutio |
4 |
Non-Preferred Drug |
46% | N/A | None |
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution |
4 |
Non-Preferred Drug |
46% | N/A | None |
Glucose 50 MG/ML / Potassium Chloride 0.04 MEQ/ML / Sodium Chloride 0.0769 MEQ/ML Injectable Solutio |
4 |
Non-Preferred Drug |
46% | N/A | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:120 /30Days |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:240 /30Days |
GLUCOTROL XL 10 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLUCOTROL XL 2.5 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:240 /30Days |
GLUCOTROL XL 5 MG TABLET ER 24 |
4 |
Non-Preferred Drug |
46% | N/A | Q:120 /30Days |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:120 /30Days |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:120 /30Days |
GLUMETZA ER 1,000 MG TABLET |
5 |
Specialty Tier |
31% | N/A | Q:60 /30Days |
GLUMETZA ER 500 MG TABLET TABERGR24H |
5 |
Specialty Tier |
31% | N/A | Q:120 /30Days |
GLYBURID-METFORMIN 1.25-250 MG [Glucovance] |
2* |
Generic |
$15.00 | N/A | P Q:240 /30Days |
GLYBURIDE 1.25MG TABLETS |
2* |
Generic |
$15.00 | N/A | P Q:480 /30Days |
GLYBURIDE 2.5MG TABLET (100 CT) |
2* |
Generic |
$15.00 | N/A | P Q:240 /30Days |
GLYBURIDE 5 MG TABLET |
2* |
Generic |
$15.00 | N/A | P Q:120 /30Days |
GLYBURIDE MICRO 1.5 MG TAB |
2* |
Generic |
$15.00 | N/A | P Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
2* |
Generic |
$15.00 | N/A | P Q:120 /30Days |
GLYBURIDE MICRO 6 MG TABLET |
2* |
Generic |
$15.00 | N/A | P Q:60 /30Days |
GLYBURIDE-METFORMIN 2.5-500 MG |
2* |
Generic |
$15.00 | N/A | P Q:120 /30Days |
GLYBURIDE-METFORMIN 5-500 MG |
2* |
Generic |
$15.00 | N/A | P Q:120 /30Days |
GLYCOPYRROLATE 4 MG/20 ML VIAL |
4 |
Non-Preferred Drug |
46% | N/A | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
3 |
Preferred Brand |
$42.00 | N/A | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
3 |
Preferred Brand |
$42.00 | N/A | None |
GLYSET 100MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:90 /30Days |
GLYSET 25MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:360 /30Days |
GLYSET 50MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | Q:180 /30Days |
Granisetron 1 MG/ML Injectable Solution |
4 |
Non-Preferred Drug |
46% | N/A | 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 Drug |
46% | N/A | None |
GRANISETRON HCL 1 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
Granisetron hcl 1 mg/ml vial |
4 |
Non-Preferred Drug |
46% | N/A | None |
GRIS-PEG 250 MG TABLET |
4 |
Non-Preferred Drug |
46% | N/A | None |
GRISEOFULVIN 125 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
46% | N/A | None |
GRISEOFULVIN MICRO 500 MG TAB |
4 |
Non-Preferred Drug |
46% | N/A | None |
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg] |
4 |
Non-Preferred Drug |
46% | N/A | None |
GRISEOFULVIN ULTRA 250 MG Tablet [Gris-Peg] |
4 |
Non-Preferred Drug |
46% | N/A | None |
GUANFACINE 1 MG TABLET |
2* |
Generic |
$15.00 | N/A | P |
GUANFACINE 2 MG TABLET |
2* |
Generic |
$15.00 | N/A | P |
Guanfacine hcl er 1 mg tablet |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Guanfacine hcl er 2 mg tablet |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
Guanfacine hcl er 3 mg tablet |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
Guanfacine hcl er 4 mg tablet |
4 |
Non-Preferred Drug |
46% | N/A | P Q:30 /30Days |
guanidine hcl 125 mg tablet |
4 |
Non-Preferred Drug |
46% | N/A | None |