2018 Medicare Part D Plan Formulary Information |
Advantra Option 1 (HMO-POS) (H2663-006-0)
Benefit Details
|
The Advantra Option 1 (HMO-POS) (H2663-006-0) Formulary Drugs Starting with the Letter G in Clinton County, IL: CMS MA Region 14 which includes: IL Plan Monthly Premium: $41.00 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 100 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | Q:180 /30Days |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
3 |
Preferred Brand |
$47.00 | N/A | Q:2160 /30Days |
GABAPENTIN 300 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | Q:180 /30Days |
GABAPENTIN 400 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | Q:270 /30Days |
GABAPENTIN 600 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:180 /30Days |
GABAPENTIN 800 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:120 /30Days |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GABITRIL 2mg/1 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GABITRIL 4mg/1 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GALANTAMINE 4 MG/ML ORAL SOLN |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:200 /30Days |
GALANTAMINE ER 16 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:30 /30Days |
GALANTAMINE ER 24 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:30 /30Days |
GALANTAMINE ER 8 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:30 /30Days |
GALANTAMINE HBR 12 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:60 /30Days |
GALANTAMINE HBR 4 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:60 /30Days |
GALANTAMINE HBR 8 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:60 /30Days |
GAMASTAN ASD S/D VL 2 ML |
3 |
Preferred Brand |
$47.00 | N/A | P |
GAMASTAN S-D 10 ML |
3 |
Preferred Brand |
$47.00 | N/A | P |
GAMMAGARD LIQUID 10% VIAL |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAGARD S-D 10 G (IGA<1) SOL |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAMMAGARD S-D 5 G (IGA<1) SOLN |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAKED 1 GRAM/10 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAPLEX 10 GRAM/100 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAPLEX 20 GRAM/200 ML VIAL |
5 |
Specialty Tier |
33% | N/A | P |
GAMMAPLEX 5 GRAM/50 ML VIAL |
5 |
Specialty Tier |
33% | 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 |
5 |
Specialty Tier |
33% | N/A | P |
GANCICLOVIR 500MG VIAL FOR INJECTION |
3 |
Preferred Brand |
$47.00 | N/A | P |
GARDASIL 9 SYRINGE |
3 |
Preferred Brand |
$47.00 | N/A | None |
GARDASIL 9 VIAL |
3 |
Preferred Brand |
$47.00 | N/A | None |
GASTROCROM 100 MG/5 ML CONC |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
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 Drug |
$100.00 | N/A | None |
GATTEX 5 MG 30-VIAL KIT |
5 |
Specialty Tier |
33% | N/A | P |
GAVILYTE-C SOLUTION |
2 |
Generic |
$7.00 | N/A | None |
GAVILYTE-G SOLUTION |
2 |
Generic |
$7.00 | N/A | None |
GAVILYTE-N SOLUTION |
2 |
Generic |
$7.00 | N/A | None |
GELNIQUE 100mg/g 30 PACKET per CARTON / 1 g in 1 PACKET |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:30 /30Days |
GEMCITABINE HCL 1 GRAM VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GEMFIBROZIL 600 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
GENERLAC 10 GM/15 ML SOLUTION |
2 |
Generic |
$7.00 | N/A | None |
GENGRAF 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GENGRAF 100MG/ML SOLUTION |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENGRAF 25 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | 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 |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Non-Preferred Drug |
$100.00 | 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 |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
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 |
2 |
Generic |
$7.00 | N/A | None |
GENTAMICIN 3 MG/ML EYE DROPS |
2 |
Generic |
$7.00 | 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 |
$100.00 | N/A | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
3 |
Preferred Brand |
$47.00 | N/A | None |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
3 |
Preferred Brand |
$47.00 | N/A | None |
GENVOYA TABLET |
5 |
Specialty Tier |
33% | N/A | None |
GEODON 20MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | S Q:60 /30Days |
GEODON 20MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:6 /3Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GEODON 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | S Q:60 /30Days |
GEODON 60MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | S Q:60 /30Days |
GEODON 80MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | S Q:60 /30Days |
GIANVI 3 MG-0.02 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
GIAZO 180 GM |
5 |
Specialty Tier |
33% | N/A | None |
GILENYA 0.5 MG CAPSULE |
5 |
Specialty Tier |
33% | N/A | P Q:28 /28Days |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
33% | N/A | P |
GLEEVEC 100MG TABLET (90 CT) |
5 |
Specialty Tier |
33% | N/A | P Q:90 /30Days |
GLEEVEC 400 MG TABLET |
5 |
Specialty Tier |
33% | 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 Drug |
$100.00 | N/A | None |
GLEOSTINE 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLEOSTINE 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLIMEPIRIDE 1 MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIMEPIRIDE 2 MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIMEPIRIDE 4 MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE 10 MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE 5 MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE ER 10 MG TABLET ER 24 [Glucotrol XL] |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1 |
Preferred Generic |
$3.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIPIZIDE-METFORMIN 2.5-250 MG |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLIPIZIDE-METFORMIN 5-500 MG |
1 |
Preferred Generic |
$3.00 | N/A | None |
GLUCAGEN 1MG HYPOKIT |
3 |
Preferred Brand |
$47.00 | N/A | None |
GLUCAGON 1MG EMERGENCY KIT |
3 |
Preferred Brand |
$47.00 | N/A | None |
GLUCOPHAGE 1000MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOPHAGE 500 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOPHAGE 850MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOPHAGE XR 500MG TABLET SA |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOPHAGE XR 750MG TABLET SA |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Glucose 50 MG/ML / Potassium Chloride 0.01 MEQ/ML / Sodium Chloride 0.0769 MEQ/ML Injectable Solutio |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution |
4 |
Non-Preferred Drug |
$100.00 | 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 |
$100.00 | N/A | None |
GLUCOTROL 10MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOTROL 5MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOTROL XL 10 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOTROL XL 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOTROL XL 5 MG TABLET ER 24 |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLUCOVANCE 2.5/500MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GLUCOVANCE 5/500MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GLYBURID-METFORMIN 1.25-250 MG [Glucovance] |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE 1.25MG TABLETS |
2 |
Generic |
$7.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE 2.5MG TABLET (100 CT) |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE 5 MG TABLET |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE MICRO 1.5 MG TAB |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE MICRO 6 MG TABLET |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE-METFORMIN 2.5-500 MG |
2 |
Generic |
$7.00 | N/A | P |
GLYBURIDE-METFORMIN 5-500 MG |
2 |
Generic |
$7.00 | N/A | P |
GLYCOPYRROLATE 4 MG/20 ML VIAL |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
3 |
Preferred Brand |
$47.00 | N/A | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
3 |
Preferred Brand |
$47.00 | N/A | None |
GLYNASE 1.5MG PRESTAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYNASE 3 MG PRESTAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GLYNASE 6 MG PRESTAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GOLYTELY PACKET 227.1 GM/2.82 GM |
3 |
Preferred Brand |
$47.00 | N/A | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
3 |
Preferred Brand |
$47.00 | N/A | None |
Gralise 600 MG 90 FILM COATED TABLETS in BOTTLE |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GRALISE ER 300 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Gralise Starter Pack 1 KIT per BLISTER PACK |
4 |
Non-Preferred Drug |
$100.00 | N/A | Q:156 /365Days |
GRANISETRON HCL 1 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | P Q:60 /30Days |
GRANIX 300 MCG/0.5 ML SAFE SYR |
5 |
Specialty Tier |
33% | N/A | P |
GRANIX 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
33% | N/A | P |
GRISEOFULVIN 125 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GRISEOFULVIN MICRO 500 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GRISEOFULVIN ULTRA 250 MG Tablet [Gris-Peg] |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |
GUANFACINE 1 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
GUANFACINE 2 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | N/A | P |
Guanfacine hcl er 1 mg tablet |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
Guanfacine hcl er 2 mg tablet |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
Guanfacine hcl er 3 mg tablet |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
Guanfacine hcl er 4 mg tablet |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
guanidine hcl 125 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | N/A | None |