2019 Medicare Part D Plan Formulary Information |
AdvantraOne (PPO) (H5522-017-0)
Benefit Details
|
The AdvantraOne (PPO) (H5522-017-0) Formulary Drugs Starting with the Letter G in Monroe County, PA: CMS MA Region 6 which includes: PA Plan Monthly Premium: $0.00 Deductible: $395 |
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 | $136.00 | Q:90 /30Days |
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:2160 /30Days |
GABAPENTIN 300 MG CAPSULE [Neurontin] |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days |
GABAPENTIN 400 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days |
GABAPENTIN 600 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:180 /30Days |
GABAPENTIN 800 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days |
GABITRIL 12 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GABITRIL 16mg/1 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GABITRIL 2mg/1 |
5 |
Specialty Tier |
25% | N/A | None |
GABITRIL 4mg/1 |
5 |
Specialty Tier |
25% | 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 | $300.00 | Q:200 /30Days |
GALANTAMINE ER 16 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
GALANTAMINE ER 24 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
GALANTAMINE ER 8 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days |
GALANTAMINE HBR 12 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
GALANTAMINE HBR 4 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
GALANTAMINE HBR 8 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days |
GAMMAGARD LIQUID 10% VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAGARD S-D 10 G (IGA<1) SOL |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAGARD S-D 5 G (IGA<1) SOLN |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAKED 1 GRAM/10 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAMMAPLEX 10 GRAM/100 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAPLEX 20 GRAM/200 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAPLEX 5 GRAM/50 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GAMMAPLEX INJECTION 5 GM/100 ML |
5 |
Specialty Tier |
25% | N/A | P |
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS |
5 |
Specialty Tier |
25% | N/A | P |
GARDASIL 9 SYRINGE |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GARDASIL 9 VIAL |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GATTEX 5 MG 30-VIAL KIT |
5 |
Specialty Tier |
25% | N/A | P |
GAVILYTE-C SOLUTION |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GAVILYTE-G SOLUTION |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GAVILYTE-N SOLUTION |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GEMFIBROZIL 600 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | None |
GENERLAC 10 GM/15 ML SOLUTION |
2* |
Generic |
$10.00 | $25.00 | None |
GENGRAF 100 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $136.00 | P |
GENGRAF 100MG/ML SOLUTION |
3* |
Preferred Brand |
$47.00 | $136.00 | P |
GENGRAF 25 MG CAPSULE |
3* |
Preferred Brand |
$47.00 | $136.00 | P |
GENOTROPIN 13.8MG CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN 5 MG CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 0.2MG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
GENOTROPIN MINIQUICK 0.4MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 0.6MG |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GENOTROPIN MINIQUICK 0.8MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 1.2MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 1.4MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 1.6MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 1.8MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 1MG |
5 |
Specialty Tier |
25% | N/A | P |
GENOTROPIN MINIQUICK 2MG |
5 |
Specialty Tier |
25% | N/A | P |
GENTAK 3MG/GM EYE OINTMENT |
2* |
Generic |
$10.00 | $25.00 | None |
GENTAMICIN 3 MG/ML EYE DROPS |
2* |
Generic |
$10.00 | $25.00 | 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 | $300.00 | None |
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GENVOYA TABLET |
5 |
Specialty Tier |
25% | N/A | None |
GEODON 20MG VIAL |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /3Days |
GIANVI 3 MG-0.02 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GILENYA 0.5 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:28 /28Days |
GILOTRIF 20 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
GILOTRIF 30 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
GILOTRIF 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
GLATIRAMER 20 MG/ML SYRINGE [Copaxone] |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
GLATIRAMER 40 MG/ML SYRINGE [Copaxone] |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Glatopa 20 mg/ml syringe |
5 |
Specialty Tier |
25% | N/A | P Q:30 /30Days |
GLATOPA 40 MG/ML SYRINGE [Glatopa] |
5 |
Specialty Tier |
25% | N/A | P Q:12 /28Days |
GLEOSTINE 10 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GLEOSTINE 100 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GLEOSTINE 40 MG CAPSULE |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GLIMEPIRIDE 1 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIMEPIRIDE 2 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIMEPIRIDE 4 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE 10 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE 5 MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLIPIZIDE ER 10 MG TABLET ER 24 [Glucotrol XL] |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE-METFORMIN 2.5-250 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE-METFORMIN 2.5-500MG TABLET |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLIPIZIDE-METFORMIN 5-500 MG |
1* |
Preferred Generic |
$0.00 | $0.00 | None |
GLUCAGEN 1MG HYPOKIT |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GLUCAGON 1MG EMERGENCY KIT |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GLYBURID-METFORMIN 1.25-250 MG [Glucovance] |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE 1.25MG TABLETS |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE 2.5MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $25.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GLYBURIDE 5 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE MICRO 1.5 MG TAB |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE MICRO 3MG TABLET (100 CT) |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE MICRO 6 MG TABLET |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE-METFORMIN 2.5-500 MG |
2* |
Generic |
$10.00 | $25.00 | P |
GLYBURIDE-METFORMIN 5-500 MG |
2* |
Generic |
$10.00 | $25.00 | P |
GLYCOPYRROLATE TABLET 1MG (100 CT) |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GLYCOPYRROLATE TABLET 2MG (100 CT) |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GOLYTELY PACKET 227.1 GM/2.82 GM |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM |
3* |
Preferred Brand |
$47.00 | $136.00 | None |
GRANISETRON HCL 1 MG TABLET |
3* |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
GRANIX 300 MCG/0.5 ML SAFE SYR |
5 |
Specialty Tier |
25% | N/A | P |
GRANIX 300 MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GRANIX 480 MCG/0.8 ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
GRANIX 480 MCG/1.6 ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
GRISEOFULVIN 125 MG/5 ML SUSP |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GRISEOFULVIN MICRO 500 MG TAB |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GRISEOFULVIN ULTRA 250 MG TABLET [Gris-Peg] |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |
GUANFACINE 1 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
GUANFACINE 2 MG TABLET |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P |
Guanfacine hcl er 1 mg tablet |
3* |
Preferred Brand |
$47.00 | $136.00 | 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 |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:30 /30Days |
Guanfacine hcl er 3 mg tablet |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:30 /30Days |
Guanfacine hcl er 4 mg tablet |
3* |
Preferred Brand |
$47.00 | $136.00 | Q:30 /30Days |
guanidine hcl 125 mg tablet |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None |