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2019 Medicare Part D and Medicare Advantage Plan Formulary Browser

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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PDP     MAPD
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SilverScript Plus (PDP) (S5601-025-0)
Tier 1 (119)
Tier 2 (430)
Tier 3 (1064)
Tier 4 (919)
Tier 5 (549)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
  *required
 
Cick on the first letter of your drug name to browse the formulary:

A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2019 Medicare Part D Plan Formulary Information
SilverScript Plus (PDP) (S5601-025-0)
Benefit Details           
The SilverScript Plus (PDP) (S5601-025-0)
Formulary Drugs Starting with the Letter G

in CMS PDP Region 12 which includes: AL TN
Plan Monthly Premium: $49.50 Deductible: $0 Qualifies for LIS: No
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 $5.00$0.00Q:1080
/30Days
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE   4 Non-Preferred Drug 40%40%Q:2160
/30Days
GABAPENTIN 300 MG CAPSULE [Neurontin]   2 Generic $5.00$0.00Q:360
/30Days
GABAPENTIN 400 MG CAPSULE   2 Generic $5.00$0.00Q:270
/30Days
GABAPENTIN 600 MG TABLET   2 Generic $5.00$0.00Q:180
/30Days
GABAPENTIN 800 MG TABLET   2 Generic $5.00$0.00Q:120
/30Days
GALANTAMINE 4 MG/ML ORAL SOLN   4 Non-Preferred Drug 40%40%None
GALANTAMINE ER 16 MG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
GALANTAMINE ER 24 MG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
GALANTAMINE ER 8 MG CAPSULE   4 Non-Preferred Drug 40%40%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GALANTAMINE HBR 12 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
GALANTAMINE HBR 4 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
GALANTAMINE HBR 8 MG TABLET   4 Non-Preferred Drug 40%40%Q:60
/30Days
GAMMAGARD LIQUID 10% VIAL   5 Specialty Tier 33%N/AP
GAMMAGARD S-D 10 G (IGA<1) SOL   5 Specialty Tier 33%N/AP
GAMMAGARD S-D 5 G (IGA<1) SOLN   5 Specialty Tier 33%N/AP
GAMMAKED 1 GRAM/10 ML VIAL   5 Specialty Tier 33%N/AP
GAMMAPLEX 10 GRAM/100 ML VIAL   5 Specialty Tier 33%N/AP
GAMMAPLEX 20 GRAM/200 ML VIAL   5 Specialty Tier 33%N/AP
GAMMAPLEX 5 GRAM/50 ML VIAL   5 Specialty Tier 33%N/AP
GAMMAPLEX INJECTION 5 GM/100 ML   5 Specialty Tier 33%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Gamunex-C 10g/100mL 10 mL in 1 VIAL, GLASS   5 Specialty Tier 33%N/AP
GARDASIL 9 SYRINGE   4 Non-Preferred Drug 40%40%None
GARDASIL 9 VIAL   4 Non-Preferred Drug 40%40%None
GATTEX 5 MG 30-VIAL KIT   5 Specialty Tier 33%N/AP
GAVILYTE-C SOLUTION   2 Generic $5.00$0.00None
GAVILYTE-G SOLUTION   2 Generic $5.00$0.00None
GAVILYTE-N SOLUTION   2 Generic $5.00$0.00None
GEMFIBROZIL 600 MG TABLET   2 Generic $5.00$0.00None
GENERLAC 10 GM/15 ML SOLUTION   2 Generic $5.00$0.00None
GENGRAF 100 MG CAPSULE   4 Non-Preferred Drug 40%40%P
GENGRAF 100MG/ML SOLUTION   4 Non-Preferred Drug 40%40%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 40%40%P
GENOTROPIN 13.8MG CARTRIDGE   5 Specialty Tier 33%N/AP
GENOTROPIN 5 MG CARTRIDGE   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 0.2MG   3 Preferred Brand $35.00$87.50P
GENOTROPIN MINIQUICK 0.4MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 0.6MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 0.8MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 1.2MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 1.4MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 1.6MG   5 Specialty Tier 33%N/AP
GENOTROPIN MINIQUICK 1.8MG   5 Specialty Tier 33%N/AP
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/AP
GENOTROPIN MINIQUICK 2MG   5 Specialty Tier 33%N/AP
GENTAK 3MG/GM EYE OINTMENT   2 Generic $5.00$0.00None
GENTAMICIN 3 MG/ML EYE DROPS   3 Preferred Brand $35.00$87.50None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE   4 Non-Preferred Drug 40%40%None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE   3 Preferred Brand $35.00$87.50None
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG   4 Non-Preferred Drug 40%40%None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE   3 Preferred Brand $35.00$87.50None
GENVOYA TABLET   5 Specialty Tier 33%N/ANone
GEODON 20MG VIAL   4 Non-Preferred Drug 40%40%Q:6
/3Days
GIANVI 3 MG-0.02 MG TABLET   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GILENYA 0.5 MG CAPSULE   5 Specialty Tier 33%N/AP Q:28
/28Days
GILOTRIF 20 MG TABLET   5 Specialty Tier 33%N/AP
GILOTRIF 30 MG TABLET   5 Specialty Tier 33%N/AP
GILOTRIF 40 MG TABLET   5 Specialty Tier 33%N/AP
GLEOSTINE 10 MG CAPSULE   4 Non-Preferred Drug 40%40%None
GLEOSTINE 100 MG CAPSULE   4 Non-Preferred Drug 40%40%None
GLEOSTINE 40 MG CAPSULE   4 Non-Preferred Drug 40%40%None
GLIMEPIRIDE 1 MG TABLET   1 Preferred Generic $1.00$0.00Q:240
/30Days
GLIMEPIRIDE 2 MG TABLET   1 Preferred Generic $1.00$0.00Q:120
/30Days
GLIMEPIRIDE 4 MG TABLET   1 Preferred Generic $1.00$0.00Q:60
/30Days
GLIPIZIDE 10 MG TABLET   1 Preferred Generic $1.00$0.00Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLIPIZIDE 5 MG TABLET   1 Preferred Generic $1.00$0.00Q:240
/30Days
GLIPIZIDE 5MG TABLETS EXTENDED RELEASE   2 Generic $5.00$0.00Q:120
/30Days
GLIPIZIDE ER 10 MG TABLET ER 24 [Glucotrol XL]   2 Generic $5.00$0.00Q:60
/30Days
GLIPIZIDE ER 2.5MG TABLET SR OSMOTIC PUSH 24HR   2 Generic $5.00$0.00Q:240
/30Days
GLIPIZIDE-METFORMIN 2.5-250 MG   3 Preferred Brand $35.00$87.50Q:240
/30Days
GLIPIZIDE-METFORMIN 2.5-500MG TABLET   3 Preferred Brand $35.00$87.50Q:120
/30Days
GLIPIZIDE-METFORMIN 5-500 MG   3 Preferred Brand $35.00$87.50Q:120
/30Days
GLUCAGEN 1MG HYPOKIT   3 Preferred Brand $35.00$87.50None
GLUCAGON 1MG EMERGENCY KIT   3 Preferred Brand $35.00$87.50None
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution   4 Non-Preferred Drug 40%40%None
GLYCOPYRROLATE TABLET 1MG (100 CT)   3 Preferred Brand $35.00$87.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GLYCOPYRROLATE TABLET 2MG (100 CT)   3 Preferred Brand $35.00$87.50None
GOLYTELY PACKET 227.1 GM/2.82 GM   3 Preferred Brand $35.00$87.50None
GOLYTELY SOLUTION 236 GM/2.97 GM/6 GM   3 Preferred Brand $35.00$87.50None
GRANISETRON HCL 1 MG TABLET   4 Non-Preferred Drug 40%40%P
GRANIX 300 MCG/0.5 ML SAFE SYR   5 Specialty Tier 33%N/AP
GRANIX 300 MCG/ML VIAL   5 Specialty Tier 33%N/AP
GRANIX 480 MCG/0.8 ML SYRINGE   5 Specialty Tier 33%N/AP
GRANIX 480 MCG/1.6 ML VIAL   5 Specialty Tier 33%N/AP
GRISEOFULVIN 125 MG/5 ML SUSP   3 Preferred Brand $35.00$87.50None
GRISEOFULVIN MICRO 500 MG TAB   4 Non-Preferred Drug 40%40%None
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg]   4 Non-Preferred Drug 40%40%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
GRISEOFULVIN ULTRA 250 MG TABLET [Gris-Peg]   4 Non-Preferred Drug 40%40%None
Guanfacine hcl er 1 mg tablet   3 Preferred Brand $35.00$87.50P
Guanfacine hcl er 2 mg tablet   3 Preferred Brand $35.00$87.50P
Guanfacine hcl er 3 mg tablet   3 Preferred Brand $35.00$87.50P
Guanfacine hcl er 4 mg tablet   3 Preferred Brand $35.00$87.50P

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D SilverScript Plus (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). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • 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 $415 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 five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs. *Some Part D plans exclude one or more drug tiers from the deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier 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 $3820) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.
    • 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 2019 )

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.









Tips & Disclaimers
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  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    Statement required by Medicare:
    "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.