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2019 Medicare Part D Plan Formulary Information
Blue Rx PDP Plus (PDP) (S5593-002-0) Benefit Details
The Blue Rx PDP Plus (PDP) (S5593-002-0) Formulary Drugs Starting with the Letter G in CMS PDP Region 6 which includes: PA WV Plan Monthly Premium: $84.70 Deductible: $415 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 100 MG CAPSULE	2	Generic	$7.00	$17.50	P
Gabapentin 250mg/5mL 470 mL in 1 BOTTLE	2	Generic	$7.00	$17.50	P
GABAPENTIN 300 MG CAPSULE [Neurontin]	2	Generic	$7.00	$17.50	P
GABAPENTIN 400 MG CAPSULE	2	Generic	$7.00	$17.50	P
GABAPENTIN 600 MG TABLET	2	Generic	$7.00	$17.50	P
GABAPENTIN 800 MG TABLET	2	Generic	$7.00	$17.50	P
GALAFOLD 123 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:14 /28Days
GALANTAMINE 4 MG/ML ORAL SOLN	2	Generic	$7.00	$17.50	None
GALANTAMINE ER 16 MG CAPSULE	2	Generic	$7.00	$17.50	None
GALANTAMINE ER 24 MG CAPSULE	2	Generic	$7.00	$17.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GALANTAMINE ER 8 MG CAPSULE	2	Generic	$7.00	$17.50	None
GALANTAMINE HBR 12 MG TABLET	2	Generic	$7.00	$17.50	None
GALANTAMINE HBR 4 MG TABLET	2	Generic	$7.00	$17.50	None
GALANTAMINE HBR 8 MG TABLET	2	Generic	$7.00	$17.50	None
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	4	Non-Preferred Drug	40%	40%	P
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
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
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	20%	20%	None
GARDASIL 9 VIAL	3	Preferred Brand	20%	20%	None
GATIFLOXACIN 0.5% EYE DROPS [Zymar, Zymaxid]	2	Generic	$7.00	$17.50	None
GATTEX 5 MG 30-VIAL KIT	5	Specialty Tier	25%	N/A	P
GAVILYTE-C SOLUTION	2	Generic	$7.00	$17.50	None
GAVILYTE-G SOLUTION	2	Generic	$7.00	$17.50	None
GAVILYTE-N SOLUTION	2	Generic	$7.00	$17.50	None
GELNIQUE 10% GEL PUMP GEL MD PMP	4	Non-Preferred Drug	40%	40%	Q:30 /30Days
GEMFIBROZIL 600 MG TABLET	2	Generic	$7.00	$17.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GENERLAC 10 GM/15 ML SOLUTION	2	Generic	$7.00	$17.50	None
GENGRAF 100 MG CAPSULE	2	Generic	$7.00	$17.50	P
GENGRAF 100MG/ML SOLUTION	2	Generic	$7.00	$17.50	P
GENGRAF 25 MG CAPSULE	2	Generic	$7.00	$17.50	P
GENOTROPIN 13.8MG CARTRIDGE	5	Specialty Tier	25%	N/A	P
GENOTROPIN 5 MG CARTRIDGE	4	Non-Preferred Drug	40%	40%	P
GENOTROPIN MINIQUICK 0.2MG	4	Non-Preferred Drug	40%	40%	P
GENOTROPIN MINIQUICK 0.4MG	5	Specialty Tier	25%	N/A	P
GENOTROPIN MINIQUICK 0.6MG	5	Specialty Tier	25%	N/A	P
GENOTROPIN MINIQUICK 0.8MG	5	Specialty Tier	25%	N/A	P
GENOTROPIN MINIQUICK 1.2MG	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 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	$7.00	$17.50	None
GENTAMICIN 3 MG/ML EYE DROPS	1	Preferred Generic	$0.00	$0.00	None
Gentamicin Sulfate 40mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 2 mL in 1 VIAL, SINGLE-DOSE	1	Preferred Generic	$0.00	$0.00	None
GENTAMICIN SULFATE CREAM USP 0.1% 15GM TUBE	1	Preferred Generic	$0.00	$0.00	None
Gentamicin Sulfate in Sodium Chloride 60mg/50mL 50 mL in 1 BAG	2	Generic	$7.00	$17.50	None
GENTAMICIN SULFATE OINTMENT USP 0.1% 15GM TUBE	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
GENVOYA TABLET	5	Specialty Tier	25%	N/A	None
GEODON 20MG VIAL	4	Non-Preferred Drug	40%	40%	None
GILENYA 0.5 MG CAPSULE	5	Specialty Tier	25%	N/A	P Q:31 /31Days
GILOTRIF 20 MG TABLET	5	Specialty Tier	25%	N/A	P Q:31 /31Days
GILOTRIF 30 MG TABLET	5	Specialty Tier	25%	N/A	P Q:31 /31Days
GILOTRIF 40 MG TABLET	5	Specialty Tier	25%	N/A	P Q:31 /31Days
GLASSIA 1g/50mL 1 VIAL, GLASS per CARTON / 50 mL in 1 VIAL, GLASS	5	Specialty Tier	25%	N/A	P
GLATIRAMER 20 MG/ML SYRINGE [Copaxone]	5	Specialty Tier	25%	N/A	Q:31 /31Days
GLATIRAMER 40 MG/ML SYRINGE [Copaxone]	5	Specialty Tier	25%	N/A	Q:12 /28Days
Glatopa 20 mg/ml syringe	5	Specialty Tier	25%	N/A	Q:31 /31Days
GLATOPA 40 MG/ML SYRINGE [Glatopa]	5	Specialty Tier	25%	N/A	Q:12 /28Days
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	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	$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
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
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	$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	20%	20%	None
GLUCAGON 1MG EMERGENCY KIT	3	Preferred Brand	20%	20%	None
Glucose 50 MG/ML / Potassium Chloride 0.02 MEQ/ML / Sodium Chloride 0.154 MEQ/ML Injectable Solution	2	Generic	$7.00	$17.50	None
GLYBURID-METFORMIN 1.25-250 MG [Glucovance]	2	Generic	$7.00	$17.50	P
GLYBURIDE 1.25MG TABLETS	2	Generic	$7.00	$17.50	P
GLYBURIDE 2.5MG TABLET (100 CT)	2	Generic	$7.00	$17.50	P
GLYBURIDE 5 MG TABLET	2	Generic	$7.00	$17.50	P
GLYBURIDE MICRO 1.5 MG TAB	2	Generic	$7.00	$17.50	P
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	$7.00	$17.50	P
GLYBURIDE MICRO 6 MG TABLET	2	Generic	$7.00	$17.50	P
GLYBURIDE-METFORMIN 2.5-500 MG	2	Generic	$7.00	$17.50	P
GLYBURIDE-METFORMIN 5-500 MG	2	Generic	$7.00	$17.50	P
GLYCOPYRROLATE TABLET 1MG (100 CT)	2	Generic	$7.00	$17.50	None
GLYCOPYRROLATE TABLET 2MG (100 CT)	2	Generic	$7.00	$17.50	None
GLYXAMBI 10 MG-5 MG TABLET	3	Preferred Brand	20%	20%	Q:31 /31Days
GLYXAMBI 25 MG-5 MG TABLET	3	Preferred Brand	20%	20%	Q:31 /31Days
GOLYTELY PACKET 227.1 GM/2.82 GM	4	Non-Preferred Drug	40%	40%	None
GONITRO 0.4 MG SUBLINGUAL PWD	4	Non-Preferred Drug	40%	40%	None
Gralise 600 MG 90 FILM COATED TABLETS in BOTTLE	3	Preferred Brand	20%	20%	P
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
GRALISE ER 300 MG TABLET	3	Preferred Brand	20%	20%	P
Gralise Starter Pack 1 KIT per BLISTER PACK	3	Preferred Brand	20%	20%	P
GRANISETRON HCL 1 MG TABLET	2	Generic	$7.00	$17.50	P
GRANIX 300 MCG/0.5 ML SAFE SYR	4	Non-Preferred Drug	40%	40%	None
GRANIX 300 MCG/ML VIAL	5	Specialty Tier	25%	N/A	None
GRANIX 480 MCG/0.8 ML SYRINGE	5	Specialty Tier	25%	N/A	None
GRANIX 480 MCG/1.6 ML VIAL	5	Specialty Tier	25%	N/A	None
GRISEOFULVIN 125 MG/5 ML SUSP	2	Generic	$7.00	$17.50	None
GRISEOFULVIN MICRO 500 MG TAB	2	Generic	$7.00	$17.50	None
GRISEOFULVIN ULTRA 125 MG TABLET [Gris-Peg]	2	Generic	$7.00	$17.50	None
GRISEOFULVIN ULTRA 250 MG TABLET [Gris-Peg]	2	Generic	$7.00	$17.50	None
Drug Name	Tier Nbr.	Tier Description	30-Day Preferred Pharm	90-Day Mail Order	Drug Usage Mgmt
Guanfacine hcl er 1 mg tablet	2	Generic	$7.00	$17.50	P
Guanfacine hcl er 2 mg tablet	2	Generic	$7.00	$17.50	P
Guanfacine hcl er 3 mg tablet	2	Generic	$7.00	$17.50	P
Guanfacine hcl er 4 mg tablet	2	Generic	$7.00	$17.50	P
guanidine hcl 125 mg tablet	2	Generic	$7.00	$17.50	None
GYNAZOLE-1 2% CREAM	4	Non-Preferred Drug	40%	40%	None

Chart Legend:

Below are a few notes to help you understand the above 2019 Medicare Part D Blue Rx PDP 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.