Drug List - G

G
Drug Name Tier Restrictions
GABAPENTIN 1
GABITRIL 3 Prior authorization
GALANTAMINE ER 1
GANIRELIX AC INJ 1
GARDASIL INJ UD $0
GASTROCROM CON 1
GATIFLOXACIN 1
GELCLAIR 1 Quantity limit
GEMFIBROZIL 1
GENOTROPIN 3 Prior authorization, Step therapy
GENTAK 1
GENTAMICIN 1 Quantity limit
GENTAMICIN SULFATE 1
GENVOYA 2
GEODON 3 Prior authorization
GG/CODEINE SOL 100-10/5 1
GIANVI 1*
GILENYA 2
GLEEVEC TAB 400MG 3 Prior Authorization
GLIMEPIRIDE 1
GLIP/METFORM TAB 5-500MG 1
GLIPIZIDE 1
GLIPIZIDE ER 1
GLIPIZIDE XL 1 Prior authorization
GLUCAGON EMERGENCY KIT 1MG UD 2
GLUCOPHAGE XR 3 Prior authorization
GLUCOTROL XL 3 Prior authorization
GLUCOVANCE 3 Prior authorization
GLUMETZA 3 Prior authorization
GLUTOSE NC Over-the-counter
GLYB/METFORM TAB 1
GLYBURIDE 1
GLYBURIDE/METFORMIN HCL 1
GLYCOLAX NC
GLYCOPYRROLATE 1
GLYXAMBI 2 Step therapy
GOLYTELY 1*
GONAL-F RFF PEN INJ 3 Prior authorization, Step therapy
GRANISETRON 1
GRANISETRON HCL 1
GRASTEK 3
GRIFULVIN-V 3
GRISEOFULVIN SUS 125/5ML 1
GUANFACINE HCL 1
GYNAZOLE-1 1