MedicarePartD.guide

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2026 HealthSpring Assurance Rx (PDP) formulary (drug list)

Contract S5617, plan 225 · Arkansas · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 19 plan.

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264 drugs starting with P.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
PACERONE 100 mg TabletAmiodarone Hydrochloride4Non-Preferred Drug29%29%None
PACERONE 200 mg TabletAmiodarone Hydrochloride2Generic10%10%None
PACERONE 400 mg TabletAmiodarone Hydrochloride4Non-Preferred Drug29%29%None
PALIPERIDONE 1.5 mg Tablet, Extended Release4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
PALIPERIDONE 3 mg Tablet, Extended Release4Non-Preferred Drug29%29%
  • PA
  • QL 6 per 30 days
PALIPERIDONE 6 mg Tablet, Extended Release4Non-Preferred Drug29%29%
  • PA
  • QL 6 per 30 days
PALIPERIDONE 9 mg Tablet, Film Coated, Extended Release4Non-Preferred Drug29%29%
  • PA
  • QL 3 per 30 days
PANRETIN 60 mg/60g GelAlitretinoin5Specialty Tier25%N/ANone
PANTOPRAZOLE SODIUM 20 mg Tablet, Delayed Release2Generic10%10%
  • QL 6 per 30 days
PANTOPRAZOLE SODIUM 40 mg Tablet, Delayed ReleasePantoprazole2Generic10%10%
  • QL 6 per 30 days
PANZYGA 100 mg/mL SolutionImmune Globulin Intravenous (Human)5Specialty Tier25%N/A
  • PA
PANZYGA 100 mg/mL SolutionImmune Globulin Intravenous (Human)5Specialty Tier25%N/A
  • PA
PANZYGA 100 mg/mL SolutionImmune Globulin Intravenous (Human)5Specialty Tier25%N/A
  • PA
PANZYGA 100 mg/mL SolutionImmune Globulin Intravenous (Human)5Specialty Tier25%N/A
  • PA
PANZYGA 100 mg/mL SolutionImmune Globulin Intravenous (Human)5Specialty Tier25%N/A
  • PA
PARICALCITOL 1 ug Capsule, Liquid Filled4Non-Preferred Drug29%29%None
PARICALCITOL 2 ug Capsule, Liquid Filled4Non-Preferred Drug29%29%None
PARICALCITOL 4 ug Capsule, Liquid Filled4Non-Preferred Drug29%29%None
PAROXETINE 10 mg Tablet, Film Coated2Generic10%10%
  • QL 18 per 30 days
PAROXETINE 10 mg/5mL Suspension4Non-Preferred Drug29%29%
  • QL 9 per 30 days
PAROXETINE 20 mg Tablet, Film Coated2Generic10%10%
  • QL 3 per 30 days
PAROXETINE 30 mg Tablet, Film Coated2Generic10%10%
  • QL 6 per 30 days
PAROXETINE 40 mg Tablet, Film Coated2Generic10%10%
  • QL 3 per 30 days
PAXLOVID KitNirmatrelvir And Ritonavir5Specialty Tier25%N/A
  • QL 3 per 90 days
PAXLOVID KitNirmatrelvir And Ritonavir5Specialty Tier25%N/A
  • QL 2 per 90 days
PAXLOVID KitNirmatrelvir And Ritonavir5Specialty Tier25%N/A
  • QL 11 per 90 days
PAZOPANIB 200 mg Tablet5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
PEDIARIX 25/10/25/25/8/10/40/8/32 [iU]/.5mL/ug/.5mL Injection, SuspensionDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) And Inactivated Poliovirus Vaccine Combined3Preferred Brand25%25%None
PEDVAXHIB 7.5 ug/.5mL Injection, SuspensionHaemophilus B Conjugate Vaccine (Meningococcal Protein Conjugate)3Preferred Brand25%25%None
PEG-3350 AND ELECTROLYTES 236/22.74/6.74/5.86/2.97 g/4L Powder, For SolutionPolyethylene Glycol 3350, Sodium Sulfate Anhydrous, Sodium Bicarbonate, Sodium Chloride, Potassium Chloride2Generic10%10%None
PEGASYS 180 ug/.5mL Injection, SolutionPeginterferon Alfa-2A5Specialty Tier25%N/A
  • QL 2 per 28 days
PEGASYS 180 ug/mL Injection, SolutionPeginterferon Alfa-2A5Specialty Tier25%N/A
  • QL 4 per 28 days
PEMAZYRE 13.5 mg TabletPemigatinib5Specialty Tier25%N/A
  • PA
  • QL 14 per 21 days
PEMAZYRE 4.5 mg TabletPemigatinib5Specialty Tier25%N/A
  • PA
  • QL 14 per 21 days
PEMAZYRE 9 mg TabletPemigatinib5Specialty Tier25%N/A
  • PA
  • QL 14 per 21 days
PENBRAYA KitMeningococcal Groups A, B, C, W, And Y Vaccine3Preferred Brand25%25%None
PENICILLAMINE 250 mg Capsule5Specialty Tier25%N/ANone
PENICILLAMINE 250 mg Tablet, Film Coated5Specialty Tier25%N/ANone
PENICILLIN G POTASSIUM 20000000 [iU] Injection, Powder, For Solution4Non-Preferred Drug29%29%
  • PA
PENICILLIN V POTASSIUM 125 mg/5mL Powder, For Solution2Generic10%10%None
PENICILLIN V POTASSIUM 250 mg Tablet, Film Coated2Generic10%10%None
PENICILLIN V POTASSIUM 250 mg/5mL Powder, For Solution2Generic10%10%None
PENICILLIN V POTASSIUM 500 mg Tablet, Film Coated2Generic10%10%None
PENMENVY KitMeningococcal (Groups A, B, C, W And Y)3Preferred Brand25%25%None
PENTACEL KitDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Inactivated Poliovirus And Haemophilus B Conjugate (Tetanus Toxoid Conjugate) Vaccine3Preferred Brand25%25%None
PENTAMIDINE ISETHIONATE 300 mg/300mg Inhalant3Preferred Brand25%25%
  • PA
  • QL 1 per 28 days
PENTAMIDINE ISETHIONATE 300 mg/300mg Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug29%29%None
PENTOXIFYLLINE 400 mg Tablet, Extended Release2Generic10%10%None
PERAMPANEL .5 mg/mL Suspension5Specialty Tier25%N/A
  • QL 72 per 30 days
PERAMPANEL 10 mg Tablet, Film Coated5Specialty Tier25%N/A
  • QL 3 per 30 days
PERAMPANEL 12 mg Tablet, Film Coated5Specialty Tier25%N/A
  • QL 3 per 30 days
PERAMPANEL 2 mg Tablet, Film Coated4Non-Preferred Drug29%29%
  • QL 6 per 30 days
PERAMPANEL 4 mg Tablet, Film Coated5Specialty Tier25%N/A
  • QL 6 per 30 days
PERAMPANEL 6 mg Tablet, Film Coated5Specialty Tier25%N/A
  • QL 6 per 30 days
PERAMPANEL 8 mg Tablet, Film Coated5Specialty Tier25%N/A
  • QL 3 per 30 days
PERINDOPRIL ERBUMINE 2 mg Tablet1Preferred Generic5%5%None
PERINDOPRIL ERBUMINE 4 mg Tablet1Preferred Generic5%5%None
PERINDOPRIL ERBUMINE 8 mg Tablet1Preferred Generic5%5%None
PERIOGARD ALCOHOL FREE 1.2 mg/mL RinseChlorhexidine Gluconate2Generic10%10%None
PERMETHRIN 50 mg/g CreamPermethrin Cream 5% W/W3Preferred Brand25%25%None
PERPHENAZINE 16 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE 2 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE 4 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE 8 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 2/10 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 2/25 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/10 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/25 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/50 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PHENELZINE SULFATE 15 mg Tablet, Film Coated3Preferred Brand25%25%None
PHENOBARBITAL 100 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 15 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 16.2 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 30 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 32.4 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 60 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 64.8 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL 97.2 mg Tablet4Non-Preferred Drug29%29%
  • PA
  • QL 12 per 30 days
PHENOBARBITAL ORAL SOLUTION 20 mg/5mL SolutionPhenobarbital Oral4Non-Preferred Drug29%29%
  • PA
  • QL 15 per 30 days
PHENYTOIN 125 mg/5mL Suspension2Generic10%10%None
PHENYTOIN 50 mg Tablet, Chewable3Preferred Brand25%25%None
PHENYTOIN SODIUM 100 mg Capsule, Extended Release2Generic10%10%None
PIFELTRO 100 mg Tablet, Film CoatedDoravirine5Specialty Tier25%N/ANone
PILOCARPINE HYDROCHLORIDE 10 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution3Preferred Brand25%25%None
PILOCARPINE HYDROCHLORIDE 20 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution3Preferred Brand25%25%None
PILOCARPINE HYDROCHLORIDE 40 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution3Preferred Brand25%25%None
PILOCARPINE HYDROCHLORIDE 5 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PILOCARPINE HYDROCHLORIDE 7.5 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PILOCARPINE HYDROCHLORIDE OPHTHALMIC 12.5 mg/mL Solution/ DropsPilocarpine Hydrochloride3Preferred Brand25%25%None
PIMECROLIMUS 10 mg/g Cream4Non-Preferred Drug29%29%
  • PA
  • QL 1 per 30 days
PIMOZIDE 1 mg Tablet4Non-Preferred Drug29%29%None
PIMOZIDE 2 mg Tablet4Non-Preferred Drug29%29%None
PIMTREA KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol4Non-Preferred Drug29%29%None
PINDOLOL 10 mg Tablet3Preferred Brand25%25%None
PINDOLOL 5 mg Tablet3Preferred Brand25%25%None
PIOGLITAZONE 15 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PIOGLITAZONE 30 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PIOGLITAZONE 45 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PIPERACILLIN AND TAZOBACTAM 2/.25 g/10mL Injection, Powder, For Solution4Non-Preferred Drug29%29%None
PIPERACILLIN AND TAZOBACTAM 3/.375 g/15mL Injection, Powder, For Solution4Non-Preferred Drug29%29%None
PIPERACILLIN AND TAZOBACTAM 4.5/36 g/180mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug29%29%None
PIPERACILLIN AND TAZOBACTAM 4/.5 g/20mL Injection, Powder, For Solution4Non-Preferred Drug29%29%None
PIQRAY 150 mg TabletAlpelisib5Specialty Tier25%N/A
  • PA
PIQRAY 200 mg TabletAlpelisib5Specialty Tier25%N/A
  • PA
PIQRAY KitAlpelisib5Specialty Tier25%N/A
  • PA
PIRFENIDONE 267 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 27 per 30 days
PIRFENIDONE 267 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 27 per 30 days
PIRFENIDONE 534 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
PIRFENIDONE 801 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
PITAVASTATIN 1 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 3 per 30 days
PITAVASTATIN 2 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 3 per 30 days
PITAVASTATIN 4 mg Tablet, Film Coated1Preferred Generic5%5%
  • QL 3 per 30 days
PLENAMINE 1.18/1.04/1.04/960/749/749/749/250/2.17/1.47/1.04/894/894/749/592/434/39 g/100mL/mg/100mL SolutionLysine Acetate, Leucine, Phenylalanine, Valine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Histidine, Proline, Glutamic Acid, Serine, Aspartic Acid, And Tyrosine4Non-Preferred Drug29%29%
  • PA
PODOFILOX 5 mg/mL Solution4Non-Preferred Drug29%29%None
POLYETHYLENE GLYCOL 3350, SODIUM CHLORIDE, SODIUM BICARBONATE AND POTASSIUM CHLORIDE WITH LEMON FLAVOR 420/11.2/5.72/1.48 g/4L Powder, For Solution2Generic10%10%None
POLYMYXIN B SULFATE AND TRIMETHOPRIM 10000/1 [USP'U]/mL/mg/mL Solution2Generic10%10%None
POMALIDOMIDE 1 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALIDOMIDE 2 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALIDOMIDE 3 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALIDOMIDE 4 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALYST 1 mg CapsulePomalidomide5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALYST 2 mg CapsulePomalidomide5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALYST 3 mg CapsulePomalidomide5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
POMALYST 4 mg CapsulePomalidomide5Specialty Tier25%N/A
  • PA
  • QL 21 per 28 days
PORTIA KitLevonorgestrel And Ethinyl Estradiol4Non-Preferred Drug29%29%None
POSACONAZOLE 100 mg Tablet, Delayed Release5Specialty Tier25%N/A
  • QL 96 per 30 days
POTASSIUM CHLORIDE 1.5 g/1.58g Powder, For Solution2Generic10%10%None
POTASSIUM CHLORIDE 1.5 g/15mL Solution4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 10 meq Tablet, Film Coated, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 1125 mg Tablet, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 1125 mg Tablet, Film Coated, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 14.9 g/1000mL Injection, Solution4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 149 mg/mL Injection, Solution, Concentrate4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 150/5 mg/100mL/g/100mL Injection, SolutionPotassium Chloride, Dextrose Monohydrate4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 1500 mg Tablet, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 1500 mg Tablet, Film Coated, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 2 meq/mL Injection, Solution, Concentrate4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 29.8 g/1000mL Injection, Solution4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 3 g/15mL Solution4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 600 mg Capsule, Extended Release3Preferred Brand25%25%None
POTASSIUM CHLORIDE 600 mg Tablet, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE 7.46 g/1000mL Injection, Solution4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE 750 mg Capsule, Extended Release3Preferred Brand25%25%None
POTASSIUM CHLORIDE 750 mg Tablet, Extended Release2Generic10%10%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 150/5/200 mg/100mL/g/100mL Injection, SolutionPotassium Chloride, Dextrose Monohydrate And Sodium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/.745 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/1.49 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/2.24 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/2.98 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/9/1.49 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/9/2.98 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN LACTATED RINGERS AND DEXTROSE 5/600/310/179/20 g/100mL/mg/100mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, Sodium Lactate, Potassium Chloride, Calcium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 450/150 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 900/150 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 900/300 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride4Non-Preferred Drug29%29%None
POTASSIUM CITRATE 10 meq Tablet, Extended Release4Non-Preferred Drug29%29%None
POTASSIUM CITRATE 5 meq Tablet, Extended Release4Non-Preferred Drug29%29%None
POTASSIUM CITRATE EXTENDED RELEASE 15 meq TabletPotassium Citrate4Non-Preferred Drug29%29%None
PRAMIPEXOLE DIHYDROCHLORIDE .125 mg Tablet2Generic10%10%None
PRAMIPEXOLE DIHYDROCHLORIDE .25 mg Tablet2Generic10%10%None
PRAMIPEXOLE DIHYDROCHLORIDE .5 mg Tablet2Generic10%10%None
PRAMIPEXOLE DIHYDROCHLORIDE .75 mg Tablet2Generic10%10%None
PRAMIPEXOLE DIHYDROCHLORIDE 1 mg Tablet2Generic10%10%None
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg Tablet2Generic10%10%None
PRAVASTATIN SODIUM 10 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PRAVASTATIN SODIUM 20 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PRAVASTATIN SODIUM 40 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PRAVASTATIN SODIUM 80 mg Tablet1Preferred Generic5%5%
  • QL 3 per 30 days
PRAZIQUANTEL 600 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PRAZOSIN HYDROCHLORIDE 1 mg Capsule4Non-Preferred Drug29%29%None
PRAZOSIN HYDROCHLORIDE 2 mg Capsule4Non-Preferred Drug29%29%None
PRAZOSIN HYDROCHLORIDE 5 mg Capsule4Non-Preferred Drug29%29%None
PREDNISOLONE 15 mg/5mL SolutionPrednisolone Oral4Non-Preferred Drug29%29%None
PREDNISOLONE ACETATE 10 mg/mL Suspension/ Drops3Preferred Brand25%25%None
PREDNISOLONE SODIUM PHOSPHATE 10 mg/mL Solution/ Drops4Non-Preferred Drug29%29%None
PREDNISOLONE SODIUM PHOSPHATE 5 mg/5mL Solution4Non-Preferred Drug29%29%None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 25 mg/5mL SolutionPrednisolone Sodium Phosphate4Non-Preferred Drug29%29%None
PREDNISONE 1 mg Tablet2Generic10%10%None
PREDNISONE 10 mg Tablet2Generic10%10%None
PREDNISONE 10 mg Tablet2Generic10%10%None
PREDNISONE 10 mg Tablet2Generic10%10%None
PREDNISONE 2.5 mg Tablet2Generic10%10%None
PREDNISONE 20 mg Tablet2Generic10%10%None
PREDNISONE 5 mg Tablet2Generic10%10%None
PREDNISONE 5 mg Tablet2Generic10%10%None
PREDNISONE 5 mg Tablet2Generic10%10%None
PREDNISONE 5 mg/5mL Solution4Non-Preferred Drug29%29%None
PREDNISONE 50 mg Tablet2Generic10%10%None
PREDNISONE DELAYED RELEASE 1 mg Tablet, Delayed ReleasePrednisone5Specialty Tier25%N/ANone
PREDNISONE DELAYED RELEASE 2 mg Tablet, Delayed ReleasePrednisone5Specialty Tier25%N/ANone
PREDNISONE INTENSOL 5 mg/mL Solution, Concentrate4Non-Preferred Drug29%29%None
PREGABALIN 100 mg Capsule4Non-Preferred Drug29%29%
  • QL 12 per 30 days
PREGABALIN 150 mg Capsule4Non-Preferred Drug29%29%
  • QL 12 per 30 days
PREGABALIN 20 mg/mL Solution3Preferred Brand25%25%
  • QL 9 per 30 days
PREGABALIN 200 mg Capsule4Non-Preferred Drug29%29%
  • QL 9 per 30 days
PREGABALIN 225 mg Capsule4Non-Preferred Drug29%29%
  • QL 6 per 30 days
PREGABALIN 25 mg Capsule4Non-Preferred Drug29%29%
  • QL 12 per 30 days
PREGABALIN 300 mg Capsule4Non-Preferred Drug29%29%
  • QL 6 per 30 days
PREGABALIN 50 mg Capsule4Non-Preferred Drug29%29%
  • QL 12 per 30 days
PREGABALIN 75 mg Capsule4Non-Preferred Drug29%29%
  • QL 12 per 30 days
PREMASOL - SULFITE-FREE (AMINO ACID) 1.4/.82/.82/.78/.48/.48/.42/.34/.2/.24/1.2/.68/.54/.5/.38/.36/.32/25/.016 g/100mL/mg/100mL Injection, SolutionLeucine, Lysine, Isoleucine, Valine, Histidine, Phenylalanine, Threonine, Methionine, Tryptophan, Tyrosine, N-Acetyl-Tyrosine, Arginine, Proline, Alanine, Glutamic Acide, Serine, Glycine, Aspartic Acid, Taurine, Cysteine Hydrochloride5Specialty Tier25%N/A
  • PA
PREMPRO .3/1.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate3Preferred Brand25%25%None
PREMPRO .45/1.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate3Preferred Brand25%25%None
PREMPRO .625/2.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate3Preferred Brand25%25%None
PREMPRO .625/5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate3Preferred Brand25%25%None
PREVALITE 4 g/5.5g Powder, For SuspensionCholestyramine3Preferred Brand25%25%None
PREVYMIS 120 mg PelletLetermovir5Specialty Tier25%N/A
  • QL 12 per 30 days
PREVYMIS 20 mg PelletLetermovir5Specialty Tier25%N/A
  • QL 12 per 30 days
PREVYMIS 240 mg Tablet, Film CoatedLetermovir5Specialty Tier25%N/A
  • QL 3 per 30 days
PREVYMIS 480 mg Tablet, Film CoatedLetermovir5Specialty Tier25%N/A
  • QL 3 per 30 days
PREZCOBIX 675/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat5Specialty Tier25%N/A
  • QL 3 per 30 days
PREZCOBIX 800/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat5Specialty Tier25%N/A
  • QL 3 per 30 days
PREZISTA 100 mg/mL SuspensionDarunavir5Specialty Tier25%N/A
  • QL 4 per 30 days
PREZISTA 150 mg Tablet, Film CoatedDarunavir4Non-Preferred Drug29%29%
  • QL 24 per 30 days
PREZISTA 75 mg Tablet, Film CoatedDarunavir4Non-Preferred Drug29%29%
  • QL 48 per 30 days
PRIFTIN 150 mg Tablet, Film CoatedRifapentine4Non-Preferred Drug29%29%None
PRIMAQUINE PHOSPHATE 15 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PRIMIDONE 125 mg Tablet4Non-Preferred Drug29%29%None
PRIMIDONE 250 mg Tablet2Generic10%10%None
PRIMIDONE 50 mg Tablet2Generic10%10%None
PRIORIX KitMeasels, Mumps, And Rubella Vaccine, Live3Preferred Brand25%25%None
PROBENECID 500 mg Tablet, Film Coated3Preferred Brand25%25%None
PROBENECID AND COLCHICINE 500/.5 mg Tablet3Preferred Brand25%25%None
PROCHLORPERAZINE 25 mg Suppository4Non-Preferred Drug29%29%None
PROCHLORPERAZINE MALEATE 10 mg Tablet2Generic10%10%None
PROCHLORPERAZINE MALEATE 5 mg Tablet2Generic10%10%None
PROCTO-MED HC 25 mg/g CreamHydrocortisone2Generic10%10%None
PROCTOSOL-HC 25 mg/g CreamHydrocortisone2Generic10%10%None
PROCTOZONE-HC 25 mg/g CreamHydrocortisone 2.5%2Generic10%10%None
PROGESTERONE 100 mg Capsule3Preferred Brand25%25%None
PROGESTERONE 200 mg Capsule3Preferred Brand25%25%None
PROGRAF .2 mg Granule, For SuspensionTacrolimus4Non-Preferred Drug29%29%
  • PA
PROGRAF 1 mg Granule, For SuspensionTacrolimus4Non-Preferred Drug29%29%
  • PA
PROLIA 60 mg/mL InjectionDenosumab4Non-Preferred Drug29%29%
  • QL 1 per 180 days
PROMETHAZINE HYDROCHLORIDE 12.5 mg Tablet2Generic10%10%
  • PA
PROMETHAZINE HYDROCHLORIDE 25 mg Tablet2Generic10%10%
  • PA
PROMETHAZINE HYDROCHLORIDE 50 mg Tablet2Generic10%10%
  • PA
PROMETHAZINE HYDROCHLORIDE 6.25 mg/5mL Syrup4Non-Preferred Drug29%29%
  • PA
PROPAFENONE HYDROCHLORIDE 150 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PROPAFENONE HYDROCHLORIDE 225 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPAFENONE HYDROCHLORIDE 225 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PROPAFENONE HYDROCHLORIDE 300 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PROPAFENONE HYDROCHLORIDE 325 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPAFENONE HYDROCHLORIDE 425 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 10 mg Tablet2Generic10%10%None
PROPRANOLOL HYDROCHLORIDE 120 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 160 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 20 mg Tablet2Generic10%10%None
PROPRANOLOL HYDROCHLORIDE 20 mg/5mL Solution4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 40 mg Tablet2Generic10%10%None
PROPRANOLOL HYDROCHLORIDE 40 mg/5mL Solution4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 60 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 80 mg Capsule, Extended Release4Non-Preferred Drug29%29%None
PROPRANOLOL HYDROCHLORIDE 80 mg Tablet2Generic10%10%None
PROPYLTHIOURACIL 50 mg Tablet3Preferred Brand25%25%None
PROQUAD 1000/20000/1000/9772 [TCID_50]/.5mL/[PFU]/.5mL Injection, Powder, Lyophilized, For SuspensionMeasles, Mumps, Rubella And Varicella Virus Vaccine Live3Preferred Brand25%25%None
PROSOL 1.44/1.35/1.18/1.08/1.08/1/980/760/320/2.76/2.06/1.96/1.34/1.02/1.02/600/50 g/100mL/mg/100mL Injection, SolutionValine, Lysine, Histidine, Isoleucine, Leucine, Phenylalanine, Threonine, Methionine, Tryptophan, Alanine, Glycine, Arginine, Proline, Glutamic Acid, Serine, Aspartic Acid And Tyrosine4Non-Preferred Drug29%29%
  • PA
PROTRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PROTRIPTYLINE HYDROCHLORIDE 5 mg Tablet, Film Coated4Non-Preferred Drug29%29%None
PULMOZYME 1 mg/mL SolutionDornase Alfa5Specialty Tier25%N/A
  • PA
  • QL 15 per 30 days
PYRAZINAMIDE 500 mg Tablet4Non-Preferred Drug29%29%None
PYRIDOSTIGMINE BROMIDE 180 mg Tablet, Extended Release4Non-Preferred Drug29%29%None
PYRIDOSTIGMINE BROMIDE 60 mg Tablet3Preferred Brand25%25%None
PYRIMETHAMINE 25 mg Tablet5Specialty Tier25%N/A
  • PA

PA = prior authorization, ST = step therapy, QL = quantity limit. Costs are the plan’s initial-coverage cost-sharing from the CMS 2026 formulary files; a drug not listed here is not on this plan’s formulary, though a formulary exception may still be possible.