2026 Humana Premier Rx Plan (PDP) formulary (drug list)
Contract S5884, plan 177 · Idaho · 3,076 drugs on file · formulary ID 00026402. Each drug links to its cost in every CMS PDP Region 31 plan.
276 drugs starting with C.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| CABERGOLINE .5 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CABOMETYX 20 mg TabletCabozantinib | 5Specialty Tier | 33% | N/A |
|
| CABOMETYX 40 mg TabletCabozantinib | 5Specialty Tier | 33% | N/A |
|
| CABOMETYX 60 mg TabletCabozantinib | 5Specialty Tier | 33% | N/A |
|
| CALCIPOTRIENE .05 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| CALCIPOTRIENE 50 ug/g Cream | 4Non-Preferred Drug | 50% | 50% |
|
| CALCITONIN SALMON 200 [iU] Spray, Metered | 3Preferred Brand | $45.00 | $125.00 |
|
| CALCITRIOL .25 ug Capsule, Liquid Filled | 2Generic | $4.00 | $0.00 | None |
| CALCITRIOL .5 ug Capsule, Liquid Filled | 2Generic | $4.00 | $0.00 | None |
| CALCITRIOL 1 ug/mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CALQUENCE 100 mg Tablet, Film CoatedAcalabrutinib | 5Specialty Tier | 33% | N/A |
|
| CAMRESE LO KitLevonorgestrel/Ethinyl Estradiol And Ethinyl Estradiol | 2Generic | $4.00 | $0.00 |
|
| CANDESARTAN 16 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN 32 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN 4 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN 8 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 16/12.5 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/12.5 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/25 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CAPLYTA 10.5 mg CapsuleLumateperone | 4Non-Preferred Drug | 50% | 50% |
|
| CAPLYTA 21 mg CapsuleLumateperone | 4Non-Preferred Drug | 50% | 50% |
|
| CAPLYTA 42 mg CapsuleLumateperone | 4Non-Preferred Drug | 50% | 50% |
|
| CAPRELSA 100 mg Tablet, Film CoatedVandetanib | 5Specialty Tier | 33% | N/A |
|
| CAPRELSA 300 mg Tablet, Film CoatedVandetanib | 5Specialty Tier | 33% | N/A |
|
| CAPTOPRIL 100 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CAPTOPRIL 12.5 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CAPTOPRIL 25 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CAPTOPRIL 50 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CARBAMAZEPINE 100 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 100 mg Tablet, Chewable | 3Preferred Brand | $45.00 | $125.00 | None |
| CARBAMAZEPINE 100 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 100 mg/5mL Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 200 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 200 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CARBAMAZEPINE 200 mg Tablet, Chewable | 3Preferred Brand | $45.00 | $125.00 | None |
| CARBAMAZEPINE 200 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 300 mg Capsule, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBAMAZEPINE 400 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA 25 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA AND LEVODOPA 10/100 mg Tablet | 2Generic | $4.00 | $0.00 | None |
| CARBIDOPA AND LEVODOPA 10/100 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA AND LEVODOPA 25/100 mg Tablet | 2Generic | $4.00 | $0.00 | None |
| CARBIDOPA AND LEVODOPA 25/100 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA AND LEVODOPA 25/250 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA-LEVODOPA 25/250 mg TabletCarbidopa And Levodopa | 2Generic | $4.00 | $0.00 | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 12.5/50/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 18.75/75/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 25/100/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 31.25/125/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 37.5/150/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARBIDOPA, LEVODOPA AND ENTACAPONE 50/200/200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CARGLUMIC ACID 200 mg Tablet, For Suspension | 5Specialty Tier | 33% | N/A |
|
| CARTEOLOL HYDROCHLORIDE 10 mg/mL Solution | 1Preferred Generic | $0.00 | $0.00 | None |
| CARTIA XT 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride | 2Generic | $4.00 | $0.00 | None |
| CARTIA XT 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride | 2Generic | $4.00 | $0.00 | None |
| CARTIA XT 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride | 2Generic | $4.00 | $0.00 | None |
| CARTIA XT 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride | 2Generic | $4.00 | $0.00 | None |
| CARVEDILOL 12.5 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CARVEDILOL 25 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CARVEDILOL 3.125 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CARVEDILOL 6.25 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CASPOFUNGIN ACETATE 5 mg/mL Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CASPOFUNGIN ACETATE 7 mg/mL Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CAYSTON KitAztreonam | 5Specialty Tier | 33% | N/A |
|
| CEFACLOR 250 mg Capsule | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFACLOR 500 mg Capsule | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFADROXIL 250 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFADROXIL 500 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CEFADROXIL 500 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFAZOLIN 1 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFAZOLIN 10 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFAZOLIN 500 mg Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFDINIR 125 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFDINIR 250 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFDINIR 300 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CEFEPIME 1 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFEPIME 2 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFIXIME 400 mg Capsule | 4Non-Preferred Drug | 50% | 50% | None |
| CEFIXIME 400 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CEFOTETAN 1 g/10mL Injection, Powder, For SolutionCefotetan Disodium | 4Non-Preferred Drug | 50% | 50% | None |
| CEFOTETAN 2 g/20mL Injection, Powder, For SolutionCefotetan Disodium | 4Non-Preferred Drug | 50% | 50% | None |
| CEFOXITIN 1 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFOXITIN 10 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFOXITIN 2 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFPODOXIME PROXETIL 100 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CEFPODOXIME PROXETIL 200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CEFPROZIL 125 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFPROZIL 250 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFPROZIL 250 mg/5mL Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFPROZIL 500 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFTAROLINE FOSAMIL 400 mg/20mL Injection, Powder, Lyophilized, For Solution | 5Specialty Tier | 33% | N/A | None |
| CEFTAROLINE FOSAMIL 600 mg/20mL Injection, Powder, Lyophilized, For Solution | 5Specialty Tier | 33% | N/A | None |
| CEFTAZIDIME 1 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTAZIDIME 2 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTAZIDIME 6 g/30mL Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTRIAXONE SODIUM 1 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTRIAXONE SODIUM 10 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTRIAXONE SODIUM 2 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTRIAXONE SODIUM 250 mg Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFTRIAXONE SODIUM 500 mg Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFUROXIME 1.5 g Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFUROXIME 750 mg Injection, Powder, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CEFUROXIME AXETIL 250 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CEFUROXIME AXETIL 500 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CELECOXIB 100 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CELECOXIB 200 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CELECOXIB 400 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CELECOXIB 50 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CEPHALEXIN 125 mg/5mL For Suspension | 2Generic | $4.00 | $0.00 | None |
| CEPHALEXIN 250 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| CEPHALEXIN 250 mg/5mL For Suspension | 2Generic | $4.00 | $0.00 | None |
| CEPHALEXIN 500 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| CETIRIZINE HYDROCHLORIDE 1 mg/mL Solution | 2Generic | $4.00 | $0.00 |
|
| CHEMET 100 mg CapsuleSuccimer | 5Specialty Tier | 33% | N/A | None |
| CHLORHEXIDINE GLUCONATE 1.2 mg/mL Rinse | 1Preferred Generic | $0.00 | $0.00 | None |
| CHLOROQUINE PHOSPHATE 250 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CHLOROQUINE PHOSPHATE 500 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORPROMAZINE HYDROCHLORIDE 10 mg Tablet, Coated | 4Non-Preferred Drug | 50% | 50% |
|
| CHLORPROMAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORPROMAZINE HYDROCHLORIDE 100 mg/mL Concentrate | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORPROMAZINE HYDROCHLORIDE 200 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORPROMAZINE HYDROCHLORIDE 25 mg Tablet, Coated | 4Non-Preferred Drug | 50% | 50% |
|
| CHLORPROMAZINE HYDROCHLORIDE 30 mg/mL Concentrate | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORPROMAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| CHLORTHALIDONE 25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| CHLORTHALIDONE 50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| CHOLESTYRAMINE 4 g/5.5g Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CHOLESTYRAMINE 4 g/9g Powder, For Suspension | 3Preferred Brand | $45.00 | $125.00 | None |
| CICLOPIROX 7.7 mg/g Gel | 4Non-Preferred Drug | 50% | 50% |
|
| CICLOPIROX 80 mg/mL Solution | 2Generic | $4.00 | $0.00 |
|
| CICLOPIROX OLAMINE 7.7 mg/g Cream | 2Generic | $4.00 | $0.00 |
|
| CICLOPIROX OLAMINE 7.7 mg/mL Suspension | 4Non-Preferred Drug | 50% | 50% |
|
| CILOSTAZOL 100 mg Tablet | 2Generic | $4.00 | $0.00 | None |
| CILOSTAZOL 50 mg Tablet | 2Generic | $4.00 | $0.00 | None |
| CIMDUO 300/300 mg Tablet, Film CoatedLamivudine And Tenofovir Disoproxil Fumarate | 5Specialty Tier | 33% | N/A |
|
| CIMETIDINE 200 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CIMETIDINE 300 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CIMETIDINE 400 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CIMETIDINE 800 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CIMETIDINE HYDROCHLORIDE 300 mg/5mL Solution | 3Preferred Brand | $45.00 | $125.00 | None |
| CIPROFLOXACIN 250 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CIPROFLOXACIN 500 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CIPROFLOXACIN 750 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CIPROFLOXACIN HYDROCHLORIDE 3 mg/mL Solution/ Drops | 2Generic | $4.00 | $0.00 | None |
| CIPROFLOXACIN IN DEXTROSE 200 mg/100mL Injection, SolutionCiprofloxacin | 4Non-Preferred Drug | 50% | 50% | None |
| CITALOPRAM 10 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CITALOPRAM 20 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CITALOPRAM 40 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| CITALOPRAM HYDROBROMIDE 10 mg/5mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CLARAVIS 10 mg Capsule, Liquid FilledIsotretinoin | 4Non-Preferred Drug | 50% | 50% | None |
| CLARAVIS 20 mg Capsule, Liquid FilledIsotretinoin | 4Non-Preferred Drug | 50% | 50% | None |
| CLARAVIS 30 mg Capsule, Liquid FilledIsotretinoin | 4Non-Preferred Drug | 50% | 50% | None |
| CLARAVIS 40 mg Capsule, Liquid FilledIsotretinoin | 4Non-Preferred Drug | 50% | 50% | None |
| CLARITHROMYCIN 125 mg/5mL For Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| CLARITHROMYCIN 250 mg Tablet, Film Coated | 3Preferred Brand | $45.00 | $125.00 | None |
| CLARITHROMYCIN 250 mg/5mL For Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| CLARITHROMYCIN 500 mg Tablet, Film Coated | 3Preferred Brand | $45.00 | $125.00 | None |
| CLARITHROMYCIN 500 mg Tablet, Film Coated, Extended Release | 3Preferred Brand | $45.00 | $125.00 | None |
| CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN HYDROCHLORIDE 150 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CLINDAMYCIN HYDROCHLORIDE 300 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CLINDAMYCIN HYDROCHLORIDE 75 mg Capsule | 2Generic | $4.00 | $0.00 | None |
| CLINDAMYCIN IN 5 PERCENT DEXTROSE 12 mg/mL Injection, Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN IN 5 PERCENT DEXTROSE 18 mg/mL Injection, Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN IN 5 PERCENT DEXTROSE 6 mg/mL Injection, Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN PALMITATE HYDROCHLORIDE (PEDIATRIC) 75 mg/5mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| CLINDAMYCIN PHOSPHATE 10 mg/g GelClindamycin Phosphate Gel Usp, 1% | 4Non-Preferred Drug | 50% | 50% |
|
| CLINDAMYCIN PHOSPHATE 10 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| CLINDAMYCIN PHOSPHATE 10 mg/mL Solution | 2Generic | $4.00 | $0.00 | None |
| CLINDAMYCIN PHOSPHATE 20 mg/g Cream | 4Non-Preferred Drug | 50% | 50% | None |
| CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/10 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/15 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/20 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX E 201/154/159/110/165/160/132/116/50/570/283/316/187/138/11/217/261/51/112/33/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX E 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/297/261/51/77/33/10 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX E 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/297/261/51/77/33/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX E 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/340/261/51/59/33/15 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINIMIX E 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/340/261/51/59/33/20 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose | 4Non-Preferred Drug | 50% | 50% |
|
| CLINISOL 1.18/1.04/1.04/960/894/749/749/749/250/2.17/1.47/1.04/894/749/592/434/39 g/100mL/mg/100mL Injection, SolutionLysine, Leucine, Phenylalanine, Valine, Histidine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Proline, Glutamic Acid, Serine, Aspartic Acid, Tyrosine | 4Non-Preferred Drug | 50% | 50% |
|
| CLINOLIPID 16/4 g/100mL Injection, EmulsionOlive Oil And Soybean Oil | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBAZAM 10 mg Tablet | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBAZAM 2.5 mg/mL Suspension | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBAZAM 20 mg Tablet | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBETASOL PROPIONATE .5 mg/g Cream | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBETASOL PROPIONATE .5 mg/g Cream | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBETASOL PROPIONATE .5 mg/g Gel | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBETASOL PROPIONATE .5 mg/g Ointment | 4Non-Preferred Drug | 50% | 50% |
|
| CLOBETASOL PROPIONATE .5 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| CLOMIPRAMINE HYDROCHLORIDE 25 mg Capsule | 4Non-Preferred Drug | 50% | 50% | None |
| CLOMIPRAMINE HYDROCHLORIDE 50 mg Capsule | 4Non-Preferred Drug | 50% | 50% | None |
| CLOMIPRAMINE HYDROCHLORIDE 75 mg Capsule | 4Non-Preferred Drug | 50% | 50% | None |
| CLONAZEPAM .125 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CLONAZEPAM .25 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CLONAZEPAM .5 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CLONAZEPAM .5 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CLONAZEPAM 1 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CLONAZEPAM 1 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CLONAZEPAM 2 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| CLONAZEPAM 2 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% | None |
| CLONIDINE HYDROCHLORIDE .1 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| CLONIDINE HYDROCHLORIDE .2 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| CLONIDINE HYDROCHLORIDE .3 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| CLONIDINE TRANSDERMAL SYSTEM .1 mg/d PatchClonidine | 4Non-Preferred Drug | 50% | 50% |
|
| CLONIDINE TRANSDERMAL SYSTEM .2 mg/d PatchClonidine | 4Non-Preferred Drug | 50% | 50% |
|
| CLONIDINE TRANSDERMAL SYSTEM .3 mg/d PatchClonidine | 4Non-Preferred Drug | 50% | 50% |
|
| CLOPIDOGREL 75 mg Tablet, Film CoatedClopidogrel Bisulfate | 1Preferred Generic | $0.00 | $0.00 |
|
| CLORAZEPATE DIPOTASSIUM 15 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CLORAZEPATE DIPOTASSIUM 3.75 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| CLOTRIMAZOLE 10 mg Lozenge | 2Generic | $4.00 | $0.00 | None |
| CLOTRIMAZOLE 10 mg/g Cream | 2Generic | $4.00 | $0.00 | None |
| CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/g Cream | 3Preferred Brand | $45.00 | $125.00 |
|
| CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/mL Lotion | 4Non-Preferred Drug | 50% | 50% |
|
| CLOTRIMAZOLE TOPICAL SOLUTION USP, 1% 10 mg/mL Solution | 3Preferred Brand | $45.00 | $125.00 | None |
| CLOZAPINE 100 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CLOZAPINE 100 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% |
|
| CLOZAPINE 12.5 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% |
|
| CLOZAPINE 150 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% |
|
| CLOZAPINE 200 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CLOZAPINE 200 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% |
|
| CLOZAPINE 25 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CLOZAPINE 25 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 50% | 50% |
|
| CLOZAPINE 50 mg Tablet | 3Preferred Brand | $45.00 | $125.00 | None |
| COARTEM 20/120 mg TabletArtemether And Lumefantrine | 4Non-Preferred Drug | 50% | 50% |
|
| COBENFY 100/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride | 4Non-Preferred Drug | 50% | 50% |
|
| COBENFY 125/30 mg Capsule, Coated PelletsXanomeline And Trospium Chloride | 4Non-Preferred Drug | 50% | 50% |
|
| COBENFY 50/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride | 4Non-Preferred Drug | 50% | 50% |
|
| COBENFY KitXanomeline And Trospium Chloride | 4Non-Preferred Drug | 50% | 50% |
|
| COLCHICINE .6 mg Tablet, Film Coated | 3Preferred Brand | $45.00 | $125.00 |
|
| COLESTIPOL HYDROCHLORIDE 1 g Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| COLESTIPOL HYDROCHLORIDE 5 g/5g Granule, For Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| COLISTIMETHATE 150 mg Injection, Powder, For SolutionColistimethate Sodium | 4Non-Preferred Drug | 50% | 50% | None |
| COLLAGENASE SANTYL 250 [arb'U]/g Ointment | 4Non-Preferred Drug | 50% | 50% |
|
| COMBIVENT RESPIMAT 20/100 ug Spray, MeteredIpratropium Bromide And Albuterol | 4Non-Preferred Drug | 50% | 50% |
|
| COMETRIQ 20 mg CapsuleCabozantinib | 5Specialty Tier | 33% | N/A |
|
| COMETRIQ KitCabozantinib | 5Specialty Tier | 33% | N/A |
|
| COMETRIQ KitCabozantinib | 5Specialty Tier | 33% | N/A |
|
| COMPRO 25 mg SuppositoryProchlorperazine | 4Non-Preferred Drug | 50% | 50% | None |
| CONSTULOSE 10 g/15mL SolutionLactulose | 2Generic | $4.00 | $0.00 | None |
| COPIKTRA 15 mg CapsuleDuvelisib | 5Specialty Tier | 33% | N/A |
|
| COPIKTRA 25 mg CapsuleDuvelisib | 5Specialty Tier | 33% | N/A |
|
| COSENTYX 150 mg/mL InjectionSecukinumab | 5Specialty Tier | 33% | N/A |
|
| COSENTYX 150 mg/mL InjectionSecukinumab | 5Specialty Tier | 33% | N/A |
|
| COSENTYX 300 mg/2mL InjectionSecukinumab | 5Specialty Tier | 33% | N/A |
|
| COSENTYX 75 mg/.5mL InjectionSecukinumab | 5Specialty Tier | 33% | N/A |
|
| COTELLIC 20 mg Tablet, Film CoatedCobimetinib | 5Specialty Tier | 33% | N/A |
|
| CREON 15000/3000/9500 [USP'U] Capsule, Delayed ReleasePancrelipase | 3Preferred Brand | $45.00 | $125.00 | None |
| CREON 24000/76000/120000 [USP'U] Capsule, Delayed Release PelletsPancrelipase | 3Preferred Brand | $45.00 | $125.00 | None |
| CREON 30000/6000/19000 [USP'U] Capsule, Delayed Release PelletsPancrelipase | 3Preferred Brand | $45.00 | $125.00 | None |
| CREON 36000/180000/114000 [USP'U] Capsule, Delayed Release PelletsPancrelipase | 3Preferred Brand | $45.00 | $125.00 | None |
| CREON 60000/12000/38000 [USP'U] Capsule, Delayed Release PelletsPancrelipase | 3Preferred Brand | $45.00 | $125.00 | None |
| CRESEMBA 100 mg CapsuleIsavuconazonium Sulfate | 5Specialty Tier | 33% | N/A |
|
| CRESEMBA 40 mg CapsuleIsavuconazonium Sulfate | 5Specialty Tier | 33% | N/A |
|
| CROMOLYN SODIUM 100 mg/5mL Solution, Concentrate | 4Non-Preferred Drug | 50% | 50% | None |
| CROMOLYN SODIUM 20 mg/2mL Solution | 3Preferred Brand | $45.00 | $125.00 |
|
| CROMOLYN SODIUM 40 mg/mL Solution/ Drops | 2Generic | $4.00 | $0.00 | None |
| CRYSELLE KitNorgestrel And Ethinyl Estradiol | 2Generic | $4.00 | $0.00 | None |
| CYCLOBENZAPRINE HYDROCHLORIDE 10 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CYCLOBENZAPRINE HYDROCHLORIDE 5 mg Tablet, Film Coated | 2Generic | $4.00 | $0.00 | None |
| CYCLOPHOSPHAMIDE 25 mg Capsule | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOPHOSPHAMIDE 50 mg Capsule | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOPHOSPHAMIDE 50 mg Tablet | 3Preferred Brand | $45.00 | $125.00 |
|
| CYCLOSPORINE .5 mg/mL Emulsion | 3Preferred Brand | $45.00 | $125.00 |
|
| CYCLOSPORINE 100 mg Capsule, Gelatin Coated | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOSPORINE 100 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOSPORINE 25 mg Capsule, Gelatin Coated | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOSPORINE MODIFIED 100 mg Capsule, Liquid FilledCyclosporine | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOSPORINE MODIFIED 50 mg Capsule, Liquid FilledCyclosporine | 4Non-Preferred Drug | 50% | 50% |
|
| CYCLOSPORINE, MODFIED 25 mg Capsule, Liquid FilledCyclosporine | 4Non-Preferred Drug | 50% | 50% |
|
| CYRED EQ KitDesogestrel And Ethinyl Estradiol | 2Generic | $4.00 | $0.00 | None |
| CYSTAGON 150 mg CapsuleCysteamine Bitartrate | 4Non-Preferred Drug | 50% | 50% | None |
| CYSTAGON 50 mg CapsuleCysteamine Bitartrate | 4Non-Preferred Drug | 50% | 50% | None |
| CYSTARAN 6.5 mg/mL SolutionCysteamine Hydrochloride | 5Specialty Tier | 33% | N/A |
|
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.