MedicarePartD.guide

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2026 Wellcare Classic (PDP) formulary (drug list)

Contract S4802, plan 086 · Kentucky · 2,922 drugs on file · formulary ID 00026191. Each drug links to its cost in every CMS PDP Region 15 plan.

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240 drugs starting with C.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
CABERGOLINE .5 mg Tablet3Preferred Brand25%25%None
CABOMETYX 20 mg TabletCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
CABOMETYX 40 mg TabletCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
CABOMETYX 60 mg TabletCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
CALCIPOTRIENE .05 mg/mL Solution4Non-Preferred Drug27%27%
  • QL 12 per 30 days
CALCITONIN SALMON 200 [iU] Spray, Metered4Non-Preferred Drug27%27%None
CALCITRIOL .25 ug Capsule, Liquid Filled2Generic$10.00$30.00None
CALCITRIOL .5 ug Capsule, Liquid Filled2Generic$10.00$30.00None
CALCITRIOL 1 ug/mL Solution4Non-Preferred Drug27%27%None
CALQUENCE 100 mg Tablet, Film CoatedAcalabrutinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
CANDESARTAN 16 mg Tablet4Non-Preferred Drug27%27%
  • QL 6 per 30 days
CANDESARTAN 32 mg Tablet4Non-Preferred Drug27%27%
  • QL 3 per 30 days
CANDESARTAN 4 mg Tablet4Non-Preferred Drug27%27%
  • QL 6 per 30 days
CANDESARTAN 8 mg Tablet4Non-Preferred Drug27%27%
  • QL 6 per 30 days
CAPLYTA 10.5 mg CapsuleLumateperone5Specialty Tier25%N/A
  • QL 3 per 30 days
CAPLYTA 21 mg CapsuleLumateperone5Specialty Tier25%N/A
  • QL 3 per 30 days
CAPLYTA 42 mg CapsuleLumateperone5Specialty Tier25%N/A
  • QL 3 per 30 days
CAPRELSA 100 mg Tablet, Film CoatedVandetanib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
CAPRELSA 300 mg Tablet, Film CoatedVandetanib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
CAPTOPRIL 100 mg Tablet1Preferred Generic$0.00$0.00None
CAPTOPRIL 12.5 mg Tablet1Preferred Generic$0.00$0.00None
CAPTOPRIL 25 mg Tablet1Preferred Generic$0.00$0.00None
CAPTOPRIL 50 mg Tablet1Preferred Generic$0.00$0.00None
CARBAMAZEPINE 100 mg Capsule, Extended Release4Non-Preferred Drug27%27%None
CARBAMAZEPINE 100 mg Tablet, Chewable3Preferred Brand25%25%None
CARBAMAZEPINE 100 mg Tablet, Extended Release4Non-Preferred Drug27%27%None
CARBAMAZEPINE 100 mg/5mL Suspension4Non-Preferred Drug27%27%None
CARBAMAZEPINE 200 mg Capsule, Extended Release4Non-Preferred Drug27%27%None
CARBAMAZEPINE 200 mg Tablet3Preferred Brand25%25%None
CARBAMAZEPINE 200 mg Tablet, Extended Release4Non-Preferred Drug27%27%None
CARBAMAZEPINE 300 mg Capsule, Extended Release4Non-Preferred Drug27%27%None
CARBAMAZEPINE 400 mg Tablet, Extended Release4Non-Preferred Drug27%27%None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet2Generic$10.00$30.00None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet2Generic$10.00$30.00None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CARBIDOPA AND LEVODOPA 25/250 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CARBIDOPA-LEVODOPA 25/250 mg TabletCarbidopa And Levodopa2Generic$10.00$30.00None
CARBIDOPA, LEVODOPA AND ENTACAPONE 12.5/50/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 18.75/75/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 25/100/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 31.25/125/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 37.5/150/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 50/200/200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CARGLUMIC ACID 200 mg Tablet, For Suspension5Specialty Tier25%N/A
  • PA
CARTEOLOL HYDROCHLORIDE 10 mg/mL Solution2Generic$10.00$30.00None
CARTIA XT 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand25%25%None
CARTIA XT 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand25%25%None
CARTIA XT 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand25%25%None
CARTIA XT 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride3Preferred Brand25%25%None
CARVEDILOL 12.5 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CARVEDILOL 25 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CARVEDILOL 3.125 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CARVEDILOL 6.25 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CASPOFUNGIN ACETATE 5 mg/mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug27%27%None
CASPOFUNGIN ACETATE 7 mg/mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug27%27%None
CAYSTON KitAztreonam5Specialty Tier25%N/A
  • PA
  • QL 84 per 56 days
CEFACLOR 250 mg Capsule4Non-Preferred Drug27%27%None
CEFACLOR 500 mg Capsule4Non-Preferred Drug27%27%None
CEFADROXIL 500 mg Capsule2Generic$10.00$30.00None
CEFAZOLIN 1 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFAZOLIN 10 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFAZOLIN 500 mg Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFDINIR 125 mg/5mL Powder, For Suspension4Non-Preferred Drug27%27%None
CEFDINIR 250 mg/5mL Powder, For Suspension4Non-Preferred Drug27%27%None
CEFDINIR 300 mg Capsule4Non-Preferred Drug27%27%None
CEFEPIME 1 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFEPIME 2 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFIXIME 400 mg Capsule4Non-Preferred Drug27%27%None
CEFOXITIN 1 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFOXITIN 10 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFOXITIN 2 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFPODOXIME PROXETIL 100 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CEFPODOXIME PROXETIL 200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CEFPROZIL 250 mg Tablet4Non-Preferred Drug27%27%None
CEFPROZIL 500 mg Tablet4Non-Preferred Drug27%27%None
CEFTAZIDIME 1 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTAZIDIME 2 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTAZIDIME 6 g/30mL Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTRIAXONE SODIUM 1 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTRIAXONE SODIUM 10 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTRIAXONE SODIUM 2 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTRIAXONE SODIUM 250 mg Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFTRIAXONE SODIUM 500 mg Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFUROXIME 1.5 g Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFUROXIME 750 mg Injection, Powder, For Solution4Non-Preferred Drug27%27%None
CEFUROXIME AXETIL 250 mg Tablet4Non-Preferred Drug27%27%None
CEFUROXIME AXETIL 500 mg Tablet4Non-Preferred Drug27%27%None
CELECOXIB 100 mg Capsule4Non-Preferred Drug27%27%None
CELECOXIB 200 mg Capsule4Non-Preferred Drug27%27%None
CELECOXIB 400 mg Capsule4Non-Preferred Drug27%27%None
CELECOXIB 50 mg Capsule4Non-Preferred Drug27%27%None
CEPHALEXIN 125 mg/5mL For Suspension4Non-Preferred Drug27%27%None
CEPHALEXIN 250 mg Capsule2Generic$10.00$30.00None
CEPHALEXIN 250 mg/5mL For Suspension4Non-Preferred Drug27%27%None
CEPHALEXIN 500 mg Capsule2Generic$10.00$30.00None
CETIRIZINE HYDROCHLORIDE 1 mg/mL Solution2Generic$10.00$30.00None
CHEMET 100 mg CapsuleSuccimer4Non-Preferred Drug27%27%None
CHLORHEXIDINE GLUCONATE 1.2 mg/mL Rinse2Generic$10.00$30.00None
CHLOROQUINE PHOSPHATE 250 mg Tablet4Non-Preferred Drug27%27%None
CHLOROQUINE PHOSPHATE 500 mg Tablet4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 10 mg Tablet, Coated4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 100 mg/mL Concentrate4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 200 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 25 mg Tablet, Coated4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 30 mg/mL Concentrate4Non-Preferred Drug27%27%None
CHLORPROMAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CHLORTHALIDONE 25 mg Tablet2Generic$10.00$30.00None
CHLORTHALIDONE 50 mg Tablet2Generic$10.00$30.00None
CHOLESTYRAMINE 4 g/5.5g Powder, For Suspension4Non-Preferred Drug27%27%None
CHOLESTYRAMINE 4 g/9g Powder, For Suspension4Non-Preferred Drug27%27%None
CICLOPIROX OLAMINE 7.7 mg/g Cream4Non-Preferred Drug27%27%
  • QL 9 per 28 days
CICLOPIROX OLAMINE 7.7 mg/mL Suspension4Non-Preferred Drug27%27%
  • QL 6 per 28 days
CILOSTAZOL 100 mg Tablet2Generic$10.00$30.00None
CILOSTAZOL 50 mg Tablet2Generic$10.00$30.00None
CIMDUO 300/300 mg Tablet, Film CoatedLamivudine And Tenofovir Disoproxil Fumarate5Specialty Tier25%N/ANone
CIPROFLOXACIN 250 mg Tablet, Film Coated2Generic$10.00$30.00None
CIPROFLOXACIN 500 mg Tablet, Film Coated2Generic$10.00$30.00None
CIPROFLOXACIN 750 mg Tablet, Film Coated2Generic$10.00$30.00None
CIPROFLOXACIN AND DEXAMETHASONE 3/1 mg/mL Suspension/ Drops4Non-Preferred Drug27%27%
  • QL 7.5 per 7 days
CIPROFLOXACIN HYDROCHLORIDE 3 mg/mL Solution/ Drops2Generic$10.00$30.00None
CIPROFLOXACIN IN DEXTROSE 200 mg/100mL Injection, SolutionCiprofloxacin4Non-Preferred Drug27%27%None
CITALOPRAM 10 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CITALOPRAM 20 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CITALOPRAM 40 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
CITALOPRAM HYDROBROMIDE 10 mg/5mL Solution4Non-Preferred Drug27%27%None
CLARAVIS 10 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug27%27%None
CLARAVIS 20 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug27%27%None
CLARAVIS 30 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug27%27%None
CLARAVIS 40 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug27%27%None
CLARITHROMYCIN 125 mg/5mL For Suspension4Non-Preferred Drug27%27%None
CLARITHROMYCIN 250 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CLARITHROMYCIN 250 mg/5mL For Suspension4Non-Preferred Drug27%27%None
CLARITHROMYCIN 500 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate4Non-Preferred Drug27%27%None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate4Non-Preferred Drug27%27%None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate4Non-Preferred Drug27%27%None
CLINDAMYCIN HYDROCHLORIDE 150 mg Capsule2Generic$10.00$30.00None
CLINDAMYCIN HYDROCHLORIDE 300 mg Capsule2Generic$10.00$30.00None
CLINDAMYCIN HYDROCHLORIDE 75 mg Capsule2Generic$10.00$30.00None
CLINDAMYCIN PHOSPHATE 10 mg/mL Lotion4Non-Preferred Drug27%27%
  • QL 12 per 30 days
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution4Non-Preferred Drug27%27%
  • QL 12 per 30 days
CLINDAMYCIN PHOSPHATE 20 mg/g Cream4Non-Preferred Drug27%27%None
CLOBAZAM 10 mg Tablet4Non-Preferred Drug27%27%
  • PA
  • QL 6 per 30 days
CLOBAZAM 2.5 mg/mL Suspension4Non-Preferred Drug27%27%
  • PA
  • QL 48 per 30 days
CLOBAZAM 20 mg Tablet4Non-Preferred Drug27%27%
  • PA
  • QL 6 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Cream4Non-Preferred Drug27%27%
  • QL 12 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Cream4Non-Preferred Drug27%27%
  • QL 12 per 28 days
CLOMIPRAMINE HYDROCHLORIDE 25 mg Capsule4Non-Preferred Drug27%27%
  • PA
CLOMIPRAMINE HYDROCHLORIDE 50 mg Capsule4Non-Preferred Drug27%27%
  • PA
CLOMIPRAMINE HYDROCHLORIDE 75 mg Capsule4Non-Preferred Drug27%27%
  • PA
CLONAZEPAM .125 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%
  • QL 9 per 30 days
CLONAZEPAM .25 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%
  • QL 9 per 30 days
CLONAZEPAM .5 mg Tablet2Generic$10.00$30.00
  • QL 9 per 30 days
CLONAZEPAM .5 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%
  • QL 9 per 30 days
CLONAZEPAM 1 mg Tablet2Generic$10.00$30.00
  • QL 9 per 30 days
CLONAZEPAM 1 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%
  • QL 9 per 30 days
CLONAZEPAM 2 mg Tablet2Generic$10.00$30.00
  • QL 3 per 30 days
CLONAZEPAM 2 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%
  • QL 3 per 30 days
CLONIDINE HYDROCHLORIDE .1 mg Tablet1Preferred Generic$0.00$0.00None
CLONIDINE HYDROCHLORIDE .2 mg Tablet1Preferred Generic$0.00$0.00None
CLONIDINE HYDROCHLORIDE .3 mg Tablet1Preferred Generic$0.00$0.00None
CLONIDINE TRANSDERMAL SYSTEM .1 mg/d PatchClonidine4Non-Preferred Drug27%27%None
CLONIDINE TRANSDERMAL SYSTEM .2 mg/d PatchClonidine4Non-Preferred Drug27%27%None
CLONIDINE TRANSDERMAL SYSTEM .3 mg/d PatchClonidine4Non-Preferred Drug27%27%None
CLOPIDOGREL 75 mg Tablet, Film CoatedClopidogrel Bisulfate2Generic$10.00$30.00None
CLORAZEPATE DIPOTASSIUM 15 mg Tablet4Non-Preferred Drug27%27%
  • PA
  • QL 18 per 30 days
CLORAZEPATE DIPOTASSIUM 3.75 mg Tablet4Non-Preferred Drug27%27%
  • PA
  • QL 9 per 30 days
CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet4Non-Preferred Drug27%27%
  • PA
  • QL 36 per 30 days
CLOTRIMAZOLE 10 mg Lozenge4Non-Preferred Drug27%27%None
CLOTRIMAZOLE 10 mg/g Cream4Non-Preferred Drug27%27%
  • QL 45 per 28 days
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/g Cream4Non-Preferred Drug27%27%
  • QL 45 per 28 days
CLOTRIMAZOLE TOPICAL SOLUTION USP, 1% 10 mg/mL Solution3Preferred Brand25%25%
  • QL 3 per 28 days
CLOZAPINE 100 mg Tablet4Non-Preferred Drug27%27%None
CLOZAPINE 100 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CLOZAPINE 12.5 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CLOZAPINE 150 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CLOZAPINE 200 mg Tablet4Non-Preferred Drug27%27%None
CLOZAPINE 200 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CLOZAPINE 25 mg Tablet2Generic$10.00$30.00None
CLOZAPINE 25 mg Tablet, Orally Disintegrating4Non-Preferred Drug27%27%None
CLOZAPINE 50 mg Tablet2Generic$10.00$30.00None
COARTEM 20/120 mg TabletArtemether And Lumefantrine4Non-Preferred Drug27%27%None
COBENFY 100/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%N/A
  • QL 6 per 30 days
COBENFY 125/30 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%N/A
  • QL 6 per 30 days
COBENFY 50/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%N/A
  • QL 6 per 30 days
COBENFY KitXanomeline And Trospium Chloride5Specialty Tier25%N/A
  • QL 56 per 180 days
COLCHICINE .6 mg Capsule4Non-Preferred Drug27%27%
  • QL 12 per 30 days
COLCHICINE .6 mg Tablet, Film Coated4Non-Preferred Drug27%27%
  • QL 12 per 30 days
COLESEVELAM HCL 625 mg Tablet, Film Coated4Non-Preferred Drug27%27%None
COLESEVELAM HYDROCHLORIDE 3.75 g Powder, For Suspension4Non-Preferred Drug27%27%None
COLESTIPOL HYDROCHLORIDE 1 g Tablet, Film Coated4Non-Preferred Drug27%27%None
COLESTIPOL HYDROCHLORIDE 5 g/5g Granule, For Suspension4Non-Preferred Drug27%27%None
COLISTIMETHATE 150 mg Injection, Powder, For SolutionColistimethate Sodium5Specialty Tier25%N/A
  • QL 3 per 10 days
COLLAGENASE SANTYL 250 [arb'U]/g Ointment4Non-Preferred Drug27%27%
  • QL 18 per 30 days
COMBIGAN 2/5 mg/mL Solution/ DropsBrimonidine Tartrate, Timolol Maleate3Preferred Brand25%25%None
COMBIVENT RESPIMAT 20/100 ug Spray, MeteredIpratropium Bromide And Albuterol3Preferred Brand25%25%
  • QL 8 per 30 days
COMETRIQ 20 mg CapsuleCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
COMETRIQ KitCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 112 per 28 days
COMETRIQ KitCabozantinib5Specialty Tier25%N/A
  • PA
  • QL 56 per 28 days
COMPRO 25 mg SuppositoryProchlorperazine4Non-Preferred Drug27%27%None
CONEXXENCE 60 mg/mL InjectionDenosumab4Non-Preferred Drug27%27%
  • QL 1 per 180 days
CONSTULOSE 10 g/15mL SolutionLactulose3Preferred Brand25%25%None
COPIKTRA 15 mg CapsuleDuvelisib5Specialty Tier25%N/A
  • PA
  • QL 56 per 28 days
COPIKTRA 25 mg CapsuleDuvelisib5Specialty Tier25%N/A
  • PA
  • QL 56 per 28 days
COSENTYX 150 mg/mL InjectionSecukinumab5Specialty Tier25%N/A
  • PA
  • QL 1 per 28 days
COSENTYX 150 mg/mL InjectionSecukinumab5Specialty Tier25%N/A
  • PA
  • QL 1 per 28 days
COSENTYX 300 mg/2mL InjectionSecukinumab5Specialty Tier25%N/A
  • PA
  • QL 1 per 28 days
COSENTYX 75 mg/.5mL InjectionSecukinumab5Specialty Tier25%N/A
  • PA
  • QL 2.5 per 28 days
COTELLIC 20 mg Tablet, Film CoatedCobimetinib5Specialty Tier25%N/A
  • PA
  • QL 63 per 28 days
CRESEMBA 100 mg CapsuleIsavuconazonium Sulfate5Specialty Tier25%N/A
  • PA
CRESEMBA 40 mg CapsuleIsavuconazonium Sulfate5Specialty Tier25%N/A
  • PA
CROMOLYN SODIUM 100 mg/5mL Solution, Concentrate4Non-Preferred Drug27%27%None
CROMOLYN SODIUM 20 mg/2mL Solution3Preferred Brand25%25%
  • PA
CROMOLYN SODIUM 40 mg/mL Solution/ Drops2Generic$10.00$30.00None
CRYSELLE KitNorgestrel And Ethinyl Estradiol3Preferred Brand25%25%None
CYCLOBENZAPRINE HYDROCHLORIDE 10 mg Tablet, Film Coated4Non-Preferred Drug27%27%
  • PA
CYCLOBENZAPRINE HYDROCHLORIDE 5 mg Tablet, Film Coated4Non-Preferred Drug27%27%
  • PA
CYCLOPHOSPHAMIDE 25 mg Capsule3Preferred Brand25%25%
  • PA
CYCLOPHOSPHAMIDE 50 mg Capsule3Preferred Brand25%25%
  • PA
CYCLOPHOSPHAMIDE 50 mg Tablet4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE .5 mg/mL Emulsion3Preferred Brand25%25%
  • QL 6 per 30 days
CYCLOSPORINE 100 mg Capsule, Gelatin Coated4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE 100 mg/mL Solution4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE 25 mg Capsule, Gelatin Coated4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE MODIFIED 100 mg Capsule, Liquid FilledCyclosporine4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE MODIFIED 50 mg Capsule, Liquid FilledCyclosporine4Non-Preferred Drug27%27%
  • PA
CYCLOSPORINE, MODFIED 25 mg Capsule, Liquid FilledCyclosporine4Non-Preferred Drug27%27%
  • PA
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
CYLTEZO KitAdalimumab-Adbm5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
CYPROHEPTADINE HYDROCHLORIDE 4 mg Tablet4Non-Preferred Drug27%27%
  • PA
CYRED EQ KitDesogestrel And Ethinyl Estradiol3Preferred Brand25%25%None
CYSTAGON 150 mg CapsuleCysteamine Bitartrate4Non-Preferred Drug27%27%
  • PA
CYSTAGON 50 mg CapsuleCysteamine Bitartrate4Non-Preferred Drug27%27%
  • PA
CYSTARAN 6.5 mg/mL SolutionCysteamine Hydrochloride5Specialty 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.