2026 Prescription Blue Select (PDP) formulary (drug list)
Contract S5584, plan 001 · Michigan · 3,017 drugs on file · formulary ID 00026449. Each drug links to its cost in every CMS PDP Region 13 plan.
251 drugs starting with A.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| ABACAVIR 20 mg/mL SolutionAbacavir Sulfate | 4Non-Preferred Drug | 25% | 25% | None |
| ABACAVIR 300 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% | None |
| ABILIFY ASIMTUFII 720 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABILIFY ASIMTUFII 960 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABILIFY MAINTENA KitAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABILIFY MAINTENA KitAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABIRTEGA 250 mg TabletAbiraterone Acetate | 4Non-Preferred Drug | 25% | 25% | None |
| ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated | 4Non-Preferred Drug | 25% | 25% | None |
| ACARBOSE 100 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| ACARBOSE 25 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| ACARBOSE 50 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| ACEBUTOLOL HYDROCHLORIDE 200 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| ACEBUTOLOL HYDROCHLORIDE 400 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution | 3Preferred Brand | 20% | 20% |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ACETAZOLAMIDE 125 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| ACETAZOLAMIDE 250 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| ACETAZOLAMIDE 500 mg Capsule, Extended Release | 4Non-Preferred Drug | 25% | 25% | None |
| ACETIC ACID 20.65 mg/mL Solution | 3Preferred Brand | 20% | 20% | None |
| ACETYLCYSTEINE 100 mg/mL Inhalant | 4Non-Preferred Drug | 25% | 25% |
|
| ACETYLCYSTEINE 200 mg/mL Solution | 4Non-Preferred Drug | 25% | 25% |
|
| ACITRETIN 10 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ACITRETIN 17.5 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ACITRETIN 25 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ACTHIB KitHaemophilus Influenzae Type B Strain 1482 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen | 3Preferred Brand | 20% | 20% | None |
| ACTIMMUNE 100 ug/.5mL Injection, SolutionInterferon Gamma-1B | 5Specialty Tier | 25% | N/A |
|
| ACYCLOVIR 200 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| ACYCLOVIR 400 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| ACYCLOVIR 800 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution | 4Non-Preferred Drug | 25% | 25% |
|
| ADACEL TDAP 5/2/2.5/5/3/5 [Lf]/.5mL/ug/.5mL Injection, SuspensionClostridium Tetani Toxoid Antigen (Formaldehyde Inactivated), Corynebacterium Diphtheriae Toxoid Antigen (Formaldehyde Inactivated), Bordetella Pertussis Toxoid Antigen (Glutaraldehyde Inactivated), Bordetella Pertussis Filamentous Hemagglutinin Antigen (Formaldehyde Inactivated), Bordetella Pertussis Pertactin Antigen, And Bordetella Pertussis Fimbriae 2/3 Antigen | 3Preferred Brand | 20% | 20% | None |
| ADALIMUMAB KitAdalimumab-Aaty | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB KitAdalimumab-Aaty | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB KitAdalimumab-Aaty | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB KitAdalimumab-Aaty | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB KitAdalimumab-Aaty | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-ADBM Kit | 5Specialty Tier | 25% | N/A |
|
| ADBRY 150 mg/mL Injection, SolutionTralokinumab-Ldrm | 5Specialty Tier | 25% | N/A |
|
| ADBRY 300 mg/2mL Injection, SolutionTralokinumab-Ldrm | 5Specialty Tier | 25% | N/A |
|
| ADEFOVIR DIPIVOXIL 10 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ADEMPAS .5 mg Tablet, Film CoatedRiociguat | 5Specialty Tier | 25% | N/A |
|
| ADEMPAS 1 mg Tablet, Film CoatedRiociguat | 5Specialty Tier | 25% | N/A |
|
| ADEMPAS 1.5 mg Tablet, Film CoatedRiociguat | 5Specialty Tier | 25% | N/A |
|
| ADEMPAS 2 mg Tablet, Film CoatedRiociguat | 5Specialty Tier | 25% | N/A |
|
| ADEMPAS 2.5 mg Tablet, Film CoatedRiociguat | 5Specialty Tier | 25% | N/A |
|
| ADVAIR HFA 115/21 ug Aerosol, MeteredFluticasone Propionate And Salmeterol Xinafoate | 3Preferred Brand | 20% | 20% |
|
| ADVAIR HFA 230/21 ug Aerosol, MeteredFluticasone Propionate And Salmeterol Xinafoate | 3Preferred Brand | 20% | 20% |
|
| ADVAIR HFA 45/21 ug Aerosol, MeteredFluticasone Propionate And Salmeterol Xinafoate | 3Preferred Brand | 20% | 20% |
|
| AIMOVIG 140 mg/mL Injection, SolutionErenumab-Aooe | 3Preferred Brand | 20% | 20% |
|
| AIMOVIG 70 mg/mL InjectionErenumab-Aooe | 3Preferred Brand | 20% | 20% |
|
| AKEEGA 100/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate | 5Specialty Tier | 25% | N/A |
|
| AKEEGA 50/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate | 5Specialty Tier | 25% | N/A |
|
| ALBENDAZOLE 200 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ALBUTEROL 2 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ALBUTEROL 4 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ALBUTEROL SULFATE 2 mg/5mL Syrup | 2Generic | $5.00 | $15.00 | None |
| ALBUTEROL SULFATE 2.5 mg/.5mL Solution | 2Generic | $5.00 | $15.00 |
|
| ALBUTEROL SULFATE 2.5 mg/3mL Solution | 2Generic | $5.00 | $15.00 |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 3Preferred Brand | 20% | 20% |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 3Preferred Brand | 20% | 20% |
|
| ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $5.00 | $15.00 |
|
| ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $5.00 | $15.00 |
|
| ALCLOMETASONE DIPROPIONATE .5 mg/g Ointment | 3Preferred Brand | 20% | 20% | None |
| ALECENSA 150 mg CapsuleAlectinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| ALENDRONATE SODIUM 10 mg Tablet | 2Generic | $5.00 | $15.00 |
|
| ALENDRONATE SODIUM 35 mg Tablet | 2Generic | $5.00 | $15.00 |
|
| ALENDRONATE SODIUM 70 mg Tablet | 2Generic | $5.00 | $15.00 |
|
| ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release | 3Preferred Brand | 20% | 20% |
|
| ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate | 4Non-Preferred Drug | 25% | 25% |
|
| ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate | 4Non-Preferred Drug | 25% | 25% |
|
| ALLOPURINOL 100 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| ALLOPURINOL 300 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% |
|
| ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% |
|
| ALPRAZOLAM .25 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ALPRAZOLAM .5 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ALPRAZOLAM 1 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ALPRAZOLAM 2 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ALTAVERA KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $5.00 | $15.00 | None |
| ALUNBRIG 180 mg Tablet, Film CoatedBrigatinib | 5Specialty Tier | 25% | N/A |
|
| ALUNBRIG 30 mg Tablet, Film CoatedBrigatinib | 5Specialty Tier | 25% | N/A |
|
| ALUNBRIG 90 mg Tablet, Film CoatedBrigatinib | 5Specialty Tier | 25% | N/A |
|
| ALUNBRIG KitBrigatinib | 5Specialty Tier | 25% | N/A |
|
| ALYQ 20 mg Tablet, Film CoatedTadalafil | 4Non-Preferred Drug | 25% | 25% |
|
| AMANTADINE HYDROCHLORIDE 100 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| AMANTADINE HYDROCHLORIDE 100 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution | 3Preferred Brand | 20% | 20% | None |
| AMBRISENTAN 10 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMBRISENTAN 5 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMIKACIN SULFATE 250 mg/mL Injection, Solution | 4Non-Preferred Drug | 25% | 25% | None |
| AMILORIDE HYDROCHLORIDE 5 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMILORIDE HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE 5/50 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| AMIODARONE HYDROCHLORIDE 100 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| AMIODARONE HYDROCHLORIDE 200 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| AMIODARONE HYDROCHLORIDE 400 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated | 3Preferred Brand | 20% | 20% | None |
| AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/20 mg Tablet | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/40 mg Tablet, Film Coated | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/20 mg Tablet | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/40 mg Tablet | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE AND VALSARTAN 10/160 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 |
|
| AMLODIPINE AND VALSARTAN 10/320 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 |
|
| AMLODIPINE AND VALSARTAN 5/160 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 |
|
| AMLODIPINE AND VALSARTAN 5/320 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 |
|
| AMLODIPINE BESYLATE 10 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| AMLODIPINE BESYLATE 2.5 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| AMLODIPINE BESYLATE 5 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule | 1Preferred Generic | $1.00 | $3.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/160/12.5 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 4Non-Preferred Drug | 25% | 25% |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/25/160 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 4Non-Preferred Drug | 25% | 25% |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/25/320 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 4Non-Preferred Drug | 25% | 25% |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 5/160/12.5 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 4Non-Preferred Drug | 25% | 25% |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 5/160/25 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 4Non-Preferred Drug | 25% | 25% |
|
| AMMONIUM LACTATE 12 g/100g Cream | 3Preferred Brand | 20% | 20% | None |
| AMMONIUM LACTATE 12 g/100g Lotion | 3Preferred Brand | 20% | 20% | None |
| AMNESTEEM 10 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| AMNESTEEM 20 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| AMNESTEEM 30 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| AMNESTEEM 40 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 25% | 25% |
|
| AMOXAPINE 100 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMOXAPINE 150 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMOXAPINE 25 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMOXAPINE 50 mg Tablet | 3Preferred Brand | 20% | 20% | None |
| AMOXICILLIN 125 mg Tablet, Chewable | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 125 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 200 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 250 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 250 mg Tablet, Chewable | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 250 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 400 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 500 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN 875 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension | 4Non-Preferred Drug | 25% | 25% | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension | 2Generic | $5.00 | $15.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AMPHOTERICIN B 50 mg/10mL Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 25% | 25% |
|
| AMPHOTERICIN B 50 mg/12.5mL Injection, Powder, Lyophilized, For Solution | 5Specialty Tier | 25% | N/A |
|
| AMPICILLIN 1 g Injection, Powder, For SolutionAmpicillin Sodium | 4Non-Preferred Drug | 25% | 25% | None |
| AMPICILLIN 500 mg Capsule | 2Generic | $5.00 | $15.00 | None |
| AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 4Non-Preferred Drug | 25% | 25% | None |
| AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 4Non-Preferred Drug | 25% | 25% | None |
| AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution | 4Non-Preferred Drug | 25% | 25% | None |
| ANAGRELIDE .5 mg Capsule | 3Preferred Brand | 20% | 20% | None |
| ANAGRELIDE 1 mg Capsule | 3Preferred Brand | 20% | 20% | None |
| ANASTROZOLE 1 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| ANORO ELLIPTA 62.5/25 ug PowderUmeclidinium Bromide And Vilanterol Trifenatate | 3Preferred Brand | 20% | 20% |
|
| APREPITANT 125 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| APREPITANT 40 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| APREPITANT 80 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| APREPITANT Kit | 4Non-Preferred Drug | 25% | 25% |
|
| ARCALYST 160 mg/2mL Injection, Powder, Lyophilized, For SolutionRilonacept | 5Specialty Tier | 25% | N/A |
|
| AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted | 3Preferred Brand | 20% | 20% | None |
| ARIKAYCE 590 mg/8.4mL SuspensionAmikacin | 5Specialty Tier | 25% | N/A |
|
| ARIPIPRAZOLE 1 mg/mL Solution | 4Non-Preferred Drug | 25% | 25% |
|
| ARIPIPRAZOLE 10 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 25% | 25% |
|
| ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating | 4Non-Preferred Drug | 25% | 25% |
|
| ARIPIPRAZOLE 15 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARIPIPRAZOLE 2 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARIPIPRAZOLE 20 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARIPIPRAZOLE 30 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARIPIPRAZOLE 5 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil | 5Specialty Tier | 25% | N/A |
|
| ARISTADA 441 mg/1.6mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil | 5Specialty Tier | 25% | N/A |
|
| ARISTADA 662 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil | 5Specialty Tier | 25% | N/A |
|
| ARISTADA 882 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil | 5Specialty Tier | 25% | N/A |
|
| ARISTADA INITIO 675 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil | 5Specialty Tier | 25% | N/A |
|
| ARMODAFINIL 150 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARMODAFINIL 200 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARMODAFINIL 250 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARMODAFINIL 50 mg Tablet | 3Preferred Brand | 20% | 20% |
|
| ARNUITY ELLIPTA 100 ug PowderFluticasone Furoate | 3Preferred Brand | 20% | 20% | None |
| ARNUITY ELLIPTA 200 ug PowderFluticasone Furoate | 3Preferred Brand | 20% | 20% | None |
| ARNUITY ELLIPTA 50 ug PowderFluticasone Furoate | 3Preferred Brand | 20% | 20% | None |
| ASENAPINE 10 mg TabletAsenapine Maleate | 4Non-Preferred Drug | 25% | 25% |
|
| ASENAPINE 2.5 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| ASENAPINE 5 mg TabletAsenapine Maleate | 4Non-Preferred Drug | 25% | 25% |
|
| ASPRIN AND EXTENDED-RELEASE DIPYRIDAMOLE 25/200 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ASTAGRAF XL .5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 4Non-Preferred Drug | 25% | 25% |
|
| ASTAGRAF XL 1 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 4Non-Preferred Drug | 25% | 25% |
|
| ASTAGRAF XL 5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 4Non-Preferred Drug | 25% | 25% |
|
| ATAZANAVIR SULFATE 150 mg CapsuleAtazanavir | 4Non-Preferred Drug | 25% | 25% | None |
| ATAZANAVIR SULFATE 200 mg CapsuleAtazanavir | 4Non-Preferred Drug | 25% | 25% | None |
| ATAZANAVIR SULFATE 300 mg CapsuleAtazanavir | 4Non-Preferred Drug | 25% | 25% | None |
| ATENOLOL 100 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| ATENOLOL 25 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| ATENOLOL 50 mg Tablet | 1Preferred Generic | $1.00 | $3.00 | None |
| ATENOLOL AND CHLORTHALIDONE 100/25 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet | 2Generic | $5.00 | $15.00 | None |
| ATOMOXETINE 10 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 100 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 18 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 25 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 40 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 60 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATOMOXETINE 80 mg Capsule | 4Non-Preferred Drug | 25% | 25% |
|
| ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated | 1Preferred Generic | $1.00 | $3.00 |
|
| ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated | 1Preferred Generic | $1.00 | $3.00 |
|
| ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated | 1Preferred Generic | $1.00 | $3.00 |
|
| ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated | 1Preferred Generic | $1.00 | $3.00 |
|
| ATOVAQUONE 750 mg/5mL Suspension | 4Non-Preferred Drug | 25% | 25% | None |
| ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% | None |
| ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate | 3Preferred Brand | 20% | 20% | None |
| ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide | 4Non-Preferred Drug | 25% | 25% |
|
| AUGTYRO 160 mg CapsuleRepotrectinib | 5Specialty Tier | 25% | N/A |
|
| AUGTYRO 40 mg CapsuleRepotrectinib | 5Specialty Tier | 25% | N/A |
|
| AUVELITY 45/105 mg Tablet, Multilayer, Extended ReleaseDextromethorphan Hydrobromide, Bupropion Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| AVIANE KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $5.00 | $15.00 | None |
| AVMAPKI FAKZYNJA CO-PACK KitAvutometinib Potassium And Defactinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| AYVAKIT 100 mg Tablet, Film CoatedAvapritinib | 5Specialty Tier | 25% | N/A |
|
| AYVAKIT 200 mg Tablet, Film CoatedAvapritinib | 5Specialty Tier | 25% | N/A |
|
| AYVAKIT 25 mg Tablet, Film CoatedAvapritinib | 5Specialty Tier | 25% | N/A |
|
| AYVAKIT 300 mg Tablet, Film CoatedAvapritinib | 5Specialty Tier | 25% | N/A |
|
| AYVAKIT 50 mg Tablet, Film CoatedAvapritinib | 5Specialty Tier | 25% | N/A |
|
| AZATHIOPRINE 50 mg Tablet | 2Generic | $5.00 | $15.00 |
|
| AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops | 3Preferred Brand | 20% | 20% | None |
| AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered | 3Preferred Brand | 20% | 20% | None |
| AZITHROMYCIN 250 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AZITHROMYCIN 250 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate | 4Non-Preferred Drug | 25% | 25% | None |
| AZITHROMYCIN 600 mg Tablet, Film Coated | 2Generic | $5.00 | $15.00 | None |
| AZITHROMYCIN DIHYDRATE 200 mg/5mL Powder, For Suspension | 3Preferred Brand | 20% | 20% | None |
| AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 25% | 25% | None |
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.