2026 HealthSpring Assurance Rx (PDP) formulary (drug list)
Contract S5617, plan 123 · Minnesota · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 25 plan.
21 drugs starting with U.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| ULTRAMICROSIZE GRISEOFULVIN 125 mg Tablet, CoatedUltramicrosize Griseofulvin Tablets | 4Non-Preferred Drug | 30% | 30% | None |
| ULTRAMICROSIZE GRISEOFULVIN 165 mg Tablet | 4Non-Preferred Drug | 30% | 30% | None |
| ULTRAMICROSIZE GRISEOFULVIN 250 mg Tablet, CoatedUltramicrosize Griseofulvin Tablets | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 100 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 112 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 125 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 137 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 150 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 175 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 200 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 25 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 300 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 50 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 75 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| UNITHROID 88 ug TabletLevothyroxine Sodium | 4Non-Preferred Drug | 30% | 30% | None |
| URSODIOL 250 mg Tablet | 4Non-Preferred Drug | 30% | 30% | None |
| URSODIOL 300 mg Capsule | 3Preferred Brand | 21% | 21% | None |
| URSODIOL 500 mg Tablet | 4Non-Preferred Drug | 30% | 30% | None |
| USTEKINUMAB 45 mg/.5mL Injection, Solution | 5Specialty Tier | 25% | N/A |
|
| USTEKINUMAB 45 mg/.5mL Injection, Solution | 5Specialty Tier | 25% | N/A |
|
| USTEKINUMAB 90 mg/mL Injection, Solution | 5Specialty Tier | 25% | 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.