2026 Blue Cross MedicareRx Value (PDP) formulary (drug list)

Contract S5715, plan 010 · Oklahoma · 3,391 drugs on file · formulary ID 00026263. Each drug links to its cost in every CMS PDP Region 23 plan.

268 drugs starting with C.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
CABERGOLINE .5 mg Tablet	3Preferred Brand	18%	18%	None
CABOMETYX 20 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CABOMETYX 40 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CABOMETYX 60 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CALCIPOTRIENE .05 mg/mL Solution	3Preferred Brand	18%	18%	QL 12 per 30 days
CALCIPOTRIENE 50 ug/g Cream	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CALCIPOTRIENE 50 ug/g Ointment	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CALCITONIN SALMON 200 [iU] Spray, Metered	3Preferred Brand	18%	18%	None
CALCITRIOL .25 ug Capsule, Liquid Filled	2Generic	$1.00	$3.00	None
CALCITRIOL .5 ug Capsule, Liquid Filled	2Generic	$1.00	$3.00	None
CALCITRIOL 1 ug/mL Solution	4Non-Preferred Drug	32%	32%	None
CALQUENCE 100 mg Tablet, Film CoatedAcalabrutinib	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
CAMRESE LO KitLevonorgestrel/Ethinyl Estradiol And Ethinyl Estradiol	4Non-Preferred Drug	32%	32%	None
CANDESARTAN 16 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
CANDESARTAN 32 mg Tablet	3Preferred Brand	18%	18%	QL 3 per 30 days
CANDESARTAN 4 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
CANDESARTAN 8 mg Tablet	3Preferred Brand	18%	18%	QL 6 per 30 days
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 16/12.5 mg Tablet	3Preferred Brand	18%	18%	QL 3 per 30 days
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/12.5 mg Tablet	3Preferred Brand	18%	18%	QL 3 per 30 days
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/25 mg Tablet	3Preferred Brand	18%	18%	QL 3 per 30 days
CAPLYTA 10.5 mg CapsuleLumateperone	5Specialty Tier	25%	N/A	QL 3 per 30 days
CAPLYTA 21 mg CapsuleLumateperone	5Specialty Tier	25%	N/A	QL 3 per 30 days
CAPLYTA 42 mg CapsuleLumateperone	5Specialty Tier	25%	N/A	QL 3 per 30 days
CAPRELSA 100 mg Tablet, Film CoatedVandetanib	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
CAPRELSA 300 mg Tablet, Film CoatedVandetanib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CAPTOPRIL 100 mg Tablet	2Generic	$1.00	$3.00	None
CAPTOPRIL 12.5 mg Tablet	2Generic	$1.00	$3.00	None
CAPTOPRIL 25 mg Tablet	2Generic	$1.00	$3.00	None
CAPTOPRIL 50 mg Tablet	2Generic	$1.00	$3.00	None
CARBAMAZEPINE 100 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 100 mg Tablet, Chewable	3Preferred Brand	18%	18%	None
CARBAMAZEPINE 100 mg Tablet, Extended Release	3Preferred Brand	18%	18%	None
CARBAMAZEPINE 100 mg/5mL Suspension	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 200 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 200 mg Tablet	3Preferred Brand	18%	18%	None
CARBAMAZEPINE 200 mg Tablet, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 300 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 400 mg Tablet, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBIDOPA 25 mg Tablet	4Non-Preferred Drug	32%	32%	None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet	2Generic	$1.00	$3.00	None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet	2Generic	$1.00	$3.00	None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	None
CARBIDOPA AND LEVODOPA 25/250 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	None
CARBIDOPA-LEVODOPA 25/250 mg TabletCarbidopa And Levodopa	2Generic	$1.00	$3.00	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 12.5/50/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 18.75/75/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 25/100/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 31.25/125/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 37.5/150/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 50/200/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARGLUMIC ACID 200 mg Tablet, For Suspension	5Specialty Tier	25%	N/A	PA
CARTEOLOL HYDROCHLORIDE 10 mg/mL Solution	2Generic	$1.00	$3.00	None
CARTIA XT 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$1.00	$3.00	None
CARTIA XT 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$1.00	$3.00	None
CARTIA XT 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$1.00	$3.00	None
CARTIA XT 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$1.00	$3.00	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	32%	32%	None
CASPOFUNGIN ACETATE 7 mg/mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	32%	32%	None
CAYSTON KitAztreonam	5Specialty Tier	25%	N/A	PA
CEFACLOR 250 mg Capsule	3Preferred Brand	18%	18%	None
CEFACLOR 500 mg Capsule	3Preferred Brand	18%	18%	None
CEFADROXIL 250 mg/5mL Powder, For Suspension	2Generic	$1.00	$3.00	None
CEFADROXIL 500 mg Capsule	2Generic	$1.00	$3.00	None
CEFADROXIL 500 mg/5mL Powder, For Suspension	2Generic	$1.00	$3.00	None
CEFAZOLIN 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFAZOLIN 10 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFAZOLIN 500 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFDINIR 125 mg/5mL Powder, For Suspension	3Preferred Brand	18%	18%	None
CEFDINIR 250 mg/5mL Powder, For Suspension	3Preferred Brand	18%	18%	None
CEFDINIR 300 mg Capsule	2Generic	$1.00	$3.00	None
CEFEPIME 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFEPIME 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFIXIME 400 mg Capsule	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 10 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFPODOXIME PROXETIL 100 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CEFPODOXIME PROXETIL 100 mg/5mL Granule, For Suspension	4Non-Preferred Drug	32%	32%	None
CEFPODOXIME PROXETIL 200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CEFPODOXIME PROXETIL 50 mg/5mL Granule, For Suspension	4Non-Preferred Drug	32%	32%	None
CEFPROZIL 125 mg/5mL Powder, For Suspension	3Preferred Brand	18%	18%	None
CEFPROZIL 250 mg Tablet	3Preferred Brand	18%	18%	None
CEFPROZIL 250 mg/5mL Powder, For Suspension	3Preferred Brand	18%	18%	None
CEFPROZIL 500 mg Tablet	3Preferred Brand	18%	18%	None
CEFTAROLINE FOSAMIL 400 mg/20mL Injection, Powder, Lyophilized, For Solution	5Specialty Tier	25%	N/A	None
CEFTAROLINE FOSAMIL 600 mg/20mL Injection, Powder, Lyophilized, For Solution	5Specialty Tier	25%	N/A	None
CEFTAZIDIME 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTAZIDIME 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTAZIDIME 6 g/30mL Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 10 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 250 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 500 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFUROXIME 1.5 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFUROXIME 750 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFUROXIME AXETIL 250 mg Tablet	2Generic	$1.00	$3.00	None
CEFUROXIME AXETIL 500 mg Tablet	2Generic	$1.00	$3.00	None
CELECOXIB 100 mg Capsule	2Generic	$1.00	$3.00	QL 6 per 30 days
CELECOXIB 200 mg Capsule	2Generic	$1.00	$3.00	QL 6 per 30 days
CELECOXIB 400 mg Capsule	2Generic	$1.00	$3.00	QL 3 per 30 days
CELECOXIB 50 mg Capsule	2Generic	$1.00	$3.00	QL 6 per 30 days
CEPHALEXIN 125 mg/5mL For Suspension	2Generic	$1.00	$3.00	None
CEPHALEXIN 250 mg Capsule	2Generic	$1.00	$3.00	None
CEPHALEXIN 250 mg/5mL For Suspension	2Generic	$1.00	$3.00	None
CEPHALEXIN 500 mg Capsule	2Generic	$1.00	$3.00	None
CEVIMELINE HYDROCHLORIDE 30 mg Capsule	4Non-Preferred Drug	32%	32%	None
CHEMET 100 mg CapsuleSuccimer	4Non-Preferred Drug	32%	32%	None
CHLORHEXIDINE GLUCONATE 1.2 mg/mL Rinse	1Preferred Generic	$0.00	$0.00	None
CHLOROQUINE PHOSPHATE 250 mg Tablet	4Non-Preferred Drug	32%	32%	None
CHLOROQUINE PHOSPHATE 500 mg Tablet	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 10 mg Tablet, Coated	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 100 mg/mL Concentrate	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 25 mg Tablet, Coated	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 30 mg/mL Concentrate	4Non-Preferred Drug	32%	32%	PA
CHLORPROMAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	PA
CHLORTHALIDONE 25 mg Tablet	2Generic	$1.00	$3.00	None
CHLORTHALIDONE 50 mg Tablet	2Generic	$1.00	$3.00	None
CHOLESTYRAMINE 4 g/5.5g Powder, For Suspension	3Preferred Brand	18%	18%	None
CHOLESTYRAMINE 4 g/9g Powder, For Suspension	3Preferred Brand	18%	18%	None
CICLOPIROX 1 g/100mL Shampoo	3Preferred Brand	18%	18%	None
CICLOPIROX 7.7 mg/g Gel	3Preferred Brand	18%	18%	None
CICLOPIROX 80 mg/mL Solution	3Preferred Brand	18%	18%	QL 6.6 per 30 days
CICLOPIROX OLAMINE 7.7 mg/g Cream	2Generic	$1.00	$3.00	None
CICLOPIROX OLAMINE 7.7 mg/mL Suspension	3Preferred Brand	18%	18%	None
CILOSTAZOL 100 mg Tablet	2Generic	$1.00	$3.00	None
CILOSTAZOL 50 mg Tablet	2Generic	$1.00	$3.00	None
CIMDUO 300/300 mg Tablet, Film CoatedLamivudine And Tenofovir Disoproxil Fumarate	5Specialty Tier	25%	N/A	QL 3 per 30 days
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	2Generic	$1.00	$3.00	None
CIPROFLOXACIN HYDROCHLORIDE 3 mg/mL Solution/ Drops	2Generic	$1.00	$3.00	None
CIPROFLOXACIN IN DEXTROSE 200 mg/100mL Injection, SolutionCiprofloxacin	4Non-Preferred Drug	32%	32%	None
CITALOPRAM 10 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	QL 45 per 30 days
CITALOPRAM 20 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	QL 45 per 30 days
CITALOPRAM 40 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	QL 3 per 30 days
CITALOPRAM HYDROBROMIDE 10 mg/5mL Solution	3Preferred Brand	18%	18%	QL 6 per 30 days
CLARAVIS 10 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 20 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 30 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 40 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARITHROMYCIN 125 mg/5mL For Suspension	4Non-Preferred Drug	32%	32%	None
CLARITHROMYCIN 250 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
CLARITHROMYCIN 250 mg/5mL For Suspension	4Non-Preferred Drug	32%	32%	None
CLARITHROMYCIN 500 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
CLARITHROMYCIN 500 mg Tablet, Film Coated, Extended Release	4Non-Preferred Drug	32%	32%	None
CLINDACIN ETZ 10 mg SwabClindamycin Phosphate	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN HYDROCHLORIDE 150 mg Capsule	2Generic	$1.00	$3.00	None
CLINDAMYCIN HYDROCHLORIDE 300 mg Capsule	2Generic	$1.00	$3.00	None
CLINDAMYCIN HYDROCHLORIDE 75 mg Capsule	2Generic	$1.00	$3.00	None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 12 mg/mL Injection, Solution	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 18 mg/mL Injection, Solution	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 6 mg/mL Injection, Solution	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN PALMITATE HYDROCHLORIDE (PEDIATRIC) 75 mg/5mL Solution	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN PHOSPHATE 1 g/100mL Gel	3Preferred Brand	18%	18%	None
CLINDAMYCIN PHOSPHATE 10 mg/g GelClindamycin Phosphate Gel Usp, 1%	3Preferred Brand	18%	18%	None
CLINDAMYCIN PHOSPHATE 10 mg/mL Lotion	3Preferred Brand	18%	18%	None
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution	3Preferred Brand	18%	18%	None
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution	4Non-Preferred Drug	32%	32%	None
CLINDAMYCIN PHOSPHATE 20 mg/g Cream	3Preferred Brand	18%	18%	None
CLOBAZAM 10 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 6 per 30 days
CLOBAZAM 2.5 mg/mL Suspension	4Non-Preferred Drug	32%	32%	PA QL 48 per 30 days
CLOBAZAM 20 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 6 per 30 days
CLOBETASOL PROPIONATE .05 g/100mL Shampoo	4Non-Preferred Drug	32%	32%	QL 236 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Cream	4Non-Preferred Drug	32%	32%	QL 21 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Cream	4Non-Preferred Drug	32%	32%	QL 21 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Gel	4Non-Preferred Drug	32%	32%	QL 21 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Ointment	4Non-Preferred Drug	32%	32%	QL 21 per 28 days
CLOBETASOL PROPIONATE .5 mg/mL Solution	3Preferred Brand	18%	18%	QL 2 per 28 days
CLODAN .5 mg/mL ShampooClobetasol Propionate	4Non-Preferred Drug	32%	32%	QL 236 per 30 days
CLOMIPRAMINE HYDROCHLORIDE 25 mg Capsule	4Non-Preferred Drug	32%	32%	None
CLOMIPRAMINE HYDROCHLORIDE 50 mg Capsule	4Non-Preferred Drug	32%	32%	None
CLOMIPRAMINE HYDROCHLORIDE 75 mg Capsule	4Non-Preferred Drug	32%	32%	None
CLONAZEPAM .125 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	QL 9 per 30 days
CLONAZEPAM .25 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	QL 9 per 30 days
CLONAZEPAM .5 mg Tablet	2Generic	$1.00	$3.00	QL 12 per 30 days
CLONAZEPAM .5 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	QL 9 per 30 days
CLONAZEPAM 1 mg Tablet	2Generic	$1.00	$3.00	QL 12 per 30 days
CLONAZEPAM 1 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	QL 9 per 30 days
CLONAZEPAM 2 mg Tablet	2Generic	$1.00	$3.00	QL 3 per 30 days
CLONAZEPAM 2 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	QL 3 per 30 days
CLONIDINE HYDROCHLORIDE .1 mg Tablet	1Preferred Generic	$0.00	$0.00	None
CLONIDINE HYDROCHLORIDE .1 mg Tablet, Extended Release	3Preferred Brand	18%	18%	QL 12 per 30 days
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	32%	32%	None
CLONIDINE TRANSDERMAL SYSTEM .2 mg/d PatchClonidine	4Non-Preferred Drug	32%	32%	None
CLONIDINE TRANSDERMAL SYSTEM .3 mg/d PatchClonidine	4Non-Preferred Drug	32%	32%	None
CLOPIDOGREL 75 mg Tablet, Film CoatedClopidogrel Bisulfate	1Preferred Generic	$0.00	$0.00	None
CLORAZEPATE DIPOTASSIUM 15 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLORAZEPATE DIPOTASSIUM 3.75 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 12 per 30 days
CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 36 per 30 days
CLOTRIMAZOLE 10 mg Lozenge	2Generic	$1.00	$3.00	None
CLOTRIMAZOLE 10 mg/g Cream	2Generic	$1.00	$3.00	None
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/g Cream	3Preferred Brand	18%	18%	None
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/mL Lotion	4Non-Preferred Drug	32%	32%	None
CLOZAPINE 100 mg Tablet	3Preferred Brand	18%	18%	PA QL 27 per 30 days
CLOZAPINE 100 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 27 per 30 days
CLOZAPINE 12.5 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 9 per 30 days
CLOZAPINE 150 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLOZAPINE 200 mg Tablet	3Preferred Brand	18%	18%	PA QL 12 per 30 days
CLOZAPINE 200 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 12 per 30 days
CLOZAPINE 25 mg Tablet	3Preferred Brand	18%	18%	PA QL 9 per 30 days
CLOZAPINE 25 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 27 per 30 days
CLOZAPINE 50 mg Tablet	3Preferred Brand	18%	18%	PA QL 9 per 30 days
COARTEM 20/120 mg TabletArtemether And Lumefantrine	4Non-Preferred Drug	32%	32%	None
COBENFY 100/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
COBENFY 125/30 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
COBENFY 50/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
COBENFY KitXanomeline And Trospium Chloride	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COLCHICINE .6 mg Tablet, Film Coated	3Preferred Brand	18%	18%	None
COLESTIPOL HYDROCHLORIDE 1 g Tablet, Film Coated	3Preferred Brand	18%	18%	None
COLESTIPOL HYDROCHLORIDE 5 g/5g Granule, For Suspension	4Non-Preferred Drug	32%	32%	None
COLISTIMETHATE 150 mg Injection, Powder, For SolutionColistimethate Sodium	4Non-Preferred Drug	32%	32%	None
COLLAGENASE SANTYL 250 [arb'U]/g Ointment	4Non-Preferred Drug	32%	32%	QL 18 per 30 days
COMBIPATCH (ESTRADIOL/NORETHINDRONE ACETATE TRANSDERMAL SYSTEM) .05/.14 mg/d Patch, Extended ReleaseEstradiol/Norethindrone Acetate Transdermal System	4Non-Preferred Drug	32%	32%	None
COMBIPATCH (ESTRADIOL/NORETHINDRONE ACETATE TRANSDERMAL SYSTEM) .05/.25 mg/d Patch, Extended ReleaseEstradiol/Norethindrone Acetate Transdermal System	4Non-Preferred Drug	32%	32%	None
COMBIVENT RESPIMAT 20/100 ug Spray, MeteredIpratropium Bromide And Albuterol	4Non-Preferred Drug	32%	32%	QL 8 per 30 days
COMETRIQ 20 mg CapsuleCabozantinib	5Specialty Tier	25%	N/A	PA QL 84 per 28 days
COMETRIQ KitCabozantinib	5Specialty Tier	25%	N/A	PA QL 112 per 28 days
COMETRIQ KitCabozantinib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COMPRO 25 mg SuppositoryProchlorperazine	4Non-Preferred Drug	32%	32%	None
CONSTULOSE 10 g/15mL SolutionLactulose	2Generic	$1.00	$3.00	None
COPIKTRA 15 mg CapsuleDuvelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COPIKTRA 25 mg CapsuleDuvelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COSENTYX 150 mg/mL InjectionSecukinumab	5Specialty Tier	25%	N/A	PA QL 8 per 28 days
COSENTYX 150 mg/mL InjectionSecukinumab	5Specialty Tier	25%	N/A	PA QL 8 per 28 days
COSENTYX 300 mg/2mL InjectionSecukinumab	5Specialty Tier	25%	N/A	PA QL 8 per 28 days
COSENTYX 75 mg/.5mL InjectionSecukinumab	5Specialty Tier	25%	N/A	PA QL 2 per 28 days
COTELLIC 20 mg Tablet, Film CoatedCobimetinib	5Specialty Tier	25%	N/A	PA QL 63 per 28 days
CREON 15000/3000/9500 [USP'U] Capsule, Delayed ReleasePancrelipase	3Preferred Brand	18%	18%	None
CREON 24000/76000/120000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	18%	18%	None
CREON 30000/6000/19000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	18%	18%	None
CREON 36000/180000/114000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	18%	18%	None
CREON 60000/12000/38000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	18%	18%	None
CRESEMBA 100 mg CapsuleIsavuconazonium Sulfate	5Specialty Tier	25%	N/A	PA
CRESEMBA 40 mg CapsuleIsavuconazonium Sulfate	5Specialty Tier	25%	N/A	PA
CROMOLYN SODIUM 100 mg/5mL Solution, Concentrate	4Non-Preferred Drug	32%	32%	None
CROMOLYN SODIUM 20 mg/2mL Solution	3Preferred Brand	18%	18%	PA
CROMOLYN SODIUM 40 mg/mL Solution/ Drops	2Generic	$1.00	$3.00	None
CRYSELLE KitNorgestrel And Ethinyl Estradiol	4Non-Preferred Drug	32%	32%	None
CYCLOBENZAPRINE HYDROCHLORIDE 10 mg Tablet, Film Coated	2Generic	$1.00	$3.00	None
CYCLOBENZAPRINE HYDROCHLORIDE 5 mg Tablet, Film Coated	2Generic	$1.00	$3.00	None
CYCLOPHOSPHAMIDE 25 mg Capsule	4Non-Preferred Drug	32%	32%	PA
CYCLOPHOSPHAMIDE 50 mg Capsule	4Non-Preferred Drug	32%	32%	PA
CYCLOPHOSPHAMIDE 50 mg Tablet	3Preferred Brand	18%	18%	PA
CYCLOSET .8 mg TabletBromocriptine Mesylate	4Non-Preferred Drug	32%	32%	QL 18 per 30 days
CYCLOSPORINE 100 mg Capsule, Gelatin Coated	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE 100 mg/mL Solution	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE 25 mg Capsule, Gelatin Coated	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE MODIFIED 100 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE MODIFIED 50 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE, MODFIED 25 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYPROHEPTADINE HYDROCHLORIDE 4 mg Tablet	4Non-Preferred Drug	32%	32%	PA
CYRED EQ KitDesogestrel And Ethinyl Estradiol	4Non-Preferred Drug	32%	32%	None
CYSTAGON 150 mg CapsuleCysteamine Bitartrate	4Non-Preferred Drug	32%	32%	PA
CYSTAGON 50 mg CapsuleCysteamine Bitartrate	4Non-Preferred Drug	32%	32%	PA
CYSTARAN 6.5 mg/mL SolutionCysteamine Hydrochloride	5Specialty Tier	25%	N/A	PA QL 6 per 28 days

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.