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

Contract S5715, plan 015 · Oklahoma · 2,948 drugs on file · formulary ID 00026260. Each drug links to its cost in every CMS PDP Region 23 plan.

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148 drugs starting with S.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
SACUBITRIL AND VALSARTAN 24/26 mg Tablet, Film Coated3Preferred Brand16%16%
  • QL 18 per 30 days
SACUBITRIL AND VALSARTAN 49/51 mg Tablet, Film Coated3Preferred Brand16%16%
  • QL 6 per 30 days
SACUBITRIL AND VALSARTAN 97/103 mg Tablet, Film Coated3Preferred Brand16%16%
  • QL 6 per 30 days
SAJAZIR 30 mg/3mL InjectionIcatibant5Specialty Tier25%N/A
  • PA
  • QL 18 per 30 days
SAPROPTERIN DIHYDROCHLORIDE 100 mg Powder, For Solution5Specialty Tier25%N/A
  • PA
SAPROPTERIN DIHYDROCHLORIDE 100 mg Tablet5Specialty Tier25%N/A
  • PA
SAPROPTERIN DIHYDROCHLORIDE 500 mg Powder, For Solution5Specialty Tier25%N/A
  • PA
SCEMBLIX 100 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
SCEMBLIX 20 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SCEMBLIX 40 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
SCOPOLAMINE 1 mg/3d Patch4Non-Preferred Drug40%40%
  • PA
SECUADO 3.8 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SECUADO 5.7 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SECUADO 7.6 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SELEGILINE HYDROCHLORIDE 5 mg Capsule3Preferred Brand16%16%None
SELEGILINE HYDROCHLORIDE 5 mg Tablet3Preferred Brand16%16%None
SELENIUM SULFIDE 2.5 mg/100mL Lotion2Generic$5.00$15.00None
SELZENTRY KitMaraviroc5Specialty Tier25%N/A
  • QL 184 per 30 days
SEREVENT DISKUS 50 ug Powder, MeteredSalmeterol Xinafoate3Preferred Brand16%16%
  • QL 6 per 30 days
SERTRALINE HYDROCHLORIDE 100 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 6 per 30 days
SERTRALINE HYDROCHLORIDE 20 mg/mL Solution, Concentrate4Non-Preferred Drug40%40%
  • QL 3 per 30 days
SERTRALINE HYDROCHLORIDE 25 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 45 per 30 days
SERTRALINE HYDROCHLORIDE 50 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 45 per 30 days
SETLAKIN KitLevonorgestrel And Ethinyl Estradiol4Non-Preferred Drug40%40%None
SHAROBEL KitNorethindrone3Preferred Brand16%16%None
SHINGRIX 50 ug/.5mL Injection, SolutionZoster Vaccine Recombinant, Adjuvanted1Preferred Generic$0.00$0.00
  • QL 1 per 999 days
SHINGRIX KitZoster Vaccine Recombinant, Adjuvanted1Preferred Generic$0.00$0.00
  • QL 2 per 999 days
SIGNIFOR .3 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
SIGNIFOR .6 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
SIGNIFOR .9 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
SILDENAFIL 20 mg Tablet3Preferred Brand16%16%
  • PA
  • QL 9 per 30 days
SILVER SULFADIAZINE 10 mg/g Cream2Generic$5.00$15.00None
SIMLANDI KitAdalimumab-Ryvk5Specialty Tier25%N/A
  • PA
  • QL 3 per 28 days
SIMLANDI KitAdalimumab-Ryvk5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
SIMLANDI KitAdalimumab-Ryvk5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
SIMLANDI KitAdalimumab-Ryvk5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
SIMVASTATIN 10 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 45 per 30 days
SIMVASTATIN 20 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 6 per 30 days
SIMVASTATIN 40 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 45 per 30 days
SIMVASTATIN 5 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 45 per 30 days
SIMVASTATIN 80 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
SIROLIMUS .5 mg Tablet, Film Coated4Non-Preferred Drug40%40%
  • PA
SIROLIMUS 1 mg Tablet4Non-Preferred Drug40%40%
  • PA
SIROLIMUS 1 mg/mL Solution4Non-Preferred Drug40%40%
  • PA
SIROLIMUS 2 mg Tablet4Non-Preferred Drug40%40%
  • PA
SIRTURO 100 mg TabletBedaquiline Fumarate5Specialty Tier25%N/ANone
SIRTURO 20 mg TabletBedaquiline Fumarate5Specialty Tier25%N/ANone
SKYLA 13.5 mg Intrauterine DeviceLevonorgestrel4Non-Preferred Drug40%40%None
SKYRIZI 150 mg/mL InjectionRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 6 per 365 days
SKYRIZI 150 mg/mL InjectionRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 6 per 365 days
SKYRIZI KitRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 8.4 per 365 days
SKYRIZI KitRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 16.8 per 365 days
SODIUM CHLORIDE 4.5 g/1000mL Injection, Solution4Non-Preferred Drug40%40%None
SODIUM CHLORIDE 9 g/1000mL Injection, Solution4Non-Preferred Drug40%40%None
SODIUM OXYBATE .5 g/mL Solution5Specialty Tier25%N/A
  • PA
  • QL 54 per 30 days
SODIUM PHENYLBUTYRATE .94 g/g Powder5Specialty Tier25%N/A
  • PA
SODIUM PHENYLBUTYRATE 500 mg TabletSodium Phenylbutyrate Tablets, 500 Mg5Specialty Tier25%N/A
  • PA
SODIUM POLYSTYRENE SULFONATE 1 g/g Powder3Preferred Brand16%16%None
SODIUM POLYSTYRENE SULFONATE 15 g/60mL Suspension4Non-Preferred Drug40%40%None
SODIUM SULFATE, POTASSIUM SULFATE, AND MAGNESIUM SULFATE BOWEL PREP KIT 17.5/3.13/1.6 g/177mL SolutionSodium Sulfate Anhydrous, Potassium Sulfate, And Magnesium Sulfate4Non-Preferred Drug40%40%None
SOLTAMOX 20 mg/10mL LiquidTamoxifen Citrate4Non-Preferred Drug40%40%None
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SORAFENIB 200 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
SOTALOL HYDROCHLORIDE 120 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE 120 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE 160 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE 240 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE 80 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE 80 mg Tablet2Generic$5.00$15.00None
SOTALOL HYDROCHLORIDE AF 160 mg TabletSotalol Hydrochloride Tablets Af2Generic$5.00$15.00None
SPIRIVA RESPIMAT 1.562 ug Spray, MeteredTiotropium Bromide Inhalation Spray3Preferred Brand16%16%
  • QL 4 per 30 days
SPIRIVA RESPIMAT 3.124 ug Spray, MeteredTiotropium Bromide Inhalation Spray3Preferred Brand16%16%
  • QL 4 per 30 days
SPIRONOLACTONE 100 mg Tablet2Generic$5.00$15.00None
SPIRONOLACTONE 25 mg Tablet2Generic$5.00$15.00None
SPIRONOLACTONE 50 mg Tablet2Generic$5.00$15.00None
SPIRONOLACTONE AND HYDROCHLOROTHIAZIDE 25/25 mg Tablet3Preferred Brand16%16%None
SPRINTEC KitNorgestimate And Ethinyl Estradiol4Non-Preferred Drug40%40%None
SPRITAM 250 mg Tablet, For SuspensionLevetiracetam4Non-Preferred Drug40%40%None
SPRITAM 500 mg Tablet, For SuspensionLevetiracetam4Non-Preferred Drug40%40%None
SSD CREAM 10 g/1000g CreamSilver Sulfadiazine2Generic$5.00$15.00None
STEQEYMA 45 mg/.5mL Injection, SolutionUstekinumab-Stba4Non-Preferred Drug40%40%
  • PA
  • QL 1.5 per 84 days
STEQEYMA 90 mg/mL Injection, SolutionUstekinumab-Stba5Specialty Tier25%N/A
  • PA
  • QL 3 per 84 days
STIOLTO RESPIMAT 3.124/2.736 ug Spray, MeteredTiotropium Bromide And Olodaterol3Preferred Brand16%16%
  • QL 4 per 30 days
STIVARGA 40 mg Tablet, Film CoatedRegorafenib5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
STOBOCLO 60 mg/mL InjectionDenosumab-Bmwo4Non-Preferred Drug40%40%
  • PA
STREPTOMYCIN 1 g Injection, Powder, Lyophilized, For Solution5Specialty Tier25%N/ANone
STRIBILD 150/150/200/300 mg Tablet, Film CoatedElvitegravir, Cobicistat, Emtricitabine, And Tenofovir Disoproxil Fumarate5Specialty Tier25%N/A
  • QL 3 per 30 days
SUBVENITE 10 mg/mL SuspensionLamotrigine5Specialty Tier25%N/ANone
SUBVENITE 100 mg TabletLamotrigine2Generic$5.00$15.00None
SUBVENITE 150 mg TabletLamotrigine2Generic$5.00$15.00None
SUBVENITE 200 mg TabletLamotrigine2Generic$5.00$15.00None
SUBVENITE 25 mg TabletLamotrigine2Generic$5.00$15.00None
SULFACETAMIDE SODIUM 100 mg/mL Lotion4Non-Preferred Drug40%40%None
SULFACETAMIDE SODIUM 100 mg/mL Solution/ Drops3Preferred Brand16%16%None
SULFACETAMIDE SODIUM AND PREDNISOLONE SODIUM PHOSPHATE 100/2.3 mg/mL Solution/ Drops2Generic$5.00$15.00None
SULFADIAZINE 500 mg Tablet5Specialty Tier25%N/ANone
SULFAMETHOXAZOLE AND TRIMETHOPRIM 200/40 mg/5mL Suspension4Non-Preferred Drug40%40%None
SULFAMETHOXAZOLE AND TRIMETHOPRIM 400/80 mg Tablet2Generic$5.00$15.00None
SULFAMETHOXAZOLE AND TRIMETHOPRIM 800/160 mg Tablet2Generic$5.00$15.00None
SULFASALAZINE 500 mg Tablet3Preferred Brand16%16%None
SULFASALAZINE 500 mg Tablet, Delayed Release3Preferred Brand16%16%None
SULINDAC 150 mg Tablet2Generic$5.00$15.00
  • QL 6 per 30 days
SULINDAC 200 mg Tablet2Generic$5.00$15.00
  • QL 6 per 30 days
SUMATRIPTAN 100 mg TabletSumatriptan Succinate2Generic$5.00$15.00
  • QL 18 per 30 days
SUMATRIPTAN 20 mg Spray4Non-Preferred Drug40%40%
  • QL 12 per 30 days
SUMATRIPTAN 25 mg TabletSumatriptan Succinate2Generic$5.00$15.00
  • QL 18 per 30 days
SUMATRIPTAN 5 mg Spray4Non-Preferred Drug40%40%
  • QL 12 per 30 days
SUMATRIPTAN 50 mg TabletSumatriptan Succinate2Generic$5.00$15.00
  • QL 18 per 30 days
SUMATRIPTAN 6 mg/.5mL Injection, Solution4Non-Preferred Drug40%40%
  • QL 5 per 30 days
SUMATRIPTAN SUCCINATE 6 mg/.5mL Injection4Non-Preferred Drug40%40%
  • QL 6 per 30 days
SUNITINIB MALATE 12.5 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
SUNITINIB MALATE 25 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SUNITINIB MALATE 37.5 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SUNITINIB MALATE 50 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 4 per 28 days
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 5 per 28 days
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 4 per 28 days
SUTAB 17.75/2.7/2.25 g TabletSodium Sulfate, Magnesium Sulfate, And Potassium Chloride4Non-Preferred Drug40%40%None
SYEDA KitDrospirenone And Ethinyl Estradiol4Non-Preferred Drug40%40%None
SYMPAZAN 10 mg FilmClobazam5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SYMPAZAN 20 mg FilmClobazam5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SYMPAZAN 5 mg FilmClobazam4Non-Preferred Drug40%40%
  • PA
  • QL 24 per 30 days
SYMTUZA 800/150/200/10 mg Tablet, Film CoatedDarunavir, Cobicistat, Emtricitabine, And Tenofovir Alafenamide5Specialty Tier25%N/A
  • QL 3 per 30 days
SYNAREL 2 mg/mL Spray, MeteredNafarelin Acetate5Specialty Tier25%N/ANone
SYNJARDY 12.5/1000 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY 12.5/500 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY 5/1000 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY 5/500 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY XR 10/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY XR 12.5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNJARDY XR 25/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand16%16%
  • QL 3 per 30 days
SYNJARDY XR 5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand16%16%
  • QL 6 per 30 days
SYNTHROID 100 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 112 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 125 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 137 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 150 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 175 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 200 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 25 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 300 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 50 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 75 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%None
SYNTHROID 88 ug TabletLevothyroxine Sodium4Non-Preferred Drug40%40%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.