MedicarePartD.guide

A non-government resource built from CMS public data

2026 SilverScript Choice (PDP) formulary (drug list)

Contract S5601, plan 060 · Oregon · 3,306 drugs on file · formulary ID 00026007. Each drug links to its cost in every CMS PDP Region 30 plan.

Hide drugs on tiers

284 drugs starting with A.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
ABACAVIR 20 mg/mL SolutionAbacavir Sulfate4Non-Preferred Drug33%33%None
ABACAVIR 300 mg Tablet4Non-Preferred Drug33%33%None
ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
ABIGALE 1/.5 mg TabletEstradiol And Norethindrone Acetate4Non-Preferred Drug33%33%None
ABILIFY ASIMTUFII 720 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole5Specialty Tier25%N/A
  • QL 2.4 per 56 days
ABILIFY ASIMTUFII 960 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole5Specialty Tier25%N/A
  • QL 3.2 per 56 days
ABILIFY MAINTENA KitAripiprazole5Specialty Tier25%N/A
  • QL 1 per 28 days
ABILIFY MAINTENA KitAripiprazole5Specialty Tier25%N/A
  • QL 1 per 28 days
ABIRATERONE 250 mg TabletAbiraterone Acetate5Specialty Tier25%N/A
  • PA
ABIRATERONE ACETATE 500 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
ABIRTEGA 250 mg TabletAbiraterone Acetate4Non-Preferred Drug33%33%
  • PA
ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated4Non-Preferred Drug33%33%None
ACARBOSE 100 mg Tablet2Generic$7.00$21.00
  • QL 9 per 30 days
ACARBOSE 25 mg Tablet2Generic$7.00$21.00
  • QL 9 per 30 days
ACARBOSE 50 mg Tablet2Generic$7.00$21.00
  • QL 9 per 30 days
ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%33%
  • PA
ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%33%
  • PA
ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%33%
  • PA
ACEBUTOLOL HYDROCHLORIDE 200 mg Capsule2Generic$7.00$21.00None
ACEBUTOLOL HYDROCHLORIDE 400 mg Capsule2Generic$7.00$21.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution3Preferred Brand18%18%
  • QL 27 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet3Preferred Brand18%18%
  • QL 18 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet3Preferred Brand18%18%
  • QL 18 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet3Preferred Brand18%18%
  • QL 18 per 30 days
ACETAZOLAMIDE 125 mg Tablet4Non-Preferred Drug33%33%None
ACETAZOLAMIDE 250 mg Tablet4Non-Preferred Drug33%33%None
ACETAZOLAMIDE 500 mg Capsule, Extended Release4Non-Preferred Drug33%33%None
ACETIC ACID 20.65 mg/mL Solution3Preferred Brand18%18%None
ACETYLCYSTEINE 100 mg/mL Inhalant3Preferred Brand18%18%
  • PA
ACETYLCYSTEINE 200 mg/mL Solution3Preferred Brand18%18%
  • PA
ACITRETIN 10 mg Capsule4Non-Preferred Drug33%33%
  • PA
ACITRETIN 17.5 mg Capsule4Non-Preferred Drug33%33%
  • PA
ACITRETIN 25 mg Capsule4Non-Preferred Drug33%33%
  • PA
ACTHIB KitHaemophilus Influenzae Type B Strain 1482 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen1Preferred Generic$0.00$0.00None
ACTIMMUNE 100 ug/.5mL Injection, SolutionInterferon Gamma-1B5Specialty Tier25%N/A
  • PA
ACYCLOVIR 200 mg Capsule3Preferred Brand18%18%None
ACYCLOVIR 200 mg/5mL Suspension2Generic$7.00$21.00None
ACYCLOVIR 400 mg Tablet3Preferred Brand18%18%None
ACYCLOVIR 800 mg Tablet3Preferred Brand18%18%None
ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution4Non-Preferred Drug33%33%
  • PA
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 Antigen1Preferred Generic$0.00$0.00None
ADALIMUMAB-BWWD 40 mg/.4mL Solution5Specialty Tier25%N/A
  • PA
  • QL 22.4 per 365 days
ADALIMUMAB-BWWD 40 mg/.4mL Solution5Specialty Tier25%N/A
  • PA
  • QL 22.4 per 365 days
ADEFOVIR DIPIVOXIL 10 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ADEMPAS .5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ADEMPAS 1 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ADEMPAS 1.5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ADEMPAS 2 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ADEMPAS 2.5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
AIMOVIG 140 mg/mL Injection, SolutionErenumab-Aooe3Preferred Brand18%18%
  • PA
  • QL 1 per 30 days
AIMOVIG 70 mg/mL InjectionErenumab-Aooe3Preferred Brand18%18%
  • PA
  • QL 1 per 30 days
AIRSUPRA 90/80 ug Aerosol, MeteredAlbuterol Sulfate And Budesonide3Preferred Brand18%18%
  • QL 32.1 per 30 days
AKEEGA 100/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AKEEGA 50/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
ALACORT 10 mg/g CreamHydrocortisone2Generic$7.00$21.00None
ALBENDAZOLE 200 mg Tablet4Non-Preferred Drug33%33%None
ALBUTEROL 2 mg Tablet4Non-Preferred Drug33%33%None
ALBUTEROL 4 mg Tablet4Non-Preferred Drug33%33%None
ALBUTEROL SULFATE 2 mg/5mL Syrup4Non-Preferred Drug33%33%None
ALBUTEROL SULFATE 2.5 mg/.5mL Solution4Non-Preferred Drug33%33%
  • PA
ALBUTEROL SULFATE 2.5 mg/3mL Solution4Non-Preferred Drug33%33%
  • PA
ALBUTEROL SULFATE 90 ug Inhalant3Preferred Brand18%18%
  • QL 17 per 30 days
ALBUTEROL SULFATE 90 ug Inhalant3Preferred Brand18%18%
  • QL 13.4 per 30 days
ALBUTEROL SULFATE HFA 90 ug Aerosol, MeteredAlbuterol Sulfate3Preferred Brand18%18%
  • QL 36 per 30 days
ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate4Non-Preferred Drug33%33%
  • PA
ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate4Non-Preferred Drug33%33%
  • PA
ALCLOMETASONE DIPROPIONATE .5 mg/g Cream4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ALCLOMETASONE DIPROPIONATE .5 mg/g Ointment4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ALECENSA 150 mg CapsuleAlectinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
ALENDRONATE SODIUM 10 mg Tablet1Preferred Generic$0.00$0.00
  • QL 12 per 30 days
ALENDRONATE SODIUM 35 mg Tablet1Preferred Generic$0.00$0.00
  • QL 4 per 28 days
ALENDRONATE SODIUM 70 mg Tablet1Preferred Generic$0.00$0.00
  • QL 4 per 28 days
ALENDRONATE SODIUM 70 mg/75mL Solution1Preferred Generic$0.00$0.00None
ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release2Generic$7.00$21.00
  • QL 3 per 30 days
ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate1Preferred Generic$0.00$0.00None
ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate1Preferred Generic$0.00$0.00None
ALLOPURINOL 100 mg Tablet2Generic$7.00$21.00None
ALLOPURINOL 300 mg Tablet2Generic$7.00$21.00None
ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated4Non-Preferred Drug33%33%
  • PA
  • QL 6 per 30 days
ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
ALPRAZOLAM .25 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 12 per 30 days
ALPRAZOLAM .5 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 12 per 30 days
ALPRAZOLAM 1 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 15 per 30 days
ALPRAZOLAM 2 mg Tablet3Preferred Brand18%18%
  • PA
  • QL 15 per 30 days
ALTAVERA KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand18%18%None
ALUNBRIG 180 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALUNBRIG 30 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
ALUNBRIG 90 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALUNBRIG KitBrigatinib5Specialty Tier25%N/A
  • PA
ALVAIZ 18 mg Tablet, Film CoatedEltrombopag5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ALVAIZ 36 mg Tablet, Film CoatedEltrombopag5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
ALVAIZ 54 mg Tablet, Film CoatedEltrombopag5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
ALVAIZ 9 mg Tablet, Film CoatedEltrombopag5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
ALVESCO 160 ug Aerosol, MeteredCiclesonide4Non-Preferred Drug33%33%
  • QL 12.2 per 30 days
ALVESCO 80 ug Aerosol, MeteredCiclesonide4Non-Preferred Drug33%33%
  • QL 12.2 per 30 days
ALYACEN 1/35 KitNorethindrone And Ethinyl Estradiol3Preferred Brand18%18%None
AMANTADINE HYDROCHLORIDE 100 mg Capsule4Non-Preferred Drug33%33%
  • QL 12 per 30 days
AMANTADINE HYDROCHLORIDE 100 mg Tablet3Preferred Brand18%18%None
AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution4Non-Preferred Drug33%33%None
AMBRISENTAN 10 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AMBRISENTAN 5 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AMIKACIN SULFATE 250 mg/mL Injection, Solution4Non-Preferred Drug33%33%None
AMILORIDE HYDROCHLORIDE 5 mg Tablet3Preferred Brand18%18%None
AMILORIDE HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE 5/50 mg Tablet2Generic$7.00$21.00None
AMIODARONE HYDROCHLORIDE 100 mg Tablet2Generic$7.00$21.00None
AMIODARONE HYDROCHLORIDE 200 mg Tablet2Generic$7.00$21.00None
AMIODARONE HYDROCHLORIDE 400 mg Tablet4Non-Preferred Drug33%33%None
AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated3Preferred Brand18%18%
  • PA
AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/20 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/40 mg Tablet, Film Coated4Non-Preferred Drug33%33%
  • QL 3 per 30 days
AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/20 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/40 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 10/160 mg Tablet, Film Coated2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 10/320 mg Tablet, Film Coated2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 5/160 mg Tablet, Film Coated2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 5/320 mg Tablet, Film Coated2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE 10 mg Tablet1Preferred Generic$0.00$0.00None
AMLODIPINE BESYLATE 2.5 mg Tablet1Preferred Generic$0.00$0.00None
AMLODIPINE BESYLATE 5 mg Tablet1Preferred Generic$0.00$0.00None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/10 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/20 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/40 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/80 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/10 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/20 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/40 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/10 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/20 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/40 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/80 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule2Generic$7.00$21.00
  • QL 3 per 30 days
AMMONIUM LACTATE 12 g/100g Cream3Preferred Brand18%18%None
AMMONIUM LACTATE 12 g/100g Lotion3Preferred Brand18%18%None
AMNESTEEM 10 mg CapsuleIsotretinoin4Non-Preferred Drug33%33%
  • PA
AMNESTEEM 20 mg CapsuleIsotretinoin4Non-Preferred Drug33%33%
  • PA
AMNESTEEM 30 mg CapsuleIsotretinoin4Non-Preferred Drug33%33%
  • PA
AMNESTEEM 40 mg CapsuleIsotretinoin4Non-Preferred Drug33%33%
  • PA
AMOXAPINE 100 mg Tablet3Preferred Brand18%18%None
AMOXAPINE 150 mg Tablet3Preferred Brand18%18%None
AMOXAPINE 25 mg Tablet3Preferred Brand18%18%None
AMOXAPINE 50 mg Tablet3Preferred Brand18%18%None
AMOXICILLIN 125 mg Tablet, Chewable1Preferred Generic$0.00$0.00None
AMOXICILLIN 125 mg/5mL Powder, For Suspension1Preferred Generic$0.00$0.00None
AMOXICILLIN 200 mg/5mL Powder, For Suspension1Preferred Generic$0.00$0.00None
AMOXICILLIN 250 mg Capsule1Preferred Generic$0.00$0.00None
AMOXICILLIN 250 mg Tablet, Chewable1Preferred Generic$0.00$0.00None
AMOXICILLIN 250 mg/5mL Powder, For Suspension1Preferred Generic$0.00$0.00None
AMOXICILLIN 400 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN 500 mg Capsule1Preferred Generic$0.00$0.00None
AMOXICILLIN 500 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
AMOXICILLIN 875 mg Tablet, Film Coated1Preferred Generic$0.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension4Non-Preferred Drug33%33%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 562.5/437.5/62.5 mg Tablet, Multilayer, Extended Release4Non-Preferred Drug33%33%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated2Generic$7.00$21.00None
AMPHOTERICIN B 50 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%33%
  • PA
AMPHOTERICIN B 50 mg/12.5mL Injection, Powder, Lyophilized, For Solution5Specialty Tier25%N/A
  • PA
AMPICILLIN 1 g Injection, Powder, For SolutionAmpicillin Sodium4Non-Preferred Drug33%33%None
AMPICILLIN 10 g Injection, Powder, For Solution4Non-Preferred Drug33%33%None
AMPICILLIN 500 mg Capsule2Generic$7.00$21.00None
AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%33%None
AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%33%None
AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution4Non-Preferred Drug33%33%None
ANAGRELIDE .5 mg Capsule4Non-Preferred Drug33%33%None
ANAGRELIDE 1 mg Capsule4Non-Preferred Drug33%33%None
ANASTROZOLE 1 mg Tablet2Generic$7.00$21.00None
ANORO ELLIPTA 62.5/25 ug PowderUmeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand18%18%
  • QL 6 per 30 days
APREPITANT 125 mg Capsule5Specialty Tier25%N/A
  • PA
APREPITANT 40 mg Capsule4Non-Preferred Drug33%33%
  • PA
APREPITANT 80 mg Capsule4Non-Preferred Drug33%33%
  • PA
APREPITANT Kit4Non-Preferred Drug33%33%
  • PA
APRI 28 DAY KitDesogestrel And Ethinyl Estradiol3Preferred Brand18%18%None
APTIOM 200 mg TabletEslicarbazepine Acetate5Specialty Tier25%N/A
  • QL 3 per 30 days
APTIOM 400 mg TabletEslicarbazepine Acetate5Specialty Tier25%N/A
  • QL 3 per 30 days
APTIOM 600 mg TabletEslicarbazepine Acetate5Specialty Tier25%N/A
  • QL 6 per 30 days
APTIOM 800 mg TabletEslicarbazepine Acetate5Specialty Tier25%N/A
  • QL 6 per 30 days
ARANELLE KitNorethindrone And Ethinyl Estradiol3Preferred Brand18%18%None
ARCALYST 160 mg/2mL Injection, Powder, Lyophilized, For SolutionRilonacept5Specialty Tier25%N/A
  • PA
AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted3Preferred Brand18%18%
  • PA
  • QL 1 per 999 days
ARIKAYCE 590 mg/8.4mL SuspensionAmikacin5Specialty Tier25%N/A
  • PA
ARIPIPRAZOLE 1 mg/mL Solution4Non-Preferred Drug33%33%
  • QL 9 per 30 days
ARIPIPRAZOLE 10 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARIPIPRAZOLE 2 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARIPIPRAZOLE 20 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARIPIPRAZOLE 30 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARIPIPRAZOLE 5 mg Tablet4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/A
  • QL 3.9 per 56 days
ARISTADA 441 mg/1.6mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/A
  • QL 1.6 per 28 days
ARISTADA 662 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/A
  • QL 2.4 per 28 days
ARISTADA 882 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/A
  • QL 3.2 per 28 days
ARISTADA INITIO 675 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARMODAFINIL 150 mg Tablet4Non-Preferred Drug33%33%
  • PA
  • QL 3 per 30 days
ARMODAFINIL 200 mg Tablet4Non-Preferred Drug33%33%
  • PA
  • QL 3 per 30 days
ARMODAFINIL 250 mg Tablet4Non-Preferred Drug33%33%
  • PA
  • QL 3 per 30 days
ARMODAFINIL 50 mg Tablet4Non-Preferred Drug33%33%
  • PA
  • QL 6 per 30 days
ARNUITY ELLIPTA 100 ug PowderFluticasone Furoate3Preferred Brand18%18%
  • QL 3 per 30 days
ARNUITY ELLIPTA 200 ug PowderFluticasone Furoate3Preferred Brand18%18%
  • QL 3 per 30 days
ARNUITY ELLIPTA 50 ug PowderFluticasone Furoate3Preferred Brand18%18%
  • QL 3 per 30 days
ASENAPINE 10 mg TabletAsenapine Maleate4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ASENAPINE 2.5 mg Tablet4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ASENAPINE 5 mg TabletAsenapine Maleate4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ASHLYNA KitLevonorgestrel And Ethinyl Estradiol And Ethinyl Estradiol3Preferred Brand18%18%None
ASPRIN AND EXTENDED-RELEASE DIPYRIDAMOLE 25/200 mg Capsule4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ASTAGRAF XL .5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules4Non-Preferred Drug33%33%
  • PA
ASTAGRAF XL 1 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules4Non-Preferred Drug33%33%
  • PA
ASTAGRAF XL 5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules5Specialty Tier25%N/A
  • PA
ATAZANAVIR SULFATE 150 mg CapsuleAtazanavir4Non-Preferred Drug33%33%None
ATAZANAVIR SULFATE 200 mg CapsuleAtazanavir4Non-Preferred Drug33%33%None
ATAZANAVIR SULFATE 300 mg CapsuleAtazanavir4Non-Preferred Drug33%33%None
ATENOLOL 100 mg Tablet1Preferred Generic$0.00$0.00None
ATENOLOL 25 mg Tablet1Preferred Generic$0.00$0.00None
ATENOLOL 50 mg Tablet1Preferred Generic$0.00$0.00None
ATENOLOL AND CHLORTHALIDONE 100/25 mg Tablet1Preferred Generic$0.00$0.00None
ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet1Preferred Generic$0.00$0.00None
ATOMOXETINE 10 mg Capsule4Non-Preferred Drug33%33%
  • QL 12 per 30 days
ATOMOXETINE 100 mg Capsule4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ATOMOXETINE 18 mg Capsule4Non-Preferred Drug33%33%
  • QL 12 per 30 days
ATOMOXETINE 25 mg Capsule4Non-Preferred Drug33%33%
  • QL 12 per 30 days
ATOMOXETINE 40 mg Capsule4Non-Preferred Drug33%33%
  • QL 6 per 30 days
ATOMOXETINE 60 mg Capsule4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ATOMOXETINE 80 mg Capsule4Non-Preferred Drug33%33%
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated1Preferred Generic$0.00$0.00
  • QL 3 per 30 days
ATOVAQUONE 750 mg/5mL Suspension4Non-Preferred Drug33%33%
  • PA
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE PEDIATRIC 62.5/25 mg Tablet, Film Coated4Non-Preferred Drug33%33%None
ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate3Preferred Brand18%18%None
ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide4Non-Preferred Drug33%33%
  • QL 25.8 per 30 days
AUBRA EQ KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand18%18%None
AUGTYRO 160 mg CapsuleRepotrectinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AUGTYRO 40 mg CapsuleRepotrectinib5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
AUSTEDO 12 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUSTEDO 6 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AUSTEDO 9 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUSTEDO XR 12 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUSTEDO XR 18 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AUSTEDO XR 24 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AUSTEDO XR 30 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AUSTEDO XR 36 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AUSTEDO XR 42 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AUSTEDO XR 48 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AUSTEDO XR 6 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
AUSTEDO XR KitDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 56 per 365 days
AUVELITY 45/105 mg Tablet, Multilayer, Extended ReleaseDextromethorphan Hydrobromide, Bupropion Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AVIANE KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand18%18%None
AVMAPKI FAKZYNJA CO-PACK KitAvutometinib Potassium And Defactinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 66 per 28 days
AYVAKIT 100 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 200 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 25 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 300 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 50 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AZATHIOPRINE 50 mg Tablet3Preferred Brand18%18%
  • PA
AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops3Preferred Brand18%18%None
AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered3Preferred Brand18%18%
  • QL 3 per 25 days
AZITHROMYCIN 100 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate4Non-Preferred Drug33%33%None
AZITHROMYCIN 600 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN DIHYDRATE 200 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AZOPT 10 mg/mL Suspension/ DropsBrinzolamide4Non-Preferred Drug33%33%None
AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%33%None
AZURETTE KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol2Generic$7.00$21.00None

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.