2026 Blue Rx PDP Complete (PDP) formulary (drug list)
Contract S5593, plan 003 · Pennsylvania · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.
303 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 | 3Preferred Brand | 25% | 25% | None |
| ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% | None |
| ABIGALE 1/.5 mg TabletEstradiol And Norethindrone Acetate | 2Generic | $5.00 | $12.50 | None |
| ABILIFY MAINTENA KitAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABILIFY MAINTENA KitAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABIRATERONE 250 mg TabletAbiraterone Acetate | 5Specialty Tier | 25% | N/A |
|
| ABIRATERONE ACETATE 500 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| ABIRTEGA 250 mg TabletAbiraterone Acetate | 3Preferred Brand | 25% | 25% |
|
| ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated | 2Generic | $5.00 | $12.50 | None |
| ACARBOSE 100 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| ACARBOSE 25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| ACARBOSE 50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 |
|
| ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| ACEBUTOLOL HYDROCHLORIDE 200 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| ACEBUTOLOL HYDROCHLORIDE 400 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution | 2Generic | $5.00 | $12.50 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ACETAZOLAMIDE 125 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| ACETAZOLAMIDE 250 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| ACETAZOLAMIDE 500 mg Capsule, Extended Release | 2Generic | $5.00 | $12.50 | None |
| ACETIC ACID 20.65 mg/mL Solution | 2Generic | $5.00 | $12.50 | None |
| ACETYLCYSTEINE 100 mg/mL Inhalant | 2Generic | $5.00 | $12.50 |
|
| ACETYLCYSTEINE 200 mg/mL Solution | 2Generic | $5.00 | $12.50 |
|
| 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% |
|
| ACTEMRA 162 mg/.9mL Injection, SolutionTocilizumab | 5Specialty Tier | 25% | N/A |
|
| ACTEMRA ACTPEN 162 mg/.9mL Injection, SolutionTocilizumab | 5Specialty Tier | 25% | N/A |
|
| ACTHIB KitHaemophilus Influenzae Type B Strain 1482 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen | 3Preferred Brand | 25% | 25% | None |
| ACTIMMUNE 100 ug/.5mL Injection, SolutionInterferon Gamma-1B | 5Specialty Tier | 25% | N/A |
|
| ACYCLOVIR 200 mg Capsule | 2Generic | $5.00 | $12.50 | None |
| ACYCLOVIR 200 mg/5mL Suspension | 2Generic | $5.00 | $12.50 | None |
| ACYCLOVIR 400 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| ACYCLOVIR 50 mg/g Cream | 3Preferred Brand | 25% | 25% |
|
| ACYCLOVIR 50 mg/g Ointment | 1Preferred Generic | $0.00 | $0.00 |
|
| ACYCLOVIR 800 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution | 2Generic | $5.00 | $12.50 |
|
| 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 | 25% | 25% | None |
| ADAPALENE 1 mg/mL Swab | 2Generic | $5.00 | $12.50 |
|
| ADAPALENE 3 mg/g Gel | 2Generic | $5.00 | $12.50 |
|
| ADAPALENE AND BENZOYL PEROXIDE 1/25 mg/g Gel | 4Non-Preferred Drug | 25% | 25% |
|
| ADAPALENE AND BENZOYL PEROXIDE 3/25 mg/g Gel | 4Non-Preferred Drug | 25% | 25% |
|
| 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 | 25% | 25% |
|
| ADVAIR HFA 230/21 ug Aerosol, MeteredFluticasone Propionate And Salmeterol Xinafoate | 3Preferred Brand | 25% | 25% |
|
| ADVAIR HFA 45/21 ug Aerosol, MeteredFluticasone Propionate And Salmeterol Xinafoate | 3Preferred Brand | 25% | 25% |
|
| AIMOVIG 140 mg/mL Injection, SolutionErenumab-Aooe | 3Preferred Brand | 25% | 25% |
|
| AIMOVIG 70 mg/mL InjectionErenumab-Aooe | 3Preferred Brand | 25% | 25% |
|
| 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 |
|
| ALACORT 10 mg/g CreamHydrocortisone | 1Preferred Generic | $0.00 | $0.00 | None |
| ALBENDAZOLE 200 mg Tablet | 4Non-Preferred Drug | 25% | 25% | None |
| ALBUTEROL 2 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALBUTEROL 4 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALBUTEROL SULFATE 2 mg/5mL Syrup | 1Preferred Generic | $0.00 | $0.00 | None |
| ALBUTEROL SULFATE 2.5 mg/.5mL Solution | 2Generic | $5.00 | $12.50 |
|
| ALBUTEROL SULFATE 2.5 mg/3mL Solution | 2Generic | $5.00 | $12.50 |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 3Preferred Brand | 25% | 25% |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 3Preferred Brand | 25% | 25% |
|
| ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $5.00 | $12.50 |
|
| ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $5.00 | $12.50 |
|
| ALCLOMETASONE DIPROPIONATE .5 mg/g Cream | 1Preferred Generic | $0.00 | $0.00 | None |
| ALCLOMETASONE DIPROPIONATE .5 mg/g Ointment | 1Preferred Generic | $0.00 | $0.00 | None |
| ALECENSA 150 mg CapsuleAlectinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| ALENDRONATE SODIUM 10 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALENDRONATE SODIUM 35 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALENDRONATE SODIUM 70 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALENDRONATE SODIUM 70 mg/75mL Solution | 1Preferred Generic | $0.00 | $0.00 | None |
| ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release | 2Generic | $5.00 | $12.50 |
|
| ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate | 4Non-Preferred Drug | 25% | 25% | None |
| ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate | 4Non-Preferred Drug | 25% | 25% | None |
| ALLOPURINOL 100 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALLOPURINOL 300 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ALMOTRIPTAN 12.5 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| ALMOTRIPTAN 6.25 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated | 4Non-Preferred Drug | 25% | 25% |
|
| ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| ALPHAGAN P 1 mg/mL Solution/ DropsBrimonidine Tartrate | 3Preferred Brand | 25% | 25% | None |
| ALPRAZOLAM .25 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM .5 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM .5 mg Tablet, Extended Release | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM 1 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM 1 mg Tablet, Extended Release | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM 1 mg/mL Solution, Concentrate | 4Non-Preferred Drug | 25% | 25% |
|
| ALPRAZOLAM 2 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM 2 mg Tablet, Extended Release | 2Generic | $5.00 | $12.50 |
|
| ALPRAZOLAM 3 mg Tablet, Extended Release | 2Generic | $5.00 | $12.50 |
|
| ALTAVERA KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | 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 |
|
| ALYACEN 1/35 KitNorethindrone And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | None |
| AMANTADINE HYDROCHLORIDE 100 mg Capsule | 2Generic | $5.00 | $12.50 |
|
| AMANTADINE HYDROCHLORIDE 100 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution | 2Generic | $5.00 | $12.50 | None |
| AMBRISENTAN 10 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMBRISENTAN 5 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMCINONIDE 1 mg/g Cream | 2Generic | $5.00 | $12.50 | None |
| AMCINONIDE 1 mg/g Ointment | 2Generic | $5.00 | $12.50 | None |
| AMIKACIN SULFATE 250 mg/mL Injection, Solution | 4Non-Preferred Drug | 25% | 25% | None |
| AMILORIDE HYDROCHLORIDE 5 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMILORIDE HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE 5/50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMIODARONE HYDROCHLORIDE 100 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| AMIODARONE HYDROCHLORIDE 200 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| AMIODARONE HYDROCHLORIDE 400 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/20 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/40 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/20 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/40 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| AMLODIPINE AND VALSARTAN 10/160 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE AND VALSARTAN 10/320 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE AND VALSARTAN 5/160 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE AND VALSARTAN 5/320 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE 10 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE 2.5 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE 5 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/10 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/20 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/40 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/80 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/10 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/20 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/40 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/10 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/20 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/40 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/80 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMMONIUM LACTATE 12 g/100g Cream | 2Generic | $5.00 | $12.50 | None |
| AMMONIUM LACTATE 12 g/100g Lotion | 2Generic | $5.00 | $12.50 | None |
| AMNESTEEM 10 mg CapsuleIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| AMNESTEEM 20 mg CapsuleIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| AMNESTEEM 30 mg CapsuleIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| AMNESTEEM 40 mg CapsuleIsotretinoin | 2Generic | $5.00 | $12.50 | None |
| AMOXAPINE 100 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXAPINE 150 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXAPINE 25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXAPINE 50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 125 mg Tablet, Chewable | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 125 mg/5mL Powder, For Suspension | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 200 mg/5mL Powder, For Suspension | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 250 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 250 mg Tablet, Chewable | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 250 mg/5mL Powder, For Suspension | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 400 mg/5mL Powder, For Suspension | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 500 mg Capsule | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 500 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN 875 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension | 2Generic | $5.00 | $12.50 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | 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 | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN 10 g Injection, Powder, For Solution | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN 2 g Injection, Powder, For SolutionAmpicillin Sodium | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN 500 mg Capsule | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 2Generic | $5.00 | $12.50 | None |
| AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution | 2Generic | $5.00 | $12.50 | None |
| ANAGRELIDE .5 mg Capsule | 3Preferred Brand | 25% | 25% | None |
| ANAGRELIDE 1 mg Capsule | 3Preferred Brand | 25% | 25% | None |
| ANASTROZOLE 1 mg Tablet | 2Generic | $5.00 | $12.50 | None |
| ANGELIQ 1/.5 mg Tablet, Film CoatedDrospirenone And Estradiol | 4Non-Preferred Drug | 25% | 25% | None |
| ANORO ELLIPTA 62.5/25 ug PowderUmeclidinium Bromide And Vilanterol Trifenatate | 3Preferred Brand | 25% | 25% |
|
| ANZUPGO 20 mg/g CreamDelgocitinib | 5Specialty Tier | 25% | N/A |
|
| APRACLONIDINE 5.75 mg/mL Solution | 2Generic | $5.00 | $12.50 | None |
| APREPITANT 125 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| 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% |
|
| APRI 28 DAY KitDesogestrel And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | None |
| ARALAST NP KitAlpha-1-Proteinase Inhibitor (Human) | 5Specialty Tier | 25% | N/A |
|
| ARANELLE KitNorethindrone And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | None |
| AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted | 3Preferred Brand | 25% | 25% |
|
| ARFORMOTEROL TARTRATE 15 ug/2mL Solution | 4Non-Preferred Drug | 25% | 25% |
|
| 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 | 25% | 25% | None |
| ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 25% | 25% |
|
| ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating | 5Specialty Tier | 25% | N/A |
|
| ARIPIPRAZOLE 15 mg Tablet | 3Preferred Brand | 25% | 25% | None |
| ARIPIPRAZOLE 2 mg Tablet | 3Preferred Brand | 25% | 25% | None |
| ARIPIPRAZOLE 20 mg Tablet | 3Preferred Brand | 25% | 25% | None |
| ARIPIPRAZOLE 30 mg Tablet | 3Preferred Brand | 25% | 25% | None |
| ARIPIPRAZOLE 5 mg Tablet | 3Preferred Brand | 25% | 25% | None |
| 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 | 4Non-Preferred Drug | 25% | 25% |
|
| ARMODAFINIL 200 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| ARMODAFINIL 250 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| ARMODAFINIL 50 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| 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% |
|
| ASMANEX 110 ug InhalantMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX 220 ug InhalantMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX 220 ug InhalantMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX 220 ug InhalantMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX HFA 100 ug AerosolMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX HFA 200 ug AerosolMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASMANEX HFA 50 ug AerosolMometasone Furoate | 3Preferred Brand | 25% | 25% |
|
| ASPRIN AND EXTENDED-RELEASE DIPYRIDAMOLE 25/200 mg Capsule | 2Generic | $5.00 | $12.50 | None |
| ASTAGRAF XL .5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 3Preferred Brand | 25% | 25% |
|
| ASTAGRAF XL 1 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 3Preferred Brand | 25% | 25% |
|
| ASTAGRAF XL 5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 5Specialty Tier | 25% | N/A |
|
| 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 | $0.00 | $0.00 | None |
| ATENOLOL 25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ATENOLOL 50 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ATENOLOL AND CHLORTHALIDONE 100/25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet | 1Preferred Generic | $0.00 | $0.00 | None |
| ATOMOXETINE 10 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 100 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 18 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 25 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 40 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 60 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATOMOXETINE 80 mg Capsule | 3Preferred Brand | 25% | 25% |
|
| ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated | 1Preferred Generic | $0.00 | $0.00 | None |
| ATOVAQUONE 750 mg/5mL Suspension | 4Non-Preferred Drug | 25% | 25% | None |
| ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| ATOVAQUONE AND PROGUANIL HYDROCHLORIDE PEDIATRIC 62.5/25 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate | 2Generic | $5.00 | $12.50 | None |
| ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide | 3Preferred Brand | 25% | 25% |
|
| ATTRUBY 356 mg Tablet, Film CoatedAcoramidis Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| AUGTYRO 160 mg CapsuleRepotrectinib | 5Specialty Tier | 25% | N/A |
|
| AUGTYRO 40 mg CapsuleRepotrectinib | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO 12 mg Tablet, CoatedDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO 6 mg Tablet, CoatedDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO 9 mg Tablet, CoatedDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 12 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 18 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 24 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 30 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 36 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 42 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 48 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR 6 mg Tablet, Film Coated, Extended ReleaseDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUSTEDO XR KitDeutetrabenazine | 5Specialty Tier | 25% | N/A |
|
| AUVELITY 45/105 mg Tablet, Multilayer, Extended ReleaseDextromethorphan Hydrobromide, Bupropion Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| AVEED 250 mg/mL InjectionTestosterone Undecanoate | 4Non-Preferred Drug | 25% | 25% |
|
| AVIANE KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | None |
| AVMAPKI FAKZYNJA CO-PACK KitAvutometinib Potassium And Defactinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| AVONEX KitInterferon Beta-1A | 5Specialty Tier | 25% | N/A |
|
| AVONEX KitInterferon Beta-1A | 5Specialty Tier | 25% | N/A |
|
| AVYCAZ 2/.5 g Powder, For SolutionCeftazidime, Avibactam | 5Specialty Tier | 25% | N/A | None |
| 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 |
|
| AZASITE 10 mg/mL Solution/ DropsAzithromycin Monohydrate | 4Non-Preferred Drug | 25% | 25% | None |
| AZATHIOPRINE 100 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| AZATHIOPRINE 50 mg Tablet | 2Generic | $5.00 | $12.50 |
|
| AZATHIOPRINE 75 mg Tablet | 4Non-Preferred Drug | 25% | 25% |
|
| AZELAIC ACID .15 g/g Gel | 4Non-Preferred Drug | 25% | 25% |
|
| AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops | 2Generic | $5.00 | $12.50 | None |
| AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered | 2Generic | $5.00 | $12.50 |
|
| AZELASTINE HYDROCHLORIDE AND FLUTICASONE PROPIONATE 137/50 ug Spray, Metered | 4Non-Preferred Drug | 25% | 25% |
|
| AZELEX .2 g/g CreamAzelaic Acid | 4Non-Preferred Drug | 25% | 25% |
|
| AZITHROMYCIN 250 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AZITHROMYCIN 250 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate | 2Generic | $5.00 | $12.50 | None |
| AZITHROMYCIN 600 mg Tablet, Film Coated | 2Generic | $5.00 | $12.50 | None |
| AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 25% | 25% | None |
| AZURETTE KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol | 2Generic | $5.00 | $12.50 | 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.