2026 SilverScript Choice (PDP) formulary (drug list)
Contract S5601, plan 012 · Pennsylvania · 3,637 drugs on file · formulary ID 00026008. Each drug links to its cost in every CMS PDP Region 06 plan.
291 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 | 35% | 35% | None |
| ABACAVIR 300 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated | 4Non-Preferred Drug | 35% | 35% | None |
| ABIGALE 1/.5 mg TabletEstradiol And Norethindrone Acetate | 4Non-Preferred Drug | 35% | 35% | None |
| ABILIFY ASIMTUFII 720 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole | 5Specialty Tier | 25% | N/A |
|
| ABILIFY ASIMTUFII 960 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole | 5Specialty Tier | 25% | N/A |
|
| 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 | 4Non-Preferred Drug | 35% | 35% |
|
| ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated | 4Non-Preferred Drug | 35% | 35% | None |
| ACARBOSE 100 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACARBOSE 25 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACARBOSE 50 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| ACEBUTOLOL HYDROCHLORIDE 200 mg Capsule | 2Generic | $10.00 | $30.00 | None |
| ACEBUTOLOL HYDROCHLORIDE 400 mg Capsule | 2Generic | $10.00 | $30.00 | None |
| ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution | 2Generic | $10.00 | $30.00 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ACETAZOLAMIDE 125 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ACETAZOLAMIDE 250 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ACETAZOLAMIDE 500 mg Capsule, Extended Release | 4Non-Preferred Drug | 35% | 35% | None |
| ACETIC ACID 20.65 mg/mL Solution | 2Generic | $10.00 | $30.00 | None |
| ACETYLCYSTEINE 100 mg/mL Inhalant | 2Generic | $10.00 | $30.00 |
|
| ACETYLCYSTEINE 200 mg/mL Solution | 2Generic | $10.00 | $30.00 |
|
| ACITRETIN 10 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ACITRETIN 17.5 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ACITRETIN 25 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ACTHIB KitHaemophilus Influenzae Type B Strain 1482 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen | 1Preferred Generic | $2.00 | $6.00 | None |
| ACTIMMUNE 100 ug/.5mL Injection, SolutionInterferon Gamma-1B | 5Specialty Tier | 25% | N/A |
|
| ACYCLOVIR 200 mg Capsule | 2Generic | $10.00 | $30.00 | None |
| ACYCLOVIR 200 mg/5mL Suspension | 2Generic | $10.00 | $30.00 | None |
| ACYCLOVIR 400 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| ACYCLOVIR 800 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution | 4Non-Preferred Drug | 35% | 35% |
|
| 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 | 1Preferred Generic | $2.00 | $6.00 | None |
| ADALIMUMAB-BWWD 40 mg/.4mL Solution | 5Specialty Tier | 25% | N/A |
|
| ADALIMUMAB-BWWD 40 mg/.4mL Solution | 5Specialty Tier | 25% | N/A |
|
| ADEFOVIR DIPIVOXIL 10 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| 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 |
|
| AIMOVIG 140 mg/mL Injection, SolutionErenumab-Aooe | 3Preferred Brand | 19% | 19% |
|
| AIMOVIG 70 mg/mL InjectionErenumab-Aooe | 3Preferred Brand | 19% | 19% |
|
| AIRSUPRA 90/80 ug Aerosol, MeteredAlbuterol Sulfate And Budesonide | 3Preferred Brand | 19% | 19% |
|
| 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 | 2Generic | $10.00 | $30.00 | None |
| ALBENDAZOLE 200 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ALBUTEROL 2 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ALBUTEROL 4 mg Tablet | 4Non-Preferred Drug | 35% | 35% | None |
| ALBUTEROL SULFATE 2 mg/5mL Syrup | 4Non-Preferred Drug | 35% | 35% | None |
| ALBUTEROL SULFATE 2.5 mg/.5mL Solution | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE 2.5 mg/3mL Solution | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE 90 ug Inhalant | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE HFA 90 ug Aerosol, MeteredAlbuterol Sulfate | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $10.00 | $30.00 |
|
| ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate | 2Generic | $10.00 | $30.00 |
|
| ALCLOMETASONE DIPROPIONATE .5 mg/g Cream | 4Non-Preferred Drug | 35% | 35% |
|
| ALCLOMETASONE DIPROPIONATE .5 mg/g Ointment | 4Non-Preferred Drug | 35% | 35% |
|
| ALECENSA 150 mg CapsuleAlectinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| ALENDRONATE SODIUM 10 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| ALENDRONATE SODIUM 35 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| ALENDRONATE SODIUM 70 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| ALENDRONATE SODIUM 70 mg/75mL Solution | 1Preferred Generic | $2.00 | $6.00 | None |
| ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release | 2Generic | $10.00 | $30.00 |
|
| ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate | 1Preferred Generic | $2.00 | $6.00 | None |
| ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate | 1Preferred Generic | $2.00 | $6.00 | None |
| ALLOPURINOL 100 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| ALLOPURINOL 300 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated | 4Non-Preferred Drug | 35% | 35% |
|
| ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| ALPRAZOLAM .25 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ALPRAZOLAM .5 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ALPRAZOLAM 1 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ALPRAZOLAM 1 mg/mL Solution, Concentrate | 4Non-Preferred Drug | 35% | 35% |
|
| ALPRAZOLAM 2 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| ALTAVERA KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | 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 |
|
| ALVAIZ 18 mg Tablet, Film CoatedEltrombopag | 5Specialty Tier | 25% | N/A |
|
| ALVAIZ 36 mg Tablet, Film CoatedEltrombopag | 5Specialty Tier | 25% | N/A |
|
| ALVAIZ 54 mg Tablet, Film CoatedEltrombopag | 5Specialty Tier | 25% | N/A |
|
| ALVAIZ 9 mg Tablet, Film CoatedEltrombopag | 5Specialty Tier | 25% | N/A |
|
| ALVESCO 160 ug Aerosol, MeteredCiclesonide | 4Non-Preferred Drug | 35% | 35% |
|
| ALVESCO 80 ug Aerosol, MeteredCiclesonide | 4Non-Preferred Drug | 35% | 35% |
|
| ALYACEN 1/35 KitNorethindrone And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| AMANTADINE HYDROCHLORIDE 100 mg Capsule | 2Generic | $10.00 | $30.00 |
|
| AMANTADINE HYDROCHLORIDE 100 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution | 2Generic | $10.00 | $30.00 | None |
| AMBRISENTAN 10 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMBRISENTAN 5 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| AMIKACIN SULFATE 250 mg/mL Injection, Solution | 4Non-Preferred Drug | 35% | 35% | None |
| AMILORIDE HYDROCHLORIDE 5 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMILORIDE HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE 5/50 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMIODARONE HYDROCHLORIDE 100 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMIODARONE HYDROCHLORIDE 200 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMIODARONE HYDROCHLORIDE 400 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated | 3Preferred Brand | 19% | 19% |
|
| AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/20 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 10/40 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/20 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND OLMESARTAN MEDOXOMIL 5/40 mg Tablet | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND VALSARTAN 10/160 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND VALSARTAN 10/320 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND VALSARTAN 5/160 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE AND VALSARTAN 5/320 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE BESYLATE 10 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE 2.5 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE 5 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/10 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/20 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/40 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 10/80 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/10 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/20 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 2.5/40 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/10 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/20 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/40 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND ATORVASTATIN CALCIUM 5/80 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/160/12.5 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/25/160 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 10/25/320 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 5/160/12.5 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 1Preferred Generic | $2.00 | $6.00 |
|
| AMLODIPINE, VALSARTAN, HYDROCHLOROTHIAZIDE 5/160/25 mg Tablet, Film CoatedAmlodipine Besylate Valsartan Hydrochlorothiazide | 1Preferred Generic | $2.00 | $6.00 |
|
| AMMONIUM LACTATE 12 g/100g Cream | 2Generic | $10.00 | $30.00 | None |
| AMMONIUM LACTATE 12 g/100g Lotion | 2Generic | $10.00 | $30.00 | None |
| AMNESTEEM 10 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| AMNESTEEM 20 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| AMNESTEEM 30 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| AMNESTEEM 40 mg CapsuleIsotretinoin | 4Non-Preferred Drug | 35% | 35% |
|
| AMOXAPINE 100 mg Tablet | 3Preferred Brand | 19% | 19% | None |
| AMOXAPINE 150 mg Tablet | 3Preferred Brand | 19% | 19% | None |
| AMOXAPINE 25 mg Tablet | 3Preferred Brand | 19% | 19% | None |
| AMOXAPINE 50 mg Tablet | 3Preferred Brand | 19% | 19% | None |
| AMOXICILLIN 125 mg Tablet, Chewable | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 125 mg/5mL Powder, For Suspension | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 200 mg/5mL Powder, For Suspension | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 250 mg Capsule | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 250 mg Tablet, Chewable | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 250 mg/5mL Powder, For Suspension | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 400 mg/5mL Powder, For Suspension | 2Generic | $10.00 | $30.00 | None |
| AMOXICILLIN 500 mg Capsule | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 500 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN 875 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension | 2Generic | $10.00 | $30.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated | 4Non-Preferred Drug | 35% | 35% | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension | 4Non-Preferred Drug | 35% | 35% | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension | 2Generic | $10.00 | $30.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated | 2Generic | $10.00 | $30.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 562.5/437.5/62.5 mg Tablet, Multilayer, Extended Release | 4Non-Preferred Drug | 35% | 35% | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension | 2Generic | $10.00 | $30.00 | None |
| AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated | 2Generic | $10.00 | $30.00 | None |
| AMPHOTERICIN B 50 mg/10mL Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 35% | 35% |
|
| AMPHOTERICIN B 50 mg/12.5mL Injection, Powder, Lyophilized, For Solution | 5Specialty Tier | 25% | N/A |
|
| AMPICILLIN 1 g Injection, Powder, For SolutionAmpicillin Sodium | 4Non-Preferred Drug | 35% | 35% | None |
| AMPICILLIN 10 g Injection, Powder, For Solution | 4Non-Preferred Drug | 35% | 35% | None |
| AMPICILLIN 2 g Injection, Powder, For SolutionAmpicillin Sodium | 4Non-Preferred Drug | 35% | 35% | None |
| AMPICILLIN 500 mg Capsule | 2Generic | $10.00 | $30.00 | None |
| AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 4Non-Preferred Drug | 35% | 35% | None |
| AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium | 4Non-Preferred Drug | 35% | 35% | None |
| AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution | 4Non-Preferred Drug | 35% | 35% | None |
| ANAGRELIDE .5 mg Capsule | 4Non-Preferred Drug | 35% | 35% | None |
| ANAGRELIDE 1 mg Capsule | 4Non-Preferred Drug | 35% | 35% | None |
| ANASTROZOLE 1 mg Tablet | 2Generic | $10.00 | $30.00 | None |
| ANORO ELLIPTA 62.5/25 ug PowderUmeclidinium Bromide And Vilanterol Trifenatate | 3Preferred Brand | 19% | 19% |
|
| APREPITANT 125 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| APREPITANT 40 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| APREPITANT 80 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| APREPITANT Kit | 4Non-Preferred Drug | 35% | 35% |
|
| APRI 28 DAY KitDesogestrel And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| APTIOM 200 mg TabletEslicarbazepine Acetate | 5Specialty Tier | 25% | N/A |
|
| APTIOM 400 mg TabletEslicarbazepine Acetate | 5Specialty Tier | 25% | N/A |
|
| APTIOM 600 mg TabletEslicarbazepine Acetate | 5Specialty Tier | 25% | N/A |
|
| APTIOM 800 mg TabletEslicarbazepine Acetate | 5Specialty Tier | 25% | N/A |
|
| ARANELLE KitNorethindrone And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| ARCALYST 160 mg/2mL Injection, Powder, Lyophilized, For SolutionRilonacept | 5Specialty Tier | 25% | N/A |
|
| AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted | 3Preferred Brand | 19% | 19% |
|
| ARIKAYCE 590 mg/8.4mL SuspensionAmikacin | 5Specialty Tier | 25% | N/A |
|
| ARIPIPRAZOLE 1 mg/mL Solution | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 10 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 15 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 2 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 20 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 30 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARIPIPRAZOLE 5 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| 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 | None |
| ARMODAFINIL 150 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARMODAFINIL 200 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARMODAFINIL 250 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARMODAFINIL 50 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ARNUITY ELLIPTA 100 ug PowderFluticasone Furoate | 3Preferred Brand | 19% | 19% |
|
| ARNUITY ELLIPTA 200 ug PowderFluticasone Furoate | 3Preferred Brand | 19% | 19% |
|
| ARNUITY ELLIPTA 50 ug PowderFluticasone Furoate | 3Preferred Brand | 19% | 19% |
|
| ASENAPINE 10 mg TabletAsenapine Maleate | 4Non-Preferred Drug | 35% | 35% |
|
| ASENAPINE 2.5 mg Tablet | 4Non-Preferred Drug | 35% | 35% |
|
| ASENAPINE 5 mg TabletAsenapine Maleate | 4Non-Preferred Drug | 35% | 35% |
|
| ASHLYNA KitLevonorgestrel And Ethinyl Estradiol And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| ASPRIN AND EXTENDED-RELEASE DIPYRIDAMOLE 25/200 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ASTAGRAF XL .5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 4Non-Preferred Drug | 35% | 35% |
|
| ASTAGRAF XL 1 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 4Non-Preferred Drug | 35% | 35% |
|
| ASTAGRAF XL 5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules | 5Specialty Tier | 25% | N/A |
|
| ATAZANAVIR SULFATE 150 mg CapsuleAtazanavir | 4Non-Preferred Drug | 35% | 35% | None |
| ATAZANAVIR SULFATE 200 mg CapsuleAtazanavir | 4Non-Preferred Drug | 35% | 35% | None |
| ATAZANAVIR SULFATE 300 mg CapsuleAtazanavir | 4Non-Preferred Drug | 35% | 35% | None |
| ATENOLOL 100 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| ATENOLOL 25 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| ATENOLOL 50 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| ATENOLOL AND CHLORTHALIDONE 100/25 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet | 1Preferred Generic | $2.00 | $6.00 | None |
| ATOMOXETINE 10 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 100 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 18 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 25 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 40 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 60 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATOMOXETINE 80 mg Capsule | 4Non-Preferred Drug | 35% | 35% |
|
| ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 |
|
| ATOVAQUONE 750 mg/5mL Suspension | 4Non-Preferred Drug | 35% | 35% |
|
| ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated | 4Non-Preferred Drug | 35% | 35% | None |
| ATOVAQUONE AND PROGUANIL HYDROCHLORIDE PEDIATRIC 62.5/25 mg Tablet, Film Coated | 4Non-Preferred Drug | 35% | 35% | None |
| ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate | 3Preferred Brand | 19% | 19% | None |
| ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide | 4Non-Preferred Drug | 35% | 35% |
|
| AUBRA EQ KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| 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 |
|
| AVIANE KitLevonorgestrel And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | None |
| AVMAPKI FAKZYNJA CO-PACK KitAvutometinib Potassium And Defactinib Hydrochloride | 5Specialty Tier | 25% | N/A |
|
| 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 |
|
| AZATHIOPRINE 50 mg Tablet | 2Generic | $10.00 | $30.00 |
|
| AZELAIC ACID .15 g/g Gel | 4Non-Preferred Drug | 35% | 35% |
|
| AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops | 2Generic | $10.00 | $30.00 | None |
| AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered | 2Generic | $10.00 | $30.00 |
|
| AZITHROMYCIN 100 mg/5mL Powder, For Suspension | 2Generic | $10.00 | $30.00 | None |
| AZITHROMYCIN 250 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AZITHROMYCIN 250 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AZITHROMYCIN 500 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate | 4Non-Preferred Drug | 35% | 35% | None |
| AZITHROMYCIN 600 mg Tablet, Film Coated | 1Preferred Generic | $2.00 | $6.00 | None |
| AZITHROMYCIN DIHYDRATE 200 mg/5mL Powder, For Suspension | 2Generic | $10.00 | $30.00 | None |
| AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 35% | 35% | None |
| AZURETTE KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol | 2Generic | $10.00 | $30.00 | 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.