MedicarePartD.guide

A non-government resource built from CMS public data

2026 Humana Basic Rx Plan (PDP) formulary (drug list)

Contract S5884, plan 104 · Pennsylvania · 2,972 drugs on file · formulary ID 00026399. Each drug links to its cost in every CMS PDP Region 06 plan.

Hide drugs on tiers

250 drugs starting with A.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
ABACAVIR 20 mg/mL SolutionAbacavir Sulfate4Non-Preferred Drug33%N/A
  • QL 96 per 30 days
ABACAVIR 300 mg Tablet4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ABIGALE 1/.5 mg TabletEstradiol And Norethindrone Acetate3Preferred Brand25%20%None
ABILIFY ASIMTUFII 720 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole4Non-Preferred Drug33%N/A
  • QL 2.4 per 56 days
ABILIFY ASIMTUFII 960 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole4Non-Preferred Drug33%N/A
  • QL 3.2 per 56 days
ABILIFY MAINTENA KitAripiprazole4Non-Preferred Drug33%N/A
  • QL 1 per 28 days
ABILIFY MAINTENA KitAripiprazole4Non-Preferred Drug33%N/A
  • QL 1 per 28 days
ABIRATERONE 250 mg TabletAbiraterone Acetate5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
ABIRTEGA 250 mg TabletAbiraterone Acetate4Non-Preferred Drug33%N/A
  • PA
  • QL 12 per 30 days
ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated4Non-Preferred Drug33%N/ANone
ACARBOSE 100 mg Tablet3Preferred Brand25%20%None
ACARBOSE 25 mg Tablet3Preferred Brand25%20%None
ACARBOSE 50 mg Tablet3Preferred Brand25%20%None
ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/ANone
ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/ANone
ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/ANone
ACEBUTOLOL HYDROCHLORIDE 200 mg Capsule4Non-Preferred Drug33%N/ANone
ACEBUTOLOL HYDROCHLORIDE 400 mg Capsule4Non-Preferred Drug33%N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution3Preferred Brand25%20%
  • QL 27 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet3Preferred Brand25%20%
  • QL 39 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet3Preferred Brand25%20%
  • QL 36 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet3Preferred Brand25%20%
  • QL 18 per 30 days
ACETAZOLAMIDE 125 mg Tablet4Non-Preferred Drug33%N/ANone
ACETAZOLAMIDE 250 mg Tablet4Non-Preferred Drug33%N/ANone
ACETAZOLAMIDE 500 mg Capsule, Extended Release4Non-Preferred Drug33%N/ANone
ACETIC ACID 20.65 mg/mL Solution2Generic$1.00$0.00None
ACETYLCYSTEINE 100 mg/mL Inhalant4Non-Preferred Drug33%N/A
  • PA
ACETYLCYSTEINE 200 mg/mL Solution4Non-Preferred Drug33%N/A
  • PA
ACITRETIN 10 mg Capsule4Non-Preferred Drug33%N/A
  • PA
ACITRETIN 17.5 mg Capsule4Non-Preferred Drug33%N/A
  • PA
ACITRETIN 25 mg Capsule4Non-Preferred Drug33%N/A
  • 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 Capsule2Generic$1.00$0.00None
ACYCLOVIR 400 mg Tablet2Generic$1.00$0.00None
ACYCLOVIR 800 mg Tablet2Generic$1.00$0.00None
ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution4Non-Preferred Drug33%N/A
  • 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 10 mg/.1mL Injection, SolutionAdalimumab-Adaz5Specialty Tier25%N/A
  • PA
  • QL 0.2 per 28 days
ADALIMUMAB 20 mg/.2mL Injection, SolutionAdalimumab-Adaz5Specialty Tier25%N/A
  • PA
  • QL 1.2 per 28 days
ADALIMUMAB 40 mg/.4mL Injection, SolutionAdalimumab-Adaz5Specialty Tier25%N/A
  • PA
  • QL 2.4 per 28 days
ADALIMUMAB 40 mg/.4mL Injection, SolutionAdalimumab-Adaz5Specialty Tier25%N/A
  • PA
  • QL 2.4 per 28 days
ADALIMUMAB 80 mg/.8mL Injection, SolutionAdalimumab-Adaz5Specialty Tier25%N/A
  • PA
  • QL 4.8 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 6 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 6 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 6 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 6 per 28 days
ADEFOVIR DIPIVOXIL 10 mg Tablet4Non-Preferred Drug33%N/ANone
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
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
ALBENDAZOLE 200 mg Tablet4Non-Preferred Drug33%N/ANone
ALBUTEROL 2 mg Tablet4Non-Preferred Drug33%N/ANone
ALBUTEROL 4 mg Tablet4Non-Preferred Drug33%N/ANone
ALBUTEROL SULFATE 2.5 mg/.5mL Solution3Preferred Brand25%20%
  • PA
ALBUTEROL SULFATE 2.5 mg/3mL Solution3Preferred Brand25%20%
  • PA
ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate3Preferred Brand25%20%
  • PA
ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate3Preferred Brand25%20%
  • PA
ALECENSA 150 mg CapsuleAlectinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
ALENDRONATE SODIUM 10 mg Tablet2Generic$1.00$0.00
  • QL 3 per 30 days
ALENDRONATE SODIUM 35 mg Tablet2Generic$1.00$0.00
  • QL 4 per 28 days
ALENDRONATE SODIUM 70 mg Tablet2Generic$1.00$0.00
  • QL 4 per 28 days
ALENDRONATE SODIUM 70 mg/75mL Solution4Non-Preferred Drug33%N/A
  • QL 3 per 28 days
ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release2Generic$1.00$0.00None
ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ALLOPURINOL 100 mg Tablet2Generic$1.00$0.00None
ALLOPURINOL 300 mg Tablet2Generic$1.00$0.00None
ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ALPRAZOLAM .25 mg Tablet3Preferred Brand25%20%
  • QL 12 per 30 days
ALPRAZOLAM .5 mg Tablet3Preferred Brand25%20%
  • QL 12 per 30 days
ALPRAZOLAM 1 mg Tablet3Preferred Brand25%20%
  • QL 12 per 30 days
ALPRAZOLAM 2 mg Tablet3Preferred Brand25%20%
  • QL 15 per 30 days
ALTAVERA KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand25%20%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 18 per 30 days
ALUNBRIG 90 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALUNBRIG KitBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALYACEN 1/35 KitNorethindrone And Ethinyl Estradiol3Preferred Brand25%20%None
ALYQ 20 mg Tablet, Film CoatedTadalafil4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
AMANTADINE HYDROCHLORIDE 100 mg Capsule4Non-Preferred Drug33%N/ANone
AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution3Preferred Brand25%20%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%N/ANone
AMILORIDE HYDROCHLORIDE 5 mg Tablet3Preferred Brand25%20%None
AMILORIDE HYDROCHLORIDE AND HYDROCHLOROTHIAZIDE 5/50 mg Tablet2Generic$1.00$0.00None
AMIODARONE HYDROCHLORIDE 100 mg Tablet4Non-Preferred Drug33%N/ANone
AMIODARONE HYDROCHLORIDE 200 mg Tablet2Generic$1.00$0.00None
AMIODARONE HYDROCHLORIDE 400 mg Tablet4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule2Generic$1.00$0.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 10/160 mg Tablet, Film Coated2Generic$1.00$0.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 10/320 mg Tablet, Film Coated2Generic$1.00$0.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 5/160 mg Tablet, Film Coated2Generic$1.00$0.00
  • QL 3 per 30 days
AMLODIPINE AND VALSARTAN 5/320 mg Tablet, Film Coated2Generic$1.00$0.00
  • 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 BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule2Generic$1.00$0.00
  • QL 6 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule2Generic$1.00$0.00
  • QL 3 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule2Generic$1.00$0.00
  • QL 6 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule2Generic$1.00$0.00
  • QL 6 per 30 days
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule2Generic$1.00$0.00
  • QL 6 per 30 days
AMMONIUM LACTATE 12 g/100g Cream2Generic$1.00$0.00None
AMMONIUM LACTATE 12 g/100g Lotion2Generic$1.00$0.00None
AMNESTEEM 10 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/ANone
AMNESTEEM 20 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/ANone
AMNESTEEM 30 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/ANone
AMNESTEEM 40 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/ANone
AMOXAPINE 100 mg Tablet3Preferred Brand25%20%None
AMOXAPINE 150 mg Tablet3Preferred Brand25%20%None
AMOXAPINE 25 mg Tablet3Preferred Brand25%20%None
AMOXAPINE 50 mg Tablet3Preferred Brand25%20%None
AMOXICILLIN 125 mg Tablet, Chewable2Generic$1.00$0.00None
AMOXICILLIN 125 mg/5mL Powder, For Suspension2Generic$1.00$0.00None
AMOXICILLIN 200 mg/5mL Powder, For Suspension2Generic$1.00$0.00None
AMOXICILLIN 250 mg Capsule2Generic$1.00$0.00None
AMOXICILLIN 250 mg Tablet, Chewable2Generic$1.00$0.00None
AMOXICILLIN 250 mg/5mL Powder, For Suspension2Generic$1.00$0.00None
AMOXICILLIN 400 mg/5mL Powder, For Suspension2Generic$1.00$0.00None
AMOXICILLIN 500 mg Capsule2Generic$1.00$0.00None
AMOXICILLIN 500 mg Tablet, Film Coated2Generic$1.00$0.00None
AMOXICILLIN 875 mg Tablet, Film Coated2Generic$1.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension3Preferred Brand25%20%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated2Generic$1.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension3Preferred Brand25%20%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension3Preferred Brand25%20%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated2Generic$1.00$0.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension3Preferred Brand25%20%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated2Generic$1.00$0.00None
AMPHOTERICIN B 50 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%N/A
  • 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%N/ANone
AMPICILLIN 10 g Injection, Powder, For Solution4Non-Preferred Drug33%N/ANone
AMPICILLIN 2 g Injection, Powder, For SolutionAmpicillin Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN 500 mg Capsule2Generic$1.00$0.00None
AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution4Non-Preferred Drug33%N/ANone
ANAGRELIDE .5 mg Capsule3Preferred Brand25%20%None
ANAGRELIDE 1 mg Capsule3Preferred Brand25%20%None
ANASTROZOLE 1 mg Tablet2Generic$1.00$0.00
  • QL 3 per 30 days
APOMORPHINE HYDROCLORIDE 30 mg/3mL InjectionApomorphine Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 84 per 28 days
APREPITANT 125 mg Capsule5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
APREPITANT 40 mg Capsule4Non-Preferred Drug33%N/A
  • PA
  • QL 2 per 28 days
APREPITANT 80 mg Capsule4Non-Preferred Drug33%N/A
  • PA
  • QL 4 per 28 days
APREPITANT Kit4Non-Preferred Drug33%N/A
  • PA
APRI 28 DAY KitDesogestrel And Ethinyl Estradiol3Preferred Brand25%20%None
ARANELLE KitNorethindrone And Ethinyl Estradiol3Preferred Brand25%20%None
ARCALYST 160 mg/2mL Injection, Powder, Lyophilized, For SolutionRilonacept5Specialty Tier25%N/A
  • PA
AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted1Preferred Generic$0.00$0.00None
ARIKAYCE 590 mg/8.4mL SuspensionAmikacin5Specialty Tier25%N/A
  • PA
  • QL 235.2 per 28 days
ARIPIPRAZOLE 1 mg/mL Solution4Non-Preferred Drug33%N/A
  • QL 75 per 30 days
ARIPIPRAZOLE 10 mg Tablet3Preferred Brand25%20%None
ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg Tablet3Preferred Brand25%20%None
ARIPIPRAZOLE 2 mg Tablet3Preferred Brand25%20%None
ARIPIPRAZOLE 20 mg Tablet3Preferred Brand25%20%None
ARIPIPRAZOLE 30 mg Tablet3Preferred Brand25%20%None
ARIPIPRAZOLE 5 mg Tablet3Preferred Brand25%20%None
ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil4Non-Preferred Drug33%N/A
  • QL 3.9 per 56 days
ARISTADA 441 mg/1.6mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil4Non-Preferred Drug33%N/A
  • QL 1.6 per 28 days
ARISTADA 662 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil4Non-Preferred Drug33%N/A
  • QL 2.4 per 28 days
ARISTADA 882 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil4Non-Preferred Drug33%N/A
  • QL 3.2 per 28 days
ARISTADA INITIO 675 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil4Non-Preferred Drug33%N/A
  • QL 2.4 per 42 days
ARNUITY ELLIPTA 100 ug PowderFluticasone Furoate3Preferred Brand25%20%
  • QL 3 per 30 days
ARNUITY ELLIPTA 200 ug PowderFluticasone Furoate3Preferred Brand25%20%
  • QL 3 per 30 days
ARNUITY ELLIPTA 50 ug PowderFluticasone Furoate3Preferred Brand25%20%
  • QL 3 per 30 days
ASENAPINE 10 mg TabletAsenapine Maleate4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ASENAPINE 2.5 mg Tablet4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ASENAPINE 5 mg TabletAsenapine Maleate4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ASHLYNA KitLevonorgestrel And Ethinyl Estradiol And Ethinyl Estradiol3Preferred Brand25%20%
  • QL 91 per 90 days
ATAZANAVIR SULFATE 150 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATAZANAVIR SULFATE 200 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATAZANAVIR SULFATE 300 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
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 Tablet3Preferred Brand25%20%None
ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet3Preferred Brand25%20%None
ATOMOXETINE 10 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 100 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATOMOXETINE 18 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 25 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 40 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 60 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATOMOXETINE 80 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated2Generic$1.00$0.00None
ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated2Generic$1.00$0.00None
ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated2Generic$1.00$0.00None
ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated2Generic$1.00$0.00None
ATOVAQUONE 750 mg/5mL Suspension4Non-Preferred Drug33%N/ANone
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE PEDIATRIC 62.5/25 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate3Preferred Brand25%20%None
ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide4Non-Preferred Drug33%N/A
  • PA
  • QL 25.8 per 30 days
AUBRA EQ KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand25%20%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 9 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 28 per 28 days
AUVELITY 45/105 mg Tablet, Multilayer, Extended ReleaseDextromethorphan Hydrobromide, Bupropion Hydrochloride4Non-Preferred Drug33%N/A
  • ST
  • QL 6 per 30 days
AUVI-Q .1 mg/.1mL Injection, SolutionEpinephrine3Preferred Brand25%20%
  • QL 4 per 30 days
AUVI-Q .15 mg/.15mL Injection, SolutionEpinephrine3Preferred Brand25%20%
  • QL 4 per 30 days
AUVI-Q .3 mg/.3mL Injection, SolutionEpinephrine3Preferred Brand25%20%
  • QL 4 per 30 days
AVIANE KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand25%20%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 Brand25%20%
  • PA
AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops3Preferred Brand25%20%None
AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered3Preferred Brand25%20%
  • QL 3 per 25 days
AZITHROMYCIN 100 mg/5mL Powder, For Suspension3Preferred Brand25%20%None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$1.00$0.00None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$1.00$0.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$1.00$0.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$1.00$0.00None
AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate4Non-Preferred Drug33%N/ANone
AZITHROMYCIN 600 mg Tablet, Film Coated2Generic$1.00$0.00None
AZITHROMYCIN DIHYDRATE 200 mg/5mL Powder, For Suspension3Preferred Brand25%20%None
AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%N/ANone
AZURETTE KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol3Preferred Brand25%20%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.