2026 Blue MedicareRx Value Plus (PDP) formulary (drug list)

Contract S2893, plan 001 · Rhode Island · 3,150 drugs on file · formulary ID 00026129. Each drug links to its cost in every CMS PDP Region 02 plan.

250 drugs starting with C.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
CABERGOLINE .5 mg Tablet	3Preferred Brand	17%	17%	None
CABOMETYX 20 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CABOMETYX 40 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CABOMETYX 60 mg TabletCabozantinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CALCIPOTRIENE .05 mg/mL Solution	3Preferred Brand	17%	17%	PA QL 12 per 30 days
CALCITONIN SALMON 200 [iU] Spray, Metered	3Preferred Brand	17%	17%	PA
CALCITRIOL .25 ug Capsule, Liquid Filled	2Generic	$3.00	$6.00	PA
CALCITRIOL .5 ug Capsule, Liquid Filled	2Generic	$3.00	$6.00	PA
CALCITRIOL 1 ug/mL Solution	4Non-Preferred Drug	32%	32%	PA
CALQUENCE 100 mg Tablet, Film CoatedAcalabrutinib	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
CANDESARTAN 16 mg Tablet	3Preferred Brand	17%	17%	QL 6 per 30 days
CANDESARTAN 32 mg Tablet	3Preferred Brand	17%	17%	QL 3 per 30 days
CANDESARTAN 4 mg Tablet	3Preferred Brand	17%	17%	QL 6 per 30 days
CANDESARTAN 8 mg Tablet	3Preferred Brand	17%	17%	QL 6 per 30 days
CAPLYTA 10.5 mg CapsuleLumateperone	4Non-Preferred Drug	32%	32%	QL 3 per 30 days
CAPLYTA 21 mg CapsuleLumateperone	4Non-Preferred Drug	32%	32%	QL 3 per 30 days
CAPLYTA 42 mg CapsuleLumateperone	4Non-Preferred Drug	32%	32%	QL 3 per 30 days
CAPRELSA 100 mg Tablet, Film CoatedVandetanib	5Specialty Tier	25%	N/A	PA QL 6 per 30 days
CAPRELSA 300 mg Tablet, Film CoatedVandetanib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
CARBAMAZEPINE 100 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 100 mg Tablet, Chewable	3Preferred Brand	17%	17%	None
CARBAMAZEPINE 100 mg Tablet, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 100 mg/5mL Suspension	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 200 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 200 mg Tablet	3Preferred Brand	17%	17%	None
CARBAMAZEPINE 200 mg Tablet, Chewable	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 200 mg Tablet, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 300 mg Capsule, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBAMAZEPINE 400 mg Tablet, Extended Release	4Non-Preferred Drug	32%	32%	None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet	2Generic	$3.00	$6.00	None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet	2Generic	$3.00	$6.00	None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	None
CARBIDOPA AND LEVODOPA 25/250 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	None
CARBIDOPA-LEVODOPA 25/250 mg TabletCarbidopa And Levodopa	2Generic	$3.00	$6.00	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 12.5/50/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 18.75/75/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 25/100/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 31.25/125/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 37.5/150/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARBIDOPA, LEVODOPA AND ENTACAPONE 50/200/200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CARGLUMIC ACID 200 mg Tablet, For Suspension	5Specialty Tier	25%	N/A	PA
CARTEOLOL HYDROCHLORIDE 10 mg/mL Solution	2Generic	$3.00	$6.00	None
CARTIA XT 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$3.00	$6.00	None
CARTIA XT 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$3.00	$6.00	None
CARTIA XT 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$3.00	$6.00	None
CARTIA XT 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride	2Generic	$3.00	$6.00	None
CARVEDILOL 12.5 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CARVEDILOL 25 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CARVEDILOL 3.125 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CARVEDILOL 6.25 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CASPOFUNGIN ACETATE 5 mg/mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	32%	32%	None
CASPOFUNGIN ACETATE 7 mg/mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	32%	32%	None
CAYSTON KitAztreonam	5Specialty Tier	25%	N/A	PA
CEFACLOR 250 mg Capsule	3Preferred Brand	17%	17%	None
CEFACLOR 500 mg Capsule	3Preferred Brand	17%	17%	None
CEFADROXIL 500 mg Capsule	2Generic	$3.00	$6.00	None
CEFAZOLIN 1 g Injection, Powder, For Solution	3Preferred Brand	17%	17%	None
CEFAZOLIN 10 g Injection, Powder, For Solution	3Preferred Brand	17%	17%	None
CEFAZOLIN 500 mg Injection, Powder, For Solution	3Preferred Brand	17%	17%	None
CEFDINIR 125 mg/5mL Powder, For Suspension	3Preferred Brand	17%	17%	None
CEFDINIR 250 mg/5mL Powder, For Suspension	3Preferred Brand	17%	17%	None
CEFDINIR 300 mg Capsule	2Generic	$3.00	$6.00	None
CEFEPIME 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFEPIME 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFIXIME 400 mg Capsule	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 10 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFOXITIN 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFPODOXIME PROXETIL 100 mg Tablet, Film Coated	3Preferred Brand	17%	17%	None
CEFPODOXIME PROXETIL 200 mg Tablet, Film Coated	3Preferred Brand	17%	17%	None
CEFPROZIL 125 mg/5mL Powder, For Suspension	3Preferred Brand	17%	17%	None
CEFPROZIL 250 mg Tablet	3Preferred Brand	17%	17%	None
CEFPROZIL 250 mg/5mL Powder, For Suspension	3Preferred Brand	17%	17%	None
CEFPROZIL 500 mg Tablet	3Preferred Brand	17%	17%	None
CEFTAROLINE FOSAMIL 400 mg/20mL Injection, Powder, Lyophilized, For Solution	5Specialty Tier	25%	N/A	None
CEFTAROLINE FOSAMIL 600 mg/20mL Injection, Powder, Lyophilized, For Solution	5Specialty Tier	25%	N/A	None
CEFTAZIDIME 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTAZIDIME 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTAZIDIME 6 g/30mL Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 1 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 10 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 2 g Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 250 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFTRIAXONE SODIUM 500 mg Injection, Powder, For Solution	4Non-Preferred Drug	32%	32%	None
CEFUROXIME 1.5 g Injection, Powder, For Solution	3Preferred Brand	17%	17%	None
CEFUROXIME 750 mg Injection, Powder, For Solution	3Preferred Brand	17%	17%	None
CEFUROXIME AXETIL 250 mg Tablet	2Generic	$3.00	$6.00	None
CEFUROXIME AXETIL 500 mg Tablet	2Generic	$3.00	$6.00	None
CELECOXIB 100 mg Capsule	3Preferred Brand	17%	17%	QL 6 per 30 days
CELECOXIB 200 mg Capsule	3Preferred Brand	17%	17%	QL 6 per 30 days
CELECOXIB 400 mg Capsule	3Preferred Brand	17%	17%	QL 3 per 30 days
CELECOXIB 50 mg Capsule	3Preferred Brand	17%	17%	QL 6 per 30 days
CEPHALEXIN 125 mg/5mL For Suspension	3Preferred Brand	17%	17%	None
CEPHALEXIN 250 mg Capsule	2Generic	$3.00	$6.00	None
CEPHALEXIN 250 mg/5mL For Suspension	3Preferred Brand	17%	17%	None
CEPHALEXIN 500 mg Capsule	2Generic	$3.00	$6.00	None
CERDELGA 84 mg CapsuleEliglustat	5Specialty Tier	25%	N/A	PA
CETIRIZINE HYDROCHLORIDE 1 mg/mL Solution	2Generic	$3.00	$6.00	QL 3 per 30 days
CHEMET 100 mg CapsuleSuccimer	5Specialty Tier	25%	N/A	None
CHLORHEXIDINE GLUCONATE 1.2 mg/mL Rinse	2Generic	$3.00	$6.00	None
CHLOROQUINE PHOSPHATE 250 mg Tablet	4Non-Preferred Drug	32%	32%	None
CHLOROQUINE PHOSPHATE 500 mg Tablet	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 10 mg Tablet, Coated	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 100 mg/mL Concentrate	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 200 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 25 mg Tablet, Coated	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 30 mg/mL Concentrate	4Non-Preferred Drug	32%	32%	None
CHLORPROMAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated	4Non-Preferred Drug	32%	32%	None
CHLORTHALIDONE 25 mg Tablet	2Generic	$3.00	$6.00	None
CHLORTHALIDONE 50 mg Tablet	2Generic	$3.00	$6.00	None
CHOLESTYRAMINE 4 g/5.5g Powder, For Suspension	3Preferred Brand	17%	17%	None
CHOLESTYRAMINE 4 g/9g Powder, For Suspension	3Preferred Brand	17%	17%	None
CICLOPIROX OLAMINE 7.7 mg/g Cream	3Preferred Brand	17%	17%	QL 9 per 30 days
CICLOPIROX OLAMINE 7.7 mg/mL Suspension	3Preferred Brand	17%	17%	QL 6 per 30 days
CILOSTAZOL 100 mg Tablet	2Generic	$3.00	$6.00	None
CILOSTAZOL 50 mg Tablet	2Generic	$3.00	$6.00	None
CILOXAN 3 mg/g OintmentCiprofloxacin Hydrochloride	3Preferred Brand	17%	17%	None
CIMDUO 300/300 mg Tablet, Film CoatedLamivudine And Tenofovir Disoproxil Fumarate	5Specialty Tier	25%	N/A	None
CIPROFLOXACIN 250 mg Tablet, Film Coated	2Generic	$3.00	$6.00	None
CIPROFLOXACIN 500 mg Tablet, Film Coated	2Generic	$3.00	$6.00	None
CIPROFLOXACIN 750 mg Tablet, Film Coated	2Generic	$3.00	$6.00	None
CIPROFLOXACIN AND DEXAMETHASONE 3/1 mg/mL Suspension/ Drops	4Non-Preferred Drug	32%	32%	None
CIPROFLOXACIN HYDROCHLORIDE 3 mg/mL Solution/ Drops	2Generic	$3.00	$6.00	None
CIPROFLOXACIN IN DEXTROSE 200 mg/100mL Injection, SolutionCiprofloxacin	3Preferred Brand	17%	17%	None
CITALOPRAM 10 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CITALOPRAM 20 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CITALOPRAM 40 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
CITALOPRAM HYDROBROMIDE 10 mg/5mL Solution	3Preferred Brand	17%	17%	None
CLARAVIS 10 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 20 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 30 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARAVIS 40 mg Capsule, Liquid FilledIsotretinoin	4Non-Preferred Drug	32%	32%	PA
CLARITHROMYCIN 125 mg/5mL For Suspension	4Non-Preferred Drug	32%	32%	None
CLARITHROMYCIN 250 mg Tablet, Film Coated	3Preferred Brand	17%	17%	None
CLARITHROMYCIN 250 mg/5mL For Suspension	4Non-Preferred Drug	32%	32%	None
CLARITHROMYCIN 500 mg Tablet, Film Coated	3Preferred Brand	17%	17%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	3Preferred Brand	17%	17%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	3Preferred Brand	17%	17%	None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate	3Preferred Brand	17%	17%	None
CLINDAMYCIN HYDROCHLORIDE 150 mg Capsule	2Generic	$3.00	$6.00	None
CLINDAMYCIN HYDROCHLORIDE 300 mg Capsule	2Generic	$3.00	$6.00	None
CLINDAMYCIN HYDROCHLORIDE 75 mg Capsule	2Generic	$3.00	$6.00	None
CLINDAMYCIN PHOSPHATE 10 mg/mL Lotion	3Preferred Brand	17%	17%	QL 6 per 30 days
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution	3Preferred Brand	17%	17%	QL 6 per 30 days
CLINDAMYCIN PHOSPHATE 20 mg/g Cream	3Preferred Brand	17%	17%	None
CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE 10/50 mg/g GelClindamycin, Benzoyl Peroxide	3Preferred Brand	17%	17%	QL 45 per 30 days
CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/10 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose	4Non-Preferred Drug	32%	32%	PA
CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose	4Non-Preferred Drug	32%	32%	PA
CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/15 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose	4Non-Preferred Drug	32%	32%	PA
CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/20 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose	4Non-Preferred Drug	32%	32%	PA
CLINISOL 1.18/1.04/1.04/960/894/749/749/749/250/2.17/1.47/1.04/894/749/592/434/39 g/100mL/mg/100mL Injection, SolutionLysine, Leucine, Phenylalanine, Valine, Histidine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Proline, Glutamic Acid, Serine, Aspartic Acid, Tyrosine	4Non-Preferred Drug	32%	32%	PA
CLINOLIPID 16/4 g/100mL Injection, EmulsionOlive Oil And Soybean Oil	4Non-Preferred Drug	32%	32%	PA
CLOBAZAM 10 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 6 per 30 days
CLOBAZAM 2.5 mg/mL Suspension	4Non-Preferred Drug	32%	32%	PA QL 48 per 30 days
CLOBAZAM 20 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 6 per 30 days
CLOBETASOL PROPIONATE .05 g/100mL Shampoo	4Non-Preferred Drug	32%	32%	QL 236 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Cream	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Cream	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Gel	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CLOBETASOL PROPIONATE .5 mg/g Ointment	4Non-Preferred Drug	32%	32%	QL 12 per 30 days
CLOBETASOL PROPIONATE .5 mg/mL Solution	4Non-Preferred Drug	32%	32%	QL 1 per 30 days
CLODAN .5 mg/mL ShampooClobetasol Propionate	4Non-Preferred Drug	32%	32%	QL 236 per 30 days
CLOMIPRAMINE HYDROCHLORIDE 25 mg Capsule	4Non-Preferred Drug	32%	32%	PA
CLOMIPRAMINE HYDROCHLORIDE 50 mg Capsule	4Non-Preferred Drug	32%	32%	PA
CLOMIPRAMINE HYDROCHLORIDE 75 mg Capsule	4Non-Preferred Drug	32%	32%	PA
CLONAZEPAM .125 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	QL 9 per 30 days
CLONAZEPAM .25 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	QL 9 per 30 days
CLONAZEPAM .5 mg Tablet	2Generic	$3.00	$6.00	QL 9 per 30 days
CLONAZEPAM .5 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	QL 9 per 30 days
CLONAZEPAM 1 mg Tablet	2Generic	$3.00	$6.00	QL 9 per 30 days
CLONAZEPAM 1 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	QL 9 per 30 days
CLONAZEPAM 2 mg Tablet	2Generic	$3.00	$6.00	QL 3 per 30 days
CLONAZEPAM 2 mg Tablet, Orally Disintegrating	3Preferred Brand	17%	17%	QL 3 per 30 days
CLONIDINE HYDROCHLORIDE .1 mg Tablet	1Preferred Generic	$0.00	$0.00	None
CLONIDINE HYDROCHLORIDE .2 mg Tablet	1Preferred Generic	$0.00	$0.00	None
CLONIDINE HYDROCHLORIDE .3 mg Tablet	1Preferred Generic	$0.00	$0.00	None
CLONIDINE TRANSDERMAL SYSTEM .1 mg/d PatchClonidine	3Preferred Brand	17%	17%	None
CLONIDINE TRANSDERMAL SYSTEM .2 mg/d PatchClonidine	3Preferred Brand	17%	17%	None
CLONIDINE TRANSDERMAL SYSTEM .3 mg/d PatchClonidine	3Preferred Brand	17%	17%	None
CLOPIDOGREL 75 mg Tablet, Film CoatedClopidogrel Bisulfate	1Preferred Generic	$0.00	$0.00	None
CLORAZEPATE DIPOTASSIUM 15 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLORAZEPATE DIPOTASSIUM 3.75 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLOTRIMAZOLE 10 mg Lozenge	3Preferred Brand	17%	17%	QL 15 per 30 days
CLOTRIMAZOLE 10 mg/g Cream	2Generic	$3.00	$6.00	QL 45 per 30 days
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/g Cream	3Preferred Brand	17%	17%	QL 45 per 30 days
CLOTRIMAZOLE TOPICAL SOLUTION USP, 1% 10 mg/mL Solution	3Preferred Brand	17%	17%	QL 6 per 30 days
CLOZAPINE 100 mg Tablet	3Preferred Brand	17%	17%	QL 27 per 30 days
CLOZAPINE 100 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 27 per 30 days
CLOZAPINE 12.5 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA
CLOZAPINE 150 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
CLOZAPINE 200 mg Tablet	3Preferred Brand	17%	17%	QL 12 per 30 days
CLOZAPINE 200 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA QL 12 per 30 days
CLOZAPINE 25 mg Tablet	3Preferred Brand	17%	17%	None
CLOZAPINE 25 mg Tablet, Orally Disintegrating	4Non-Preferred Drug	32%	32%	PA
CLOZAPINE 50 mg Tablet	3Preferred Brand	17%	17%	None
COARTEM 20/120 mg TabletArtemether And Lumefantrine	4Non-Preferred Drug	32%	32%	None
COBENFY 100/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	4Non-Preferred Drug	32%	32%	QL 6 per 30 days
COBENFY 125/30 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	4Non-Preferred Drug	32%	32%	QL 6 per 30 days
COBENFY 50/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride	4Non-Preferred Drug	32%	32%	QL 6 per 30 days
COBENFY KitXanomeline And Trospium Chloride	4Non-Preferred Drug	32%	32%	QL 112 per 365 days
COLCHICINE .6 mg Tablet, Film Coated	3Preferred Brand	17%	17%	QL 12 per 30 days
COLESTIPOL HYDROCHLORIDE 1 g Tablet, Film Coated	3Preferred Brand	17%	17%	None
COLESTIPOL HYDROCHLORIDE 5 g/5g Granule, For Suspension	4Non-Preferred Drug	32%	32%	None
COLISTIMETHATE 150 mg Injection, Powder, For SolutionColistimethate Sodium	4Non-Preferred Drug	32%	32%	None
COLLAGENASE SANTYL 250 [arb'U]/g Ointment	4Non-Preferred Drug	32%	32%	PA QL 18 per 30 days
COMBIGAN 2/5 mg/mL Solution/ DropsBrimonidine Tartrate, Timolol Maleate	3Preferred Brand	17%	17%	None
COMBIVENT RESPIMAT 20/100 ug Spray, MeteredIpratropium Bromide And Albuterol	4Non-Preferred Drug	32%	32%	QL 8 per 30 days
COMETRIQ 20 mg CapsuleCabozantinib	5Specialty Tier	25%	N/A	PA QL 84 per 28 days
COMETRIQ KitCabozantinib	5Specialty Tier	25%	N/A	PA QL 112 per 28 days
COMETRIQ KitCabozantinib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COMPRO 25 mg SuppositoryProchlorperazine	4Non-Preferred Drug	32%	32%	None
CONSTULOSE 10 g/15mL SolutionLactulose	3Preferred Brand	17%	17%	None
COPAXONE 20 mg/mL Injection, SolutionGlatiramer Acetate	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
COPAXONE 40 mg/mL Injection, SolutionGlatiramer Acetate	5Specialty Tier	25%	N/A	PA QL 12 per 28 days
COPIKTRA 15 mg CapsuleDuvelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COPIKTRA 25 mg CapsuleDuvelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
COTELLIC 20 mg Tablet, Film CoatedCobimetinib	5Specialty Tier	25%	N/A	PA QL 63 per 28 days
CREON 15000/3000/9500 [USP'U] Capsule, Delayed ReleasePancrelipase	3Preferred Brand	17%	17%	None
CREON 24000/76000/120000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	17%	17%	None
CREON 30000/6000/19000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	17%	17%	None
CREON 36000/180000/114000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	17%	17%	None
CREON 60000/12000/38000 [USP'U] Capsule, Delayed Release PelletsPancrelipase	3Preferred Brand	17%	17%	None
CRESEMBA 100 mg CapsuleIsavuconazonium Sulfate	5Specialty Tier	25%	N/A	PA
CRESEMBA 40 mg CapsuleIsavuconazonium Sulfate	5Specialty Tier	25%	N/A	PA
CROMOLYN SODIUM 100 mg/5mL Solution, Concentrate	4Non-Preferred Drug	32%	32%	None
CROMOLYN SODIUM 20 mg/2mL Solution	3Preferred Brand	17%	17%	PA
CROMOLYN SODIUM 40 mg/mL Solution/ Drops	2Generic	$3.00	$6.00	None
CRYSELLE KitNorgestrel And Ethinyl Estradiol	3Preferred Brand	17%	17%	None
CYCLOBENZAPRINE HYDROCHLORIDE 10 mg Tablet, Film Coated	3Preferred Brand	17%	17%	PA QL 9 per 30 days
CYCLOBENZAPRINE HYDROCHLORIDE 5 mg Tablet, Film Coated	3Preferred Brand	17%	17%	PA QL 9 per 30 days
CYCLOPHOSPHAMIDE 25 mg Capsule	3Preferred Brand	17%	17%	PA
CYCLOPHOSPHAMIDE 50 mg Capsule	3Preferred Brand	17%	17%	PA
CYCLOPHOSPHAMIDE 50 mg Tablet	4Non-Preferred Drug	32%	32%	PA
CYCLOSERINE 250 mg Capsule	5Specialty Tier	25%	N/A	None
CYCLOSPORINE 100 mg Capsule, Gelatin Coated	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE 100 mg/mL Solution	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE 25 mg Capsule, Gelatin Coated	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE MODIFIED 100 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE MODIFIED 50 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYCLOSPORINE, MODFIED 25 mg Capsule, Liquid FilledCyclosporine	4Non-Preferred Drug	32%	32%	PA
CYPROHEPTADINE HYDROCHLORIDE 2 mg/5mL Syrup	3Preferred Brand	17%	17%	PA
CYPROHEPTADINE HYDROCHLORIDE 4 mg Tablet	3Preferred Brand	17%	17%	PA
CYRED EQ KitDesogestrel And Ethinyl Estradiol	3Preferred Brand	17%	17%	None
CYSTADROPS 3.5 mg/mL SolutionCysteamine Hydrochloride	5Specialty Tier	25%	N/A	PA
CYSTAGON 150 mg CapsuleCysteamine Bitartrate	4Non-Preferred Drug	32%	32%	PA
CYSTAGON 50 mg CapsuleCysteamine Bitartrate	4Non-Preferred Drug	32%	32%	PA
CYSTARAN 6.5 mg/mL SolutionCysteamine Hydrochloride	5Specialty Tier	25%	N/A	PA

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.