2026 BlueCross Rx Value (PDP) formulary (drug list)
Contract S5953, plan 001 · South Carolina · 3,082 drugs on file · formulary ID 00026220. Each drug links to its cost in every CMS PDP Region 09 plan.
242 drugs starting with P.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| PACERONE 100 mg TabletAmiodarone Hydrochloride | 4Non-Preferred Drug | 50% | 50% | None |
| PACERONE 200 mg TabletAmiodarone Hydrochloride | 2Generic | $17.00 | $42.50 | None |
| PALIPERIDONE 1.5 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% |
|
| PALIPERIDONE 3 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% |
|
| PALIPERIDONE 6 mg Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% |
|
| PALIPERIDONE 9 mg Tablet, Film Coated, Extended Release | 4Non-Preferred Drug | 50% | 50% |
|
| PANRETIN 60 mg/60g GelAlitretinoin | 5Specialty Tier | 25% | N/A | None |
| PANTOPRAZOLE SODIUM 20 mg Tablet, Delayed Release | 2Generic | $17.00 | $42.50 |
|
| PANTOPRAZOLE SODIUM 40 mg Tablet, Delayed ReleasePantoprazole | 2Generic | $17.00 | $42.50 |
|
| PARICALCITOL 1 ug Capsule, Liquid Filled | 4Non-Preferred Drug | 50% | 50% | None |
| PARICALCITOL 2 ug Capsule, Liquid Filled | 4Non-Preferred Drug | 50% | 50% | None |
| PARICALCITOL 4 ug Capsule, Liquid Filled | 4Non-Preferred Drug | 50% | 50% | None |
| PAROXETINE 10 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PAROXETINE 10 mg/5mL Suspension | 4Non-Preferred Drug | 50% | 50% | None |
| PAROXETINE 20 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PAROXETINE 30 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PAROXETINE 40 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PAXLOVID KitNirmatrelvir And Ritonavir | 3Preferred Brand | 17% | 17% |
|
| PAXLOVID KitNirmatrelvir And Ritonavir | 3Preferred Brand | 17% | 17% |
|
| PAXLOVID KitNirmatrelvir And Ritonavir | 3Preferred Brand | 17% | 17% |
|
| PAZOPANIB 200 mg Tablet | 5Specialty Tier | 25% | N/A |
|
| PEDIARIX 25/10/25/25/8/10/40/8/32 [iU]/.5mL/ug/.5mL Injection, SuspensionDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) And Inactivated Poliovirus Vaccine Combined | 3Preferred Brand | 17% | 17% | None |
| PEDVAXHIB 7.5 ug/.5mL Injection, SuspensionHaemophilus B Conjugate Vaccine (Meningococcal Protein Conjugate) | 3Preferred Brand | 17% | 17% | None |
| PEG-3350 AND ELECTROLYTES 236/22.74/6.74/5.86/2.97 g/4L Powder, For SolutionPolyethylene Glycol 3350, Sodium Sulfate Anhydrous, Sodium Bicarbonate, Sodium Chloride, Potassium Chloride | 2Generic | $17.00 | $42.50 | None |
| PEGASYS 180 ug/.5mL Injection, SolutionPeginterferon Alfa-2A | 5Specialty Tier | 25% | N/A |
|
| PEGASYS 180 ug/mL Injection, SolutionPeginterferon Alfa-2A | 5Specialty Tier | 25% | N/A |
|
| PEMAZYRE 13.5 mg TabletPemigatinib | 5Specialty Tier | 25% | N/A |
|
| PEMAZYRE 4.5 mg TabletPemigatinib | 5Specialty Tier | 25% | N/A |
|
| PEMAZYRE 9 mg TabletPemigatinib | 5Specialty Tier | 25% | N/A |
|
| PENBRAYA KitMeningococcal Groups A, B, C, W, And Y Vaccine | 1Preferred Generic | $12.00 | $30.00 | None |
| PENICILLAMINE 250 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PENICILLIN G SODIUM 5000000 [USP'U] Injection, Powder, For Solution | 5Specialty Tier | 25% | N/A | None |
| PENICILLIN V POTASSIUM 125 mg/5mL Powder, For Solution | 2Generic | $17.00 | $42.50 | None |
| PENICILLIN V POTASSIUM 250 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PENICILLIN V POTASSIUM 250 mg/5mL Powder, For Solution | 2Generic | $17.00 | $42.50 | None |
| PENICILLIN V POTASSIUM 500 mg Tablet, Film Coated | 2Generic | $17.00 | $42.50 | None |
| PENMENVY KitMeningococcal (Groups A, B, C, W And Y) | 1Preferred Generic | $12.00 | $30.00 | None |
| PENTACEL KitDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Inactivated Poliovirus And Haemophilus B Conjugate (Tetanus Toxoid Conjugate) Vaccine | 3Preferred Brand | 17% | 17% | None |
| PENTAMIDINE ISETHIONATE 300 mg/300mg Inhalant | 3Preferred Brand | 17% | 17% |
|
| PENTAMIDINE ISETHIONATE 300 mg/300mg Injection, Powder, Lyophilized, For Solution | 4Non-Preferred Drug | 50% | 50% | None |
| PENTOXIFYLLINE 400 mg Tablet, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PERAMPANEL .5 mg/mL Suspension | 5Specialty Tier | 25% | N/A | None |
| PERAMPANEL 10 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PERAMPANEL 12 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PERAMPANEL 2 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PERAMPANEL 4 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PERAMPANEL 6 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PERAMPANEL 8 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A | None |
| PERINDOPRIL ERBUMINE 2 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PERINDOPRIL ERBUMINE 4 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PERINDOPRIL ERBUMINE 8 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PERIOGARD ALCOHOL FREE 1.2 mg/mL RinseChlorhexidine Gluconate | 2Generic | $17.00 | $42.50 | None |
| PERMETHRIN 50 mg/g CreamPermethrin Cream 5% W/W | 3Preferred Brand | 17% | 17% | None |
| PERPHENAZINE 16 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PERPHENAZINE 2 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PERPHENAZINE 4 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PERPHENAZINE 8 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PHENELZINE SULFATE 15 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| PHENOBARBITAL 100 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 15 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 16.2 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 30 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 32.4 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 60 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 64.8 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL 97.2 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PHENOBARBITAL ORAL SOLUTION 20 mg/5mL SolutionPhenobarbital Oral | 4Non-Preferred Drug | 50% | 50% | None |
| PHENYTEK 200 mg Capsule, Extended ReleaseExtended Phenytoin Sodium | 3Preferred Brand | 17% | 17% | None |
| PHENYTEK 300 mg Capsule, Extended ReleasePhenytoin Sodium | 3Preferred Brand | 17% | 17% | None |
| PHENYTOIN 125 mg/5mL Suspension | 2Generic | $17.00 | $42.50 | None |
| PHENYTOIN 50 mg Tablet, Chewable | 2Generic | $17.00 | $42.50 | None |
| PHENYTOIN SODIUM 100 mg Capsule, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PIFELTRO 100 mg Tablet, Film CoatedDoravirine | 5Specialty Tier | 25% | N/A |
|
| PILOCARPINE HYDROCHLORIDE 10 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution | 3Preferred Brand | 17% | 17% | None |
| PILOCARPINE HYDROCHLORIDE 20 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution | 3Preferred Brand | 17% | 17% | None |
| PILOCARPINE HYDROCHLORIDE 40 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution | 3Preferred Brand | 17% | 17% | None |
| PILOCARPINE HYDROCHLORIDE 5 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PILOCARPINE HYDROCHLORIDE 7.5 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PIMECROLIMUS 10 mg/g Cream | 4Non-Preferred Drug | 50% | 50% | None |
| PIMOZIDE 1 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PIMOZIDE 2 mg Tablet | 4Non-Preferred Drug | 50% | 50% | None |
| PIMTREA KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| PIOGLITAZONE 15 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PIOGLITAZONE 30 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PIOGLITAZONE 45 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PIOGLITAZONE HYDROCHLORIDE AND METFORMIN HYDROCHLORIDE 15/500 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| PIOGLITAZONE HYDROCHLORIDE AND METFORMIN HYDROCHLORIDE 15/850 mg Tablet, Film Coated | 6Select Care Drugs | $5.00 | $12.50 | None |
| PIPERACILLIN AND TAZOBACTAM 2/.25 g/10mL Injection, Powder, For Solution | 3Preferred Brand | 17% | 17% | None |
| PIPERACILLIN AND TAZOBACTAM 3/.375 g/15mL Injection, Powder, For Solution | 3Preferred Brand | 17% | 17% | None |
| PIPERACILLIN AND TAZOBACTAM 4.5/36 g/180mL Injection, Powder, Lyophilized, For Solution | 3Preferred Brand | 17% | 17% | None |
| PIPERACILLIN AND TAZOBACTAM 4/.5 g/20mL Injection, Powder, For Solution | 3Preferred Brand | 17% | 17% | None |
| PIQRAY 150 mg TabletAlpelisib | 5Specialty Tier | 25% | N/A |
|
| PIQRAY 200 mg TabletAlpelisib | 5Specialty Tier | 25% | N/A |
|
| PIQRAY KitAlpelisib | 5Specialty Tier | 25% | N/A |
|
| PIRFENIDONE 267 mg Capsule | 5Specialty Tier | 25% | N/A |
|
| PIRFENIDONE 267 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| PIRFENIDONE 534 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| PIRFENIDONE 801 mg Tablet, Film Coated | 5Specialty Tier | 25% | N/A |
|
| PLENAMINE 1.18/1.04/1.04/960/749/749/749/250/2.17/1.47/1.04/894/894/749/592/434/39 g/100mL/mg/100mL SolutionLysine Acetate, Leucine, Phenylalanine, Valine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Histidine, Proline, Glutamic Acid, Serine, Aspartic Acid, And Tyrosine | 4Non-Preferred Drug | 50% | 50% |
|
| PODOFILOX 5 mg/mL Solution | 3Preferred Brand | 17% | 17% | None |
| POLYETHYLENE GLYCOL 3350, SODIUM CHLORIDE, SODIUM BICARBONATE AND POTASSIUM CHLORIDE WITH LEMON FLAVOR 420/11.2/5.72/1.48 g/4L Powder, For Solution | 2Generic | $17.00 | $42.50 | None |
| POLYMYXIN B SULFATE AND TRIMETHOPRIM 10000/1 [USP'U]/mL/mg/mL Solution | 2Generic | $17.00 | $42.50 | None |
| POMALYST 1 mg CapsulePomalidomide | 5Specialty Tier | 25% | N/A |
|
| POMALYST 2 mg CapsulePomalidomide | 5Specialty Tier | 25% | N/A |
|
| POMALYST 3 mg CapsulePomalidomide | 5Specialty Tier | 25% | N/A |
|
| POMALYST 4 mg CapsulePomalidomide | 5Specialty Tier | 25% | N/A |
|
| PORTIA KitLevonorgestrel And Ethinyl Estradiol | 3Preferred Brand | 17% | 17% | None |
| POSACONAZOLE 100 mg Tablet, Delayed Release | 4Non-Preferred Drug | 50% | 50% |
|
| POSACONAZOLE 40 mg/mL Suspension | 5Specialty Tier | 25% | N/A |
|
| POTASSIUM CHLORIDE 1.5 g/15mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| POTASSIUM CHLORIDE 10 meq Tablet, Film Coated, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 1125 mg Tablet, Extended Release | 3Preferred Brand | 17% | 17% | None |
| POTASSIUM CHLORIDE 1125 mg Tablet, Film Coated, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 14.9 g/1000mL Injection, Solution | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 1500 mg Tablet, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 1500 mg Tablet, Film Coated, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 29.8 g/1000mL Injection, Solution | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 600 mg Capsule, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 600 mg Tablet, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 7.46 g/1000mL Injection, Solution | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 750 mg Capsule, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CHLORIDE 750 mg Tablet, Extended Release | 2Generic | $17.00 | $42.50 | None |
| POTASSIUM CITRATE 10 meq Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| POTASSIUM CITRATE 5 meq Tablet, Extended Release | 4Non-Preferred Drug | 50% | 50% | None |
| POTASSIUM CITRATE EXTENDED RELEASE 15 meq TabletPotassium Citrate | 4Non-Preferred Drug | 50% | 50% | None |
| PRAMIPEXOLE DIHYDROCHLORIDE .125 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRAMIPEXOLE DIHYDROCHLORIDE .25 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRAMIPEXOLE DIHYDROCHLORIDE .5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRAMIPEXOLE DIHYDROCHLORIDE .75 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRAMIPEXOLE DIHYDROCHLORIDE 1 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRASUGREL 10 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PRASUGREL 5 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PRAVASTATIN SODIUM 10 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PRAVASTATIN SODIUM 20 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PRAVASTATIN SODIUM 40 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PRAVASTATIN SODIUM 80 mg Tablet | 6Select Care Drugs | $5.00 | $12.50 | None |
| PRAZIQUANTEL 600 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PRAZOSIN HYDROCHLORIDE 1 mg Capsule | 2Generic | $17.00 | $42.50 | None |
| PRAZOSIN HYDROCHLORIDE 2 mg Capsule | 2Generic | $17.00 | $42.50 | None |
| PRAZOSIN HYDROCHLORIDE 5 mg Capsule | 2Generic | $17.00 | $42.50 | None |
| PREDNISOLONE 15 mg/5mL SolutionPrednisolone Oral | 2Generic | $17.00 | $42.50 | None |
| PREDNISOLONE ACETATE 10 mg/mL Suspension/ Drops | 3Preferred Brand | 17% | 17% | None |
| PREDNISOLONE SODIUM PHOSPHATE 5 mg/5mL Solution | 4Non-Preferred Drug | 50% | 50% | None |
| PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 25 mg/5mL SolutionPrednisolone Sodium Phosphate | 4Non-Preferred Drug | 50% | 50% | None |
| PREDNISONE 1 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 10 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 10 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 10 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 2.5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 20 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREDNISONE 50 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PREGABALIN 100 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 150 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 20 mg/mL Solution | 4Non-Preferred Drug | 50% | 50% |
|
| PREGABALIN 200 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 225 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 25 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 300 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 50 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREGABALIN 75 mg Capsule | 2Generic | $17.00 | $42.50 |
|
| PREMARIN .3 mg Tablet, Film CoatedEstrogens, Conjugated | 4Non-Preferred Drug | 50% | 50% | None |
| PREMARIN .45 mg Tablet, Film CoatedEstrogens, Conjugated | 4Non-Preferred Drug | 50% | 50% | None |
| PREMARIN .625 mg Tablet, Film CoatedEstrogens, Conjugated | 4Non-Preferred Drug | 50% | 50% | None |
| PREMARIN .9 mg Tablet, Film CoatedEstrogens, Conjugated | 4Non-Preferred Drug | 50% | 50% | None |
| PREMARIN 1.25 mg Tablet, Film CoatedEstrogens, Conjugated | 4Non-Preferred Drug | 50% | 50% | None |
| PREMARIN VAGINAL .625 mg/g CreamConjugated Estrogens | 4Non-Preferred Drug | 50% | 50% | None |
| PREMPHASE KitConjugated Estrogens And Medroxyprogesterone Acetate | 4Non-Preferred Drug | 50% | 50% | None |
| PREMPRO .3/1.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate | 4Non-Preferred Drug | 50% | 50% | None |
| PREMPRO .45/1.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate | 4Non-Preferred Drug | 50% | 50% | None |
| PREMPRO .625/2.5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate | 4Non-Preferred Drug | 50% | 50% | None |
| PREMPRO .625/5 mg Tablet, Sugar CoatedConjugated Estrogens And Medroxyprogesterone Acetate | 4Non-Preferred Drug | 50% | 50% | None |
| PREVALITE 4 g/5.5g Powder, For SuspensionCholestyramine | 4Non-Preferred Drug | 50% | 50% | None |
| PREVYMIS 120 mg PelletLetermovir | 5Specialty Tier | 25% | N/A | None |
| PREVYMIS 20 mg PelletLetermovir | 5Specialty Tier | 25% | N/A | None |
| PREVYMIS 240 mg Tablet, Film CoatedLetermovir | 5Specialty Tier | 25% | N/A | None |
| PREVYMIS 480 mg Tablet, Film CoatedLetermovir | 5Specialty Tier | 25% | N/A | None |
| PREZCOBIX 675/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat | 5Specialty Tier | 25% | N/A |
|
| PREZCOBIX 800/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat | 5Specialty Tier | 25% | N/A |
|
| PREZISTA 100 mg/mL SuspensionDarunavir | 5Specialty Tier | 25% | N/A |
|
| PREZISTA 150 mg Tablet, Film CoatedDarunavir | 4Non-Preferred Drug | 50% | 50% |
|
| PREZISTA 75 mg Tablet, Film CoatedDarunavir | 4Non-Preferred Drug | 50% | 50% |
|
| PRIFTIN 150 mg Tablet, Film CoatedRifapentine | 4Non-Preferred Drug | 50% | 50% | None |
| PRIMAQUINE PHOSPHATE 15 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| PRIMIDONE 125 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRIMIDONE 250 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRIMIDONE 50 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PRIORIX KitMeasels, Mumps, And Rubella Vaccine, Live | 1Preferred Generic | $12.00 | $30.00 | None |
| PRIVIGEN 20 g/200mL LiquidHuman Immunoglobulin G | 5Specialty Tier | 25% | N/A |
|
| PROAIR RESPICLICK 90 ug Powder, MeteredAlbuterol Sulfate | 3Preferred Brand | 17% | 17% |
|
| PROBENECID 500 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PROBENECID AND COLCHICINE 500/.5 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PROCHLORPERAZINE 25 mg Suppository | 4Non-Preferred Drug | 50% | 50% | None |
| PROCHLORPERAZINE MALEATE 10 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROCHLORPERAZINE MALEATE 5 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROCRIT 10000 [iU]/mL Injection, SolutionErythropoietin | 4Non-Preferred Drug | 50% | 50% |
|
| PROCRIT 2000 [iU]/mL Injection, SolutionErythropoietin | 4Non-Preferred Drug | 50% | 50% |
|
| PROCRIT 20000 [iU]/mL Injection, SolutionErythropoietin | 5Specialty Tier | 25% | N/A |
|
| PROCRIT 3000 [iU]/mL Injection, SolutionErythropoietin | 4Non-Preferred Drug | 50% | 50% |
|
| PROCRIT 4000 [iU]/mL Injection, SolutionErythropoietin | 4Non-Preferred Drug | 50% | 50% |
|
| PROCRIT 40000 [iU]/mL Injection, SolutionErythropoietin | 5Specialty Tier | 25% | N/A |
|
| PROCTO-MED HC 25 mg/g CreamHydrocortisone | 2Generic | $17.00 | $42.50 | None |
| PROCTOSOL-HC 25 mg/g CreamHydrocortisone | 2Generic | $17.00 | $42.50 | None |
| PROCTOZONE-HC 25 mg/g CreamHydrocortisone 2.5% | 2Generic | $17.00 | $42.50 | None |
| PROGRAF .2 mg Granule, For SuspensionTacrolimus | 4Non-Preferred Drug | 50% | 50% |
|
| PROGRAF 1 mg Granule, For SuspensionTacrolimus | 4Non-Preferred Drug | 50% | 50% |
|
| PROLASTIN-C LIQUID 1000 mg/20mL Injection, SolutionAlpha1-Proteinase Inhibitor (Human) | 5Specialty Tier | 25% | N/A |
|
| PROMETHAZINE HYDROCHLORIDE 12.5 mg Suppository | 4Non-Preferred Drug | 50% | 50% | None |
| PROMETHAZINE HYDROCHLORIDE 12.5 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PROMETHAZINE HYDROCHLORIDE 25 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PROMETHAZINE HYDROCHLORIDE 50 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PROMETHAZINE HYDROCHLORIDE 6.25 mg/5mL Syrup | 4Non-Preferred Drug | 50% | 50% | None |
| PROPAFENONE HYDROCHLORIDE 150 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| PROPAFENONE HYDROCHLORIDE 225 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| PROPAFENONE HYDROCHLORIDE 300 mg Tablet, Film Coated | 3Preferred Brand | 17% | 17% | None |
| PROPRANOLOL HYDROCHLORIDE 10 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROPRANOLOL HYDROCHLORIDE 120 mg Capsule, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PROPRANOLOL HYDROCHLORIDE 160 mg Capsule, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PROPRANOLOL HYDROCHLORIDE 20 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROPRANOLOL HYDROCHLORIDE 40 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROPRANOLOL HYDROCHLORIDE 60 mg Capsule, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PROPRANOLOL HYDROCHLORIDE 80 mg Capsule, Extended Release | 3Preferred Brand | 17% | 17% | None |
| PROPRANOLOL HYDROCHLORIDE 80 mg Tablet | 2Generic | $17.00 | $42.50 | None |
| PROPYLTHIOURACIL 50 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PROQUAD 1000/20000/1000/9772 [TCID_50]/.5mL/[PFU]/.5mL Injection, Powder, Lyophilized, For SuspensionMeasles, Mumps, Rubella And Varicella Virus Vaccine Live | 3Preferred Brand | 17% | 17% | None |
| PROTRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PROTRIPTYLINE HYDROCHLORIDE 5 mg Tablet, Film Coated | 4Non-Preferred Drug | 50% | 50% | None |
| PRUCALOPRIDE 1 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| PRUCALOPRIDE 2 mg Tablet | 3Preferred Brand | 17% | 17% |
|
| PULMOZYME 1 mg/mL SolutionDornase Alfa | 5Specialty Tier | 25% | N/A |
|
| PYRAZINAMIDE 500 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PYRIDOSTIGMINE BROMIDE 60 mg Tablet | 3Preferred Brand | 17% | 17% | None |
| PYRIMETHAMINE 25 mg Tablet | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND 20 mg Tablet, Film CoatedMitapivat | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND 5 mg Tablet, Film CoatedMitapivat | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND 5 mg Tablet, Film CoatedMitapivat | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND 50 mg Tablet, Film CoatedMitapivat | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND KitMitapivat | 5Specialty Tier | 25% | N/A |
|
| PYRUKYND KitMitapivat | 5Specialty Tier | 25% | N/A |
|
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.