MedicarePartD.guide

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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.

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144 drugs starting with S.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
SACUBITRIL AND VALSARTAN 24/26 mg Tablet, Film Coated3Preferred Brand17%17%
  • QL 6 per 30 days
SACUBITRIL AND VALSARTAN 49/51 mg Tablet, Film Coated3Preferred Brand17%17%
  • QL 6 per 30 days
SACUBITRIL AND VALSARTAN 97/103 mg Tablet, Film Coated3Preferred Brand17%17%
  • QL 6 per 30 days
SAPROPTERIN DIHYDROCHLORIDE 100 mg Powder, For Solution5Specialty Tier25%N/A
  • PA
SAPROPTERIN DIHYDROCHLORIDE 100 mg Tablet5Specialty Tier25%N/A
  • PA
SAPROPTERIN DIHYDROCHLORIDE 500 mg Powder, For Solution5Specialty Tier25%N/A
  • PA
SAVELLA 100 mg Tablet, Film CoatedMilnacipran Hydrochloride3Preferred Brand17%17%
  • QL 6 per 30 days
SAVELLA 12.5 mg Tablet, Film CoatedMilnacipran Hydrochloride3Preferred Brand17%17%
  • QL 6 per 30 days
SAVELLA 25 mg Tablet, Film CoatedMilnacipran Hydrochloride3Preferred Brand17%17%
  • QL 6 per 30 days
SAVELLA 50 mg Tablet, Film CoatedMilnacipran Hydrochloride3Preferred Brand17%17%
  • QL 6 per 30 days
SAVELLA KitMilnacipran Hydrochloride3Preferred Brand17%17%
  • QL 11 per 365 days
SCEMBLIX 100 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
SCEMBLIX 20 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SCEMBLIX 40 mg Tablet, Film CoatedAsciminib5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
SCOPOLAMINE 1 mg/3d Patch4Non-Preferred Drug50%50%None
SECUADO 3.8 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • ST
  • QL 3 per 30 days
SECUADO 5.7 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • ST
  • QL 3 per 30 days
SECUADO 7.6 mg/d Film, Extended ReleaseAsenapine5Specialty Tier25%N/A
  • ST
  • QL 3 per 30 days
SELEGILINE HYDROCHLORIDE 5 mg Capsule3Preferred Brand17%17%None
SELEGILINE HYDROCHLORIDE 5 mg Tablet3Preferred Brand17%17%None
SELENIUM SULFIDE 2.5 mg/100mL Lotion2Generic$17.00$42.50None
SELZENTRY KitMaraviroc5Specialty Tier25%N/ANone
SEREVENT DISKUS 50 ug Powder, MeteredSalmeterol Xinafoate3Preferred Brand17%17%
  • QL 6 per 30 days
SERTRALINE HYDROCHLORIDE 100 mg Tablet, Film Coated1Preferred Generic$12.00$30.00None
SERTRALINE HYDROCHLORIDE 20 mg/mL Solution, Concentrate4Non-Preferred Drug50%50%None
SERTRALINE HYDROCHLORIDE 25 mg Tablet, Film Coated1Preferred Generic$12.00$30.00None
SERTRALINE HYDROCHLORIDE 50 mg Tablet, Film Coated1Preferred Generic$12.00$30.00None
SETLAKIN KitLevonorgestrel And Ethinyl Estradiol4Non-Preferred Drug50%50%
  • QL 91 per 91 days
SHAROBEL KitNorethindrone3Preferred Brand17%17%None
SHINGRIX 50 ug/.5mL Injection, SolutionZoster Vaccine Recombinant, Adjuvanted1Preferred Generic$12.00$30.00None
SHINGRIX KitZoster Vaccine Recombinant, Adjuvanted1Preferred Generic$12.00$30.00None
SIGNIFOR .3 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SIGNIFOR .6 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SIGNIFOR .9 mg/mL InjectionPasireotide5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
SILDENAFIL 20 mg Tablet3Preferred Brand17%17%
  • PA
  • QL 9 per 30 days
SILVER SULFADIAZINE 10 mg/g Cream2Generic$17.00$42.50None
SIMBRINZA 10/2 mg/mL Suspension/ DropsBrinzolamide/Brimonidine Tartrate3Preferred Brand17%17%None
SIMVASTATIN 10 mg Tablet, Film Coated6Select Care Drugs$5.00$12.50None
SIMVASTATIN 20 mg Tablet, Film Coated6Select Care Drugs$5.00$12.50None
SIMVASTATIN 40 mg Tablet, Film Coated6Select Care Drugs$5.00$12.50None
SIMVASTATIN 5 mg Tablet, Film Coated6Select Care Drugs$5.00$12.50None
SIMVASTATIN 80 mg Tablet, Film Coated6Select Care Drugs$5.00$12.50None
SIROLIMUS .5 mg Tablet, Film Coated4Non-Preferred Drug50%50%
  • PA
SIROLIMUS 1 mg Tablet4Non-Preferred Drug50%50%
  • PA
SIROLIMUS 1 mg/mL Solution4Non-Preferred Drug50%50%
  • PA
SIROLIMUS 2 mg Tablet4Non-Preferred Drug50%50%
  • PA
SIRTURO 100 mg TabletBedaquiline Fumarate5Specialty Tier25%N/ANone
SIRTURO 20 mg TabletBedaquiline Fumarate5Specialty Tier25%N/ANone
SKYCLARYS 50 mg CapsuleOmaveloxolone5Specialty Tier25%N/A
  • PA
  • QL 9 per 30 days
SKYRIZI 150 mg/mL InjectionRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 1 per 28 days
SKYRIZI 150 mg/mL InjectionRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 1 per 28 days
SKYRIZI KitRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 1.2 per 56 days
SKYRIZI KitRisankizumab-Rzaa5Specialty Tier25%N/A
  • PA
  • QL 2.4 per 56 days
SODIUM CHLORIDE 4.5 g/1000mL Injection, Solution3Preferred Brand17%17%None
SODIUM CHLORIDE 9 g/1000mL Injection, Solution3Preferred Brand17%17%None
SODIUM CHLORIDE 900 mg/100mL Irrigant2Generic$17.00$42.50None
SODIUM OXYBATE .5 g/mL Solution5Specialty Tier25%N/A
  • PA
  • QL 54 per 30 days
SODIUM PHENYLBUTYRATE .94 g/g Powder5Specialty Tier25%N/ANone
SODIUM POLYSTYRENE SULFONATE 1 g/g Powder3Preferred Brand17%17%None
SODIUM POLYSTYRENE SULFONATE 15 g/60mL Suspension3Preferred Brand17%17%None
SODIUM SULFATE, POTASSIUM SULFATE, AND MAGNESIUM SULFATE BOWEL PREP KIT 17.5/3.13/1.6 g/177mL SolutionSodium Sulfate Anhydrous, Potassium Sulfate, And Magnesium Sulfate3Preferred Brand17%17%None
SOLIQUA 100/33 100/33 U/mL/ug/mL Injection, SolutionInsulin Glargine And Lixisenatide3Preferred Brand17%17%None
SOLTAMOX 20 mg/10mL LiquidTamoxifen Citrate4Non-Preferred Drug50%50%None
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SOMAVERT KitPegvisomant5Specialty Tier25%N/A
  • PA
SORAFENIB 200 mg Tablet, Film Coated5Specialty Tier25%N/A
  • PA
SOTALOL HYDROCHLORIDE 120 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE 120 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE 160 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE 240 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE 80 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE 80 mg Tablet2Generic$17.00$42.50None
SOTALOL HYDROCHLORIDE AF 160 mg TabletSotalol Hydrochloride Tablets Af2Generic$17.00$42.50None
SPEVIGO 150 mg InjectionSpesolimab-Sbzo5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
SPEVIGO 300 mg InjectionSpesolimab-Sbzo5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
SPIRIVA RESPIMAT 1.562 ug Spray, MeteredTiotropium Bromide Inhalation Spray3Preferred Brand17%17%
  • QL 8 per 30 days
SPIRIVA RESPIMAT 3.124 ug Spray, MeteredTiotropium Bromide Inhalation Spray3Preferred Brand17%17%None
SPIRONOLACTONE 100 mg Tablet2Generic$17.00$42.50None
SPIRONOLACTONE 25 mg Tablet2Generic$17.00$42.50None
SPIRONOLACTONE 50 mg Tablet2Generic$17.00$42.50None
SPIRONOLACTONE AND HYDROCHLOROTHIAZIDE 25/25 mg Tablet3Preferred Brand17%17%None
SPRINTEC KitNorgestimate And Ethinyl Estradiol3Preferred Brand17%17%None
SPRITAM 250 mg Tablet, For SuspensionLevetiracetam4Non-Preferred Drug50%50%None
SPRITAM 500 mg Tablet, For SuspensionLevetiracetam4Non-Preferred Drug50%50%None
SSD CREAM 10 g/1000g CreamSilver Sulfadiazine2Generic$17.00$42.50None
STELARA 45 mg/.5mL Injection, SolutionUstekinumab5Specialty Tier25%N/A
  • PA
  • QL 3 per 84 days
STELARA 45 mg/.5mL Injection, SolutionUstekinumab5Specialty Tier25%N/A
  • PA
  • QL 3 per 84 days
STELARA 90 mg/mL Injection, SolutionUstekinumab5Specialty Tier25%N/A
  • PA
  • QL 3 per 84 days
STEQEYMA 45 mg/.5mL Injection, SolutionUstekinumab-Stba3Preferred Brand17%17%
  • PA
  • QL 3 per 84 days
STEQEYMA 90 mg/mL Injection, SolutionUstekinumab-Stba5Specialty Tier25%N/A
  • PA
  • QL 3 per 84 days
STIOLTO RESPIMAT 3.124/2.736 ug Spray, MeteredTiotropium Bromide And Olodaterol3Preferred Brand17%17%
  • QL 24 per 30 days
STIVARGA 40 mg Tablet, Film CoatedRegorafenib5Specialty Tier25%N/A
  • PA
STOBOCLO 60 mg/mL InjectionDenosumab-Bmwo4Non-Preferred Drug50%50%
  • QL 2 per 365 days
STREPTOMYCIN 1 g Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug50%50%None
STRIBILD 150/150/200/300 mg Tablet, Film CoatedElvitegravir, Cobicistat, Emtricitabine, And Tenofovir Disoproxil Fumarate5Specialty Tier25%N/A
  • QL 3 per 30 days
SUBVENITE 10 mg/mL SuspensionLamotrigine4Non-Preferred Drug50%50%None
SUBVENITE 100 mg TabletLamotrigine2Generic$17.00$42.50None
SUBVENITE 150 mg TabletLamotrigine2Generic$17.00$42.50None
SUBVENITE 200 mg TabletLamotrigine2Generic$17.00$42.50None
SUBVENITE 25 mg TabletLamotrigine2Generic$17.00$42.50None
SUBVENITE KitLamotrigine4Non-Preferred Drug50%50%None
SUBVENITE KitLamotrigine4Non-Preferred Drug50%50%None
SUBVENITE KitLamotrigine4Non-Preferred Drug50%50%None
SUCRAID 8500 [iU]/mL SolutionSacrosidase5Specialty Tier25%N/A
  • PA
SULFACETAMIDE SODIUM 100 mg/mL Solution/ Drops3Preferred Brand17%17%None
SULFACETAMIDE SODIUM AND PREDNISOLONE SODIUM PHOSPHATE 100/2.3 mg/mL Solution/ Drops2Generic$17.00$42.50None
SULFADIAZINE 500 mg Tablet5Specialty Tier25%N/ANone
SULFAMETHOXAZOLE AND TRIMETHOPRIM 200/40 mg/5mL Suspension3Preferred Brand17%17%None
SULFAMETHOXAZOLE AND TRIMETHOPRIM 400/80 mg Tablet2Generic$17.00$42.50None
SULFAMETHOXAZOLE AND TRIMETHOPRIM 800/160 mg Tablet2Generic$17.00$42.50None
SULFASALAZINE 500 mg Tablet2Generic$17.00$42.50None
SULFASALAZINE 500 mg Tablet, Delayed Release2Generic$17.00$42.50None
SULINDAC 150 mg Tablet2Generic$17.00$42.50None
SULINDAC 200 mg Tablet2Generic$17.00$42.50None
SUMATRIPTAN 100 mg TabletSumatriptan Succinate2Generic$17.00$42.50
  • QL 9 per 30 days
SUMATRIPTAN 20 mg Spray4Non-Preferred Drug50%50%
  • QL 12 per 30 days
SUMATRIPTAN 25 mg TabletSumatriptan Succinate2Generic$17.00$42.50
  • QL 9 per 30 days
SUMATRIPTAN 5 mg Spray4Non-Preferred Drug50%50%
  • QL 12 per 30 days
SUMATRIPTAN 50 mg TabletSumatriptan Succinate2Generic$17.00$42.50
  • QL 9 per 30 days
SUMATRIPTAN 6 mg/.5mL Injection, Solution4Non-Preferred Drug50%50%
  • QL 5 per 30 days
SUMATRIPTAN SUCCINATE 6 mg/.5mL Injection4Non-Preferred Drug50%50%
  • QL 5 per 30 days
SUNITINIB MALATE 12.5 mg Capsule5Specialty Tier25%N/A
  • PA
SUNITINIB MALATE 25 mg Capsule5Specialty Tier25%N/A
  • PA
SUNITINIB MALATE 37.5 mg Capsule5Specialty Tier25%N/A
  • PA
SUNITINIB MALATE 50 mg Capsule5Specialty Tier25%N/A
  • PA
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 8 per 365 days
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 1 per 365 days
SUNLENCA 300 mg Tablet, Film CoatedLenacapavir Sodium5Specialty Tier25%N/A
  • QL 24 per 168 days
SUTAB 17.75/2.7/2.25 g TabletSodium Sulfate, Magnesium Sulfate, And Potassium Chloride3Preferred Brand17%17%None
SYMPAZAN 10 mg FilmClobazam4Non-Preferred Drug50%50%None
SYMPAZAN 20 mg FilmClobazam5Specialty Tier25%N/ANone
SYMPAZAN 5 mg FilmClobazam4Non-Preferred Drug50%50%None
SYMTUZA 800/150/200/10 mg Tablet, Film CoatedDarunavir, Cobicistat, Emtricitabine, And Tenofovir Alafenamide5Specialty Tier25%N/A
  • QL 3 per 30 days
SYNJARDY 12.5/1000 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY 12.5/500 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY 5/1000 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY 5/500 mg TabletEmpagliflozin And Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY XR 10/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY XR 12.5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY XR 25/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand17%17%None
SYNJARDY XR 5/1000 mg Tablet, Extended ReleaseEmpagliflozin, Metformin Hydrochloride3Preferred Brand17%17%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.