2026 HealthSpring Assurance Rx (PDP) formulary (drug list)

Contract S5617, plan 123 · South Dakota · 3,188 drugs on file · formulary ID 00026089. Each drug links to its cost in every CMS PDP Region 25 plan.

185 drugs starting with M.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
M-M-R II 1000/12500/1000 [TCID_50]/.5mL Injection, Powder, Lyophilized, For SuspensionMeasles, Mumps, And Rubella Virus Vaccine Live	3Preferred Brand	21%	21%	None
MALATHION .0005 g/mL Lotion	4Non-Preferred Drug	30%	30%	None
MARAVIROC 150 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 6 per 30 days
MARAVIROC 300 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 12 per 30 days
MARLISSA KitLevonorgestrel And Ethinyl Estradiol	4Non-Preferred Drug	30%	30%	None
MATULANE 50 mg CapsuleProcarbazine Hydrochloride	5Specialty Tier	25%	N/A	None
MATZIM LA 180 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	3Preferred Brand	21%	21%	None
MATZIM LA 240 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	3Preferred Brand	21%	21%	None
MATZIM LA 300 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	3Preferred Brand	21%	21%	None
MATZIM LA 360 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	3Preferred Brand	21%	21%	None
MATZIM LA 420 mg Tablet, Extended ReleaseDiltiazem Hydrochloride	3Preferred Brand	21%	21%	None
MECLIZINE HYDROCHLORIDE 12.5 mg TabletMeclizine	2Generic	$2.00	$2.00	None
MECLIZINE HYDROCHLORIDE 25 mg Tablet	2Generic	$2.00	$2.00	None
MEDROXYPROGESTERONE ACETATE 10 mg Tablet	2Generic	$2.00	$2.00	None
MEDROXYPROGESTERONE ACETATE 150 mg/mL Injection, Suspension	3Preferred Brand	21%	21%	None
MEDROXYPROGESTERONE ACETATE 150 mg/mL Injection, Suspension	3Preferred Brand	21%	21%	None
MEDROXYPROGESTERONE ACETATE 2.5 mg Tablet	2Generic	$2.00	$2.00	None
MEDROXYPROGESTERONE ACETATE 5 mg Tablet	2Generic	$2.00	$2.00	None
MEFLOQUINE HYDROCHLORIDE 250 mg Tablet	3Preferred Brand	21%	21%	None
MEGESTROL ACETATE 20 mg Tablet	4Non-Preferred Drug	30%	30%	PA
MEGESTROL ACETATE 40 mg Tablet	3Preferred Brand	21%	21%	PA
MEGESTROL ACETATE 40 mg/mL Suspension	4Non-Preferred Drug	30%	30%	PA
MEKINIST .05 mg/mL Powder, For SolutionTrametinib	5Specialty Tier	25%	N/A	PA QL 12 per 30 days
MEKINIST .5 mg Tablet, Film CoatedTrametinib	5Specialty Tier	25%	N/A	PA QL 9 per 30 days
MEKINIST 2 mg Tablet, Film CoatedTrametinib	5Specialty Tier	25%	N/A	PA QL 3 per 30 days
MEKTOVI 15 mg Tablet, Film CoatedBinimetinib	5Specialty Tier	25%	N/A	PA QL 18 per 30 days
MELOXICAM 15 mg Tablet	1Preferred Generic	$0.00	$0.00	None
MELOXICAM 7.5 mg Tablet	1Preferred Generic	$0.00	$0.00	QL 6 per 30 days
MEMANTINE 2 mg/mL SolutionMemantine Hydrochloride	4Non-Preferred Drug	30%	30%	PA QL 3 per 30 days
MEMANTINE AND DONEPEZIL HYDROCHLORIDES 21/10 mg Capsule, Extended Release	3Preferred Brand	21%	21%	PA
MEMANTINE AND DONEPEZIL HYDROCHLORIDES EXTENDED-RELEASE 14/10 mg Capsule, Extended ReleaseMemantine And Donepezil	3Preferred Brand	21%	21%	PA
MEMANTINE AND DONEPEZIL HYDROCHLORIDES EXTENDED-RELEASE 28/10 mg Capsule, Extended ReleaseMemantine And Donepezil	3Preferred Brand	21%	21%	PA
MEMANTINE HYDROCHLORIDE 10 mg Tablet	3Preferred Brand	21%	21%	PA QL 6 per 30 days
MEMANTINE HYDROCHLORIDE 5 mg Tablet, Film Coated	3Preferred Brand	21%	21%	PA QL 9 per 30 days
MEMANTINE HYDROCHLORIDE Kit	3Preferred Brand	21%	21%	PA QL 98 per 365 days
MENQUADFI 10/10/10/10 ug/.5mL Injection, SolutionNeisseria Meningitidis Group A Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, Neisseria Meningitidis Group C Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, Neisseria Meningitidis Group Y Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen, And Neisseria Meningitidis Group W-135 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen	3Preferred Brand	21%	21%	None
MENVEO KitMeningococcal (Groups A, C, Y And W-135) Oligosaccharide Diphtheria Crm197 Conjugate Vaccine	3Preferred Brand	21%	21%	None
MERCAPTOPURINE 20 mg/mL Suspension	5Specialty Tier	25%	N/A	None
MERCAPTOPURINE 50 mg Tablet	4Non-Preferred Drug	30%	30%	None
MEROPENEM 1 g Injection, Powder, For Solution	3Preferred Brand	21%	21%	None
MEROPENEM 500 mg Injection, Powder, For Solution	3Preferred Brand	21%	21%	None
MESALAMINE .375 g Capsule, Extended Release	4Non-Preferred Drug	30%	30%	None
MESALAMINE 4 g/60mL Enema	4Non-Preferred Drug	30%	30%	None
MESALAMINE 500 mg Capsule, Extended Release	4Non-Preferred Drug	30%	30%	None
MESNA 400 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	None
METFORMIN 500 mg Tablet, Extended ReleaseMetformin Er 500 Mg	1Preferred Generic	$0.00	$0.00	QL 12 per 30 days
METFORMIN HYDROCHLORIDE 500 mg Tablet	1Preferred Generic	$0.00	$0.00	QL 15 per 30 days
METFORMIN HYDROCHLORIDE 750 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	QL 6 per 30 days
METFORMIN HYDROCHLORIDE 850 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	QL 9 per 30 days
METFORMIN HYDROCHLORIDE ORAL SOLUTION 500 mg/5mL SolutionMetformin Hydrochloride	1Preferred Generic	$0.00	$0.00	QL 765 per 30 days
METHADONE HYDROCHLORIDE 10 mg Tablet	3Preferred Brand	21%	21%	QL 12 per 30 days
METHADONE HYDROCHLORIDE 10 mg/5mL Solution	4Non-Preferred Drug	30%	30%	QL 6 per 30 days
METHADONE HYDROCHLORIDE 5 mg Tablet	3Preferred Brand	21%	21%	QL 24 per 30 days
METHADONE HYDROCHLORIDE 5 mg/5mL Solution	4Non-Preferred Drug	30%	30%	QL 12 per 30 days
METHAZOLAMIDE 25 mg Tablet	4Non-Preferred Drug	30%	30%	None
METHAZOLAMIDE 50 mg Tablet	4Non-Preferred Drug	30%	30%	None
METHENAMINE HIPPURATE 1 g Tablet	4Non-Preferred Drug	30%	30%	None
METHIMAZOLE 10 mg Tablet	2Generic	$2.00	$2.00	None
METHIMAZOLE 5 mg Tablet	2Generic	$2.00	$2.00	None
METHOCARBAMOL 500 mg Tablet, CoatedMethocarbamol Tablets	3Preferred Brand	21%	21%	None
METHOCARBAMOL 750 mg Tablet, CoatedMethocarbamol Tablets	3Preferred Brand	21%	21%	None
METHOTREXATE 2.5 mg Tablet	3Preferred Brand	21%	21%	None
METHOTREXATE 25 mg/mL Injection, Solution	4Non-Preferred Drug	30%	30%	PA
METHOTREXATE 25 mg/mL Solution	4Non-Preferred Drug	30%	30%	PA
METHOXSALEN 10 mg Capsule, Liquid Filled	5Specialty Tier	25%	N/A	None
METHSUXIMIDE 300 mg Capsule	3Preferred Brand	21%	21%	None
METHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet	3Preferred Brand	21%	21%	QL 9 per 30 days
METHYLPHENIDATE HYDROCHLORIDE 10 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 18 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 18 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 20 mg Tablet	3Preferred Brand	21%	21%	QL 9 per 30 days
METHYLPHENIDATE HYDROCHLORIDE 20 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 27 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 36 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE 5 mg Tablet	3Preferred Brand	21%	21%	QL 9 per 30 days
METHYLPHENIDATE HYDROCHLORIDE 54 mg Tablet, Extended Release	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 27 mg Tablet, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 36 mg Tablet, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	30%	30%	None
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 54 mg Tablet, Extended ReleaseMethylphenidate Hydrochloride	4Non-Preferred Drug	30%	30%	None
METHYLPREDNISOLONE 16 mg Tablet	2Generic	$2.00	$2.00	None
METHYLPREDNISOLONE 32 mg Tablet	2Generic	$2.00	$2.00	None
METHYLPREDNISOLONE 4 mg Tablet	2Generic	$2.00	$2.00	None
METHYLPREDNISOLONE 4 mg Tablet	2Generic	$2.00	$2.00	None
METHYLPREDNISOLONE 8 mg Tablet	2Generic	$2.00	$2.00	None
METOCLOPRAMIDE 10 mg Tablet	2Generic	$2.00	$2.00	None
METOCLOPRAMIDE 5 mg Tablet	2Generic	$2.00	$2.00	None
METOCLOPRAMIDE 5 mg/5mL Solution	2Generic	$2.00	$2.00	None
METOLAZONE 10 mg Tablet	3Preferred Brand	21%	21%	None
METOLAZONE 2.5 mg Tablet	3Preferred Brand	21%	21%	None
METOLAZONE 5 mg Tablet	3Preferred Brand	21%	21%	None
METOPROLOL SUCCINATE 100 mg Tablet, Film Coated, Extended Release	2Generic	$2.00	$2.00	None
METOPROLOL SUCCINATE 200 mg Tablet, Film Coated, Extended Release	2Generic	$2.00	$2.00	None
METOPROLOL SUCCINATE 25 mg Tablet, Extended Release	2Generic	$2.00	$2.00	None
METOPROLOL SUCCINATE 50 mg Tablet, Extended Release	2Generic	$2.00	$2.00	None
METOPROLOL TARTRATE 100 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 25 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE 50 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 100/25 mg Tablet	3Preferred Brand	21%	21%	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 100/50 mg Tablet	3Preferred Brand	21%	21%	None
METOPROLOL TARTRATE AND HYDROCHLOROTHIAZIDE 50/25 mg Tablet	3Preferred Brand	21%	21%	None
METRONIDAZOLE 10 mg/g Gel	4Non-Preferred Drug	30%	30%	None
METRONIDAZOLE 250 mg Tablet	2Generic	$2.00	$2.00	None
METRONIDAZOLE 500 mg Tablet	2Generic	$2.00	$2.00	None
METRONIDAZOLE 500 mg/100mL Injection, Solution	4Non-Preferred Drug	30%	30%	PA
METRONIDAZOLE 7.5 mg/g Cream	4Non-Preferred Drug	30%	30%	None
METRONIDAZOLE 7.5 mg/g Gel	4Non-Preferred Drug	30%	30%	None
METRONIDAZOLE 7.5 mg/mL Lotion	4Non-Preferred Drug	30%	30%	None
METRONIDAZOLE VAGINAL 7.5 mg/g GelMetronidazole	4Non-Preferred Drug	30%	30%	None
METYROSINE 250 mg Capsule	5Specialty Tier	25%	N/A	PA
MEXILETINE HYDROCHLORIDE 150 mg Capsule	4Non-Preferred Drug	30%	30%	None
MEXILETINE HYDROCHLORIDE 200 mg Capsule	4Non-Preferred Drug	30%	30%	None
MEXILETINE HYDROCHLORIDE 250 mg Capsule	4Non-Preferred Drug	30%	30%	None
MICAFUNGIN 100 mg Injection, Powder, Lyophilized, For SolutionMicafungin Sodium	4Non-Preferred Drug	30%	30%	None
MICAFUNGIN 50 mg Injection, Powder, Lyophilized, For SolutionMicafungin Sodium	4Non-Preferred Drug	30%	30%	None
MICROGESTIN 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol	4Non-Preferred Drug	30%	30%	None
MICROGESTIN 1/20 KitNorethindrone Acetate/Ethinyl Estradiol	4Non-Preferred Drug	30%	30%	None
MICROGESTIN FE 1.5/30 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate	4Non-Preferred Drug	30%	30%	None
MICROGESTIN FE 1/20 KitNorethindrone Acetate/Ethinyl Estradiol And Ferrous Fumarate	4Non-Preferred Drug	30%	30%	None
MIDODRINE HYDROCHLORIDE 10 mg Tablet	4Non-Preferred Drug	30%	30%	None
MIDODRINE HYDROCHLORIDE 2.5 mg Tablet	4Non-Preferred Drug	30%	30%	None
MIDODRINE HYDROCHLORIDE 5 mg Tablet	4Non-Preferred Drug	30%	30%	None
MIFEPRISTONE 300 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	PA QL 12 per 30 days
MILI KitNorgestimate And Ethinyl Estradiol	4Non-Preferred Drug	30%	30%	None
MINOCYCLINE HYDROCHLORIDE 100 mg Capsule	2Generic	$2.00	$2.00	None
MINOCYCLINE HYDROCHLORIDE 50 mg Capsule	2Generic	$2.00	$2.00	None
MINOCYCLINE HYDROCHLORIDE 75 mg Capsule	2Generic	$2.00	$2.00	None
MINOXIDIL 10 mg Tablet	2Generic	$2.00	$2.00	None
MINOXIDIL 2.5 mg Tablet	2Generic	$2.00	$2.00	None
MINZOYA KitLevonorgestrel And Ethinyl Estradiol And Ferrous Bisglycinate	4Non-Preferred Drug	30%	30%	None
MIRTAZAPINE 15 mg Tablet, Film Coated	2Generic	$2.00	$2.00	None
MIRTAZAPINE 15 mg Tablet, Orally Disintegrating	3Preferred Brand	21%	21%	QL 3 per 30 days
MIRTAZAPINE 30 mg Tablet, Film Coated	2Generic	$2.00	$2.00	None
MIRTAZAPINE 30 mg Tablet, Orally Disintegrating	3Preferred Brand	21%	21%	QL 3 per 30 days
MIRTAZAPINE 45 mg Tablet, Film Coated	2Generic	$2.00	$2.00	None
MIRTAZAPINE 45 mg Tablet, Orally Disintegrating	3Preferred Brand	21%	21%	QL 3 per 30 days
MIRTAZAPINE 7.5 mg Tablet, Film Coated	2Generic	$2.00	$2.00	None
MISOPROSTOL 100 ug Tablet	3Preferred Brand	21%	21%	None
MISOPROSTOL 200 ug Tablet	3Preferred Brand	21%	21%	None
MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 2.5/2.5/2.5/2.5 mg Capsule, Extended ReleaseDextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate	4Non-Preferred Drug	30%	30%	QL 6 per 30 days
MIXED SALTS OF A SINGLE ENTITY AMPHETAMINE PRODUCT XR 5/5/5/5 mg Capsule, Extended ReleaseDextroamphetamine Saccharate, Amphetamine Aspartate Monohydrate, Dextroamphetamine Sulfate, Amphetamine Sulfate	4Non-Preferred Drug	30%	30%	QL 6 per 30 days
MODAFINIL 100 mg Tablet	3Preferred Brand	21%	21%	PA QL 3 per 30 days
MODAFINIL 200 mg Tablet	3Preferred Brand	21%	21%	PA QL 6 per 30 days
MODEYSO 125 mg CapsuleDordaviprone	5Specialty Tier	25%	N/A	PA QL 2 per 28 days
MOEXIPRIL HYDROCHLORIDE 15 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
MOEXIPRIL HYDROCHLORIDE 7.5 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
MOLINDONE HYDROCHLORIDE 10 mg Tablet	4Non-Preferred Drug	30%	30%	None
MOLINDONE HYDROCHLORIDE 25 mg Tablet	4Non-Preferred Drug	30%	30%	None
MOLINDONE HYDROCHLORIDE 5 mg Tablet	4Non-Preferred Drug	30%	30%	None
MOMETASONE FUROATE 1 mg/g Cream	2Generic	$2.00	$2.00	None
MOMETASONE FUROATE 1 mg/g Ointment	2Generic	$2.00	$2.00	None
MOMETASONE FUROATE 1 mg/mL Solution	2Generic	$2.00	$2.00	None
MONTELUKAST SODIUM 10 mg Tablet, Film Coated	2Generic	$2.00	$2.00	QL 3 per 30 days
MONTELUKAST SODIUM 4 mg Granule	4Non-Preferred Drug	30%	30%	QL 3 per 30 days
MONTELUKAST SODIUM 4 mg Tablet, Chewable	2Generic	$2.00	$2.00	QL 3 per 30 days
MONTELUKAST SODIUM 5 mg Tablet, Chewable	2Generic	$2.00	$2.00	QL 3 per 30 days
MORPHINE SULFATE 15 mg Tablet	3Preferred Brand	21%	21%	QL 18 per 30 days
MORPHINE SULFATE 20 mg/5mL Solution	4Non-Preferred Drug	30%	30%	QL 9 per 30 days
MORPHINE SULFATE 20 mg/mL Solution	4Non-Preferred Drug	30%	30%	QL 9 per 30 days
MORPHINE SULFATE 30 mg Tablet	3Preferred Brand	21%	21%	QL 18 per 30 days
MORPHINE SULFATE EXTENDED RELEASE 100 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	21%	21%	QL 12 per 30 days
MORPHINE SULFATE EXTENDED RELEASE 15 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	21%	21%	QL 12 per 30 days
MORPHINE SULFATE EXTENDED RELEASE 200 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	21%	21%	QL 12 per 30 days
MORPHINE SULFATE EXTENDED RELEASE 30 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	21%	21%	QL 12 per 30 days
MORPHINE SULFATE EXTENDED RELEASE 60 mg Tablet, Film Coated, Extended ReleaseMorphine Sulfate	3Preferred Brand	21%	21%	QL 12 per 30 days
MOUNJARO 10 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOUNJARO 12.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOUNJARO 15 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOUNJARO 2.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOUNJARO 5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOUNJARO 7.5 mg/.5mL Injection, SolutionTirzepatide	3Preferred Brand	21%	21%	PA QL 2 per 28 days
MOVANTIK 12.5 mg Tablet, Film CoatedNaloxegol Oxalate	4Non-Preferred Drug	30%	30%	QL 3 per 30 days
MOVANTIK 25 mg Tablet, Film CoatedNaloxegol Oxalate	4Non-Preferred Drug	30%	30%	QL 3 per 30 days
MOXIFLOXACIN 400 mg Tablet, Film Coated	4Non-Preferred Drug	30%	30%	None
MOXIFLOXACIN 5 mg/mL Solution/ Drops	3Preferred Brand	21%	21%	None
MOXIFLOXACIN HYDROCHLORIDE 400 mg/250mL Injection, Solution	4Non-Preferred Drug	30%	30%	PA
MRESVIA 50 ug/.5mL SuspensionRespiratory Syncytial Virus Vaccine	3Preferred Brand	21%	21%	PA QL 1 per 365 days
MUPIROCIN 2 g/100g Cream	4Non-Preferred Drug	30%	30%	QL 3 per 30 days
MUPIROCIN 20 mg/g Ointment	2Generic	$2.00	$2.00	QL 44 per 30 days
MYCOPHENOLATE MOFETIL 200 mg/mL Powder, For Suspension	5Specialty Tier	25%	N/A	PA
MYCOPHENOLATE MOFETIL 250 mg Capsule	3Preferred Brand	21%	21%	PA
MYCOPHENOLATE MOFETIL 500 mg Tablet, Film Coated	4Non-Preferred Drug	30%	30%	PA
MYCOPHENOLIC ACID 180 mg Tablet, Delayed Release	4Non-Preferred Drug	30%	30%	PA
MYCOPHENOLIC ACID 360 mg Tablet, Delayed Release	4Non-Preferred Drug	30%	30%	PA
MYRBETRIQ 25 mg Tablet, Film Coated, Extended ReleaseMirabegron	3Preferred Brand	21%	21%	None
MYRBETRIQ 50 mg Tablet, Film Coated, Extended ReleaseMirabegron	3Preferred Brand	21%	21%	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.