2026 BlueRx Essential (PDP) formulary (drug list)
Contract S1030, plan 006 · Tennessee · 2,948 drugs on file · formulary ID 00026206. Each drug links to its cost in every CMS PDP Region 12 plan.
19 drugs starting with U.
| Drug name | Tier | 30-day preferred pharmacy | 90-day mail order | Usage management |
|---|---|---|---|---|
| ULTRAMICROSIZE GRISEOFULVIN 125 mg Tablet, CoatedUltramicrosize Griseofulvin Tablets | 4Non-Preferred Drug | 41% | 41% | None |
| ULTRAMICROSIZE GRISEOFULVIN 250 mg Tablet, CoatedUltramicrosize Griseofulvin Tablets | 4Non-Preferred Drug | 41% | 41% | None |
| UNITHROID 100 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 112 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 125 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 137 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 150 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 175 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 200 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 25 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 300 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 50 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 75 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| UNITHROID 88 ug TabletLevothyroxine Sodium | 3Preferred Brand | 19% | 19% | None |
| URSODIOL 250 mg Tablet | 4Non-Preferred Drug | 41% | 41% | None |
| URSODIOL 300 mg Capsule | 3Preferred Brand | 19% | 19% | None |
| URSODIOL 500 mg Tablet | 4Non-Preferred Drug | 41% | 41% | None |
| USTEKINUMAB-AEKN 45 mg/.5mL Injection, Solution | 4Non-Preferred Drug | 41% | 41% |
|
| USTEKINUMAB-AEKN 90 mg/mL Injection, Solution | 5Specialty Tier | 25% | 25% |
|
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.