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2026 AARP Medicare Rx Saver from UHC (PDP) formulary (drug list)

Contract S5921, plan 361 · Wisconsin · 3,062 drugs on file · formulary ID 00026001. Each drug links to its cost in every CMS PDP Region 16 plan.

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256 drugs starting with A.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
ABACAVIR 20 mg/mL SolutionAbacavir Sulfate4Non-Preferred Drug33%N/A
  • QL 96 per 30 days
ABACAVIR 300 mg Tablet4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ABACAVIR AND LAMIVUDINE 600/300 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ABIGALE 1/.5 mg TabletEstradiol And Norethindrone Acetate3Preferred Brand17%17%None
ABILIFY ASIMTUFII 720 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole5Specialty Tier25%N/A
  • QL 2.4 per 56 days
ABILIFY ASIMTUFII 960 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole5Specialty Tier25%N/A
  • QL 3.2 per 56 days
ABILIFY MAINTENA KitAripiprazole5Specialty Tier25%N/ANone
ABILIFY MAINTENA KitAripiprazole5Specialty Tier25%N/ANone
ABIRATERONE 250 mg TabletAbiraterone Acetate4Non-Preferred Drug33%N/A
  • QL 12 per 30 days
ABIRATERONE ACETATE 500 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ABIRTEGA 250 mg TabletAbiraterone Acetate4Non-Preferred Drug33%N/A
  • QL 12 per 30 days
ACAMPROSATE CALCIUM 333 mg Tablet, Delayed ReleaseAcamprosate Calcium Enteric-Coated4Non-Preferred Drug33%N/ANone
ACARBOSE 100 mg Tablet3Preferred Brand17%17%
  • QL 9 per 30 days
ACARBOSE 25 mg Tablet3Preferred Brand17%17%
  • QL 36 per 30 days
ACARBOSE 50 mg Tablet3Preferred Brand17%17%
  • QL 18 per 30 days
ACCUTANE 10 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/A
  • PA
ACCUTANE 20 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/A
  • PA
ACCUTANE 40 mg Capsule, Gelatin CoatedIsotretinoin4Non-Preferred Drug33%N/A
  • PA
ACETAMINOPHEN AND CODEINE PHOSPHATE 120/12 mg/5mL Solution4Non-Preferred Drug33%N/A
  • QL 45 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/15 mg Tablet4Non-Preferred Drug33%N/A
  • QL 39 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/30 mg Tablet4Non-Preferred Drug33%N/A
  • QL 39 per 30 days
ACETAMINOPHEN AND CODEINE PHOSPHATE 300/60 mg Tablet4Non-Preferred Drug33%N/A
  • QL 39 per 30 days
ACETAZOLAMIDE 125 mg Tablet3Preferred Brand17%17%None
ACETAZOLAMIDE 250 mg Tablet3Preferred Brand17%17%None
ACETAZOLAMIDE 500 mg Capsule, Extended Release4Non-Preferred Drug33%N/ANone
ACETIC ACID 20.65 mg/mL Solution2Generic$7.00$21.00None
ACETYLCYSTEINE 100 mg/mL Inhalant4Non-Preferred Drug33%N/A
  • PA
ACETYLCYSTEINE 200 mg/mL Solution4Non-Preferred Drug33%N/A
  • PA
ACITRETIN 10 mg Capsule4Non-Preferred Drug33%N/ANone
ACITRETIN 17.5 mg Capsule4Non-Preferred Drug33%N/ANone
ACITRETIN 25 mg Capsule4Non-Preferred Drug33%N/ANone
ACTHIB KitHaemophilus Influenzae Type B Strain 1482 Capsular Polysaccharide Tetanus Toxoid Conjugate Antigen3Preferred Brand17%17%
  • QL 1 per 1 days
ACTIMMUNE 100 ug/.5mL Injection, SolutionInterferon Gamma-1B5Specialty Tier25%N/ANone
ACYCLOVIR 200 mg Capsule2Generic$7.00$21.00None
ACYCLOVIR 200 mg/5mL Suspension4Non-Preferred Drug33%N/ANone
ACYCLOVIR 400 mg Tablet2Generic$7.00$21.00None
ACYCLOVIR 800 mg Tablet2Generic$7.00$21.00None
ACYCLOVIR SODIUM 500 mg/10mL Injection, Solution4Non-Preferred Drug33%N/A
  • PA
ADACEL TDAP 5/2/2.5/5/3/5 [Lf]/.5mL/ug/.5mL Injection, SuspensionClostridium Tetani Toxoid Antigen (Formaldehyde Inactivated), Corynebacterium Diphtheriae Toxoid Antigen (Formaldehyde Inactivated), Bordetella Pertussis Toxoid Antigen (Glutaraldehyde Inactivated), Bordetella Pertussis Filamentous Hemagglutinin Antigen (Formaldehyde Inactivated), Bordetella Pertussis Pertactin Antigen, And Bordetella Pertussis Fimbriae 2/3 Antigen3Preferred Brand17%17%
  • QL 0.5 per 1 days
ADALIMUMAB KitAdalimumab-Aaty5Specialty Tier25%N/A
  • PA
ADALIMUMAB KitAdalimumab-Aaty5Specialty Tier25%N/A
  • PA
ADALIMUMAB KitAdalimumab-Aaty5Specialty Tier25%N/A
  • PA
ADALIMUMAB KitAdalimumab-Aaty5Specialty Tier25%N/A
  • PA
ADALIMUMAB KitAdalimumab-Aaty5Specialty Tier25%N/A
  • PA
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 2 per 28 days
ADALIMUMAB-ADBM Kit5Specialty Tier25%N/A
  • PA
  • QL 4 per 28 days
ADAPALENE 3 mg/g Gel3Preferred Brand17%17%None
ADEMPAS .5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
ADEMPAS 1 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
ADEMPAS 1.5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
ADEMPAS 2 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
ADEMPAS 2.5 mg Tablet, Film CoatedRiociguat5Specialty Tier25%N/A
  • PA
AIMOVIG 140 mg/mL Injection, SolutionErenumab-Aooe3Preferred Brand17%17%
  • PA
  • QL 1 per 28 days
AIMOVIG 70 mg/mL InjectionErenumab-Aooe3Preferred Brand17%17%
  • PA
  • QL 1 per 28 days
AIRSUPRA 90/80 ug Aerosol, MeteredAlbuterol Sulfate And Budesonide3Preferred Brand17%17%
  • QL 32.1 per 30 days
AKEEGA 100/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AKEEGA 50/500 mg Tablet, Film CoatedNiraparib Tosylate Monohydrate And Abiraterone Acetate5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
ALACORT 10 mg/g CreamHydrocortisone3Preferred Brand17%17%None
ALBENDAZOLE 200 mg Tablet4Non-Preferred Drug33%N/A
  • QL 48 per 30 days
ALBUTEROL SULFATE 2.5 mg/.5mL Solution3Preferred Brand17%17%
  • PA
ALBUTEROL SULFATE 2.5 mg/3mL Solution3Preferred Brand17%17%
  • PA
ALBUTEROL SULFATE 90 ug Inhalant2Generic$7.00$21.00None
ALBUTEROL SULFATE 90 ug Inhalant2Generic$7.00$21.00None
ALBUTEROL SULFATE HFA 90 ug Aerosol, MeteredAlbuterol Sulfate2Generic$7.00$21.00None
ALBUTEROL SULFATE INHALATION SOLUTION .63 mg/3mL SolutionAlbuterol Sulfate3Preferred Brand17%17%
  • PA
ALBUTEROL SULFATE INHALATION SOLUTION 1.25 mg/3mL SolutionAlbuterol Sulfate3Preferred Brand17%17%
  • PA
ALCLOMETASONE DIPROPIONATE .5 mg/g Cream4Non-Preferred Drug33%N/ANone
ALCLOMETASONE DIPROPIONATE .5 mg/g Ointment4Non-Preferred Drug33%N/ANone
ALECENSA 150 mg CapsuleAlectinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
ALENDRONATE SODIUM 10 mg Tablet2Generic$7.00$21.00
  • QL 3 per 30 days
ALENDRONATE SODIUM 35 mg Tablet2Generic$7.00$21.00
  • QL 8 per 28 days
ALENDRONATE SODIUM 70 mg Tablet2Generic$7.00$21.00
  • QL 4 per 28 days
ALFUZOSIN HYDROCHLORIDE 10 mg Tablet, Film Coated, Extended Release2Generic$7.00$21.00None
ALISKIREN 150 mg Tablet, Film CoatedAliskiren Hemifumarate4Non-Preferred Drug33%N/ANone
ALISKIREN 300 mg Tablet, Film CoatedAliskiren Hemifumarate4Non-Preferred Drug33%N/ANone
ALLOPURINOL 100 mg Tablet2Generic$7.00$21.00None
ALLOPURINOL 300 mg Tablet2Generic$7.00$21.00None
ALOSETRON HYDROCHLORIDE .5 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • PA
ALOSETRON HYDROCHLORIDE 1 mg Tablet, Film Coated4Non-Preferred Drug33%N/A
  • PA
ALPRAZOLAM .25 mg Tablet2Generic$7.00$21.00
  • PA
  • QL 12 per 30 days
ALPRAZOLAM .5 mg Tablet2Generic$7.00$21.00
  • PA
  • QL 12 per 30 days
ALPRAZOLAM 1 mg Tablet2Generic$7.00$21.00
  • PA
  • QL 12 per 30 days
ALPRAZOLAM 2 mg Tablet2Generic$7.00$21.00
  • PA
  • QL 15 per 30 days
ALTAVERA KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand17%17%None
ALUNBRIG 180 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALUNBRIG 30 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
ALUNBRIG 90 mg Tablet, Film CoatedBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
ALUNBRIG KitBrigatinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 365 days
ALYACEN 1/35 KitNorethindrone And Ethinyl Estradiol3Preferred Brand17%17%None
AMANTADINE HYDROCHLORIDE 100 mg Capsule3Preferred Brand17%17%None
AMANTADINE HYDROCHLORIDE 50 mg/5mL Solution3Preferred Brand17%17%None
AMIKACIN SULFATE 250 mg/mL Injection, Solution4Non-Preferred Drug33%N/ANone
AMILORIDE HYDROCHLORIDE 5 mg Tablet3Preferred Brand17%17%None
AMIODARONE HYDROCHLORIDE 200 mg Tablet2Generic$7.00$21.00None
AMITRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 100 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 150 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 25 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 50 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMITRIPTYLINE HYDROCHLORIDE 75 mg Tablet, Film Coated3Preferred Brand17%17%
  • PA
AMLODIPINE AND BENAZEPRIL HYDROCHLORIDE 5/40 mg Capsule2Generic$7.00$21.00None
AMLODIPINE BESYLATE 10 mg Tablet1Preferred Generic$2.00$6.00None
AMLODIPINE BESYLATE 2.5 mg Tablet1Preferred Generic$2.00$6.00None
AMLODIPINE BESYLATE 5 mg Tablet1Preferred Generic$2.00$6.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/20 mg Capsule2Generic$7.00$21.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 10/40 mg Capsule2Generic$7.00$21.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 2.5/10 mg Capsule2Generic$7.00$21.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/10 mg Capsule2Generic$7.00$21.00None
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE 5/20 mg Capsule2Generic$7.00$21.00None
AMMONIUM LACTATE 12 g/100g Cream3Preferred Brand17%17%None
AMMONIUM LACTATE 12 g/100g Lotion3Preferred Brand17%17%None
AMNESTEEM 10 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/A
  • PA
AMNESTEEM 20 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/A
  • PA
AMNESTEEM 30 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/A
  • PA
AMNESTEEM 40 mg CapsuleIsotretinoin4Non-Preferred Drug33%N/A
  • PA
AMOXAPINE 100 mg Tablet3Preferred Brand17%17%
  • PA
AMOXAPINE 150 mg Tablet3Preferred Brand17%17%
  • PA
AMOXAPINE 25 mg Tablet3Preferred Brand17%17%
  • PA
AMOXAPINE 50 mg Tablet3Preferred Brand17%17%
  • PA
AMOXICILLIN 125 mg Tablet, Chewable2Generic$7.00$21.00None
AMOXICILLIN 125 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN 200 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN 250 mg Capsule2Generic$7.00$21.00None
AMOXICILLIN 250 mg Tablet, Chewable2Generic$7.00$21.00None
AMOXICILLIN 250 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN 400 mg/5mL Powder, For Suspension2Generic$7.00$21.00None
AMOXICILLIN 500 mg Capsule2Generic$7.00$21.00None
AMOXICILLIN 500 mg Tablet, Film Coated2Generic$7.00$21.00None
AMOXICILLIN 875 mg Tablet, Film Coated2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 200/28.5 mg/5mL Powder, For Suspension3Preferred Brand17%17%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/125 mg Tablet, Film Coated2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 250/62.5 mg/5mL Powder, For Suspension3Preferred Brand17%17%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 400/57 mg/5mL Powder, For Suspension3Preferred Brand17%17%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 500/125 mg Tablet, Film Coated2Generic$7.00$21.00None
AMOXICILLIN AND CLAVULANATE POTASSIUM 562.5/437.5/62.5 mg Tablet, Multilayer, Extended Release4Non-Preferred Drug33%N/ANone
AMOXICILLIN AND CLAVULANATE POTASSIUM 600/42.9 mg/5mL Suspension3Preferred Brand17%17%None
AMOXICILLIN AND CLAVULANATE POTASSIUM 875/125 mg Tablet, Film Coated2Generic$7.00$21.00None
AMPHOTERICIN B 50 mg/10mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%N/A
  • PA
AMPHOTERICIN B 50 mg/12.5mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%N/A
  • PA
AMPICILLIN 1 g Injection, Powder, For SolutionAmpicillin Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN 10 g Injection, Powder, For Solution4Non-Preferred Drug33%N/ANone
AMPICILLIN 2 g Injection, Powder, For SolutionAmpicillin Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN 500 mg Capsule2Generic$7.00$21.00None
AMPICILLIN AND SULBACTAM 1/.5 g Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN AND SULBACTAM 100/50 mg/mL Injection, Powder, For SolutionAmpicillin Sodium And Sulbactam Sodium4Non-Preferred Drug33%N/ANone
AMPICILLIN AND SULBACTAM 2/1 g/3g Injection, Powder, For Solution4Non-Preferred Drug33%N/ANone
ANAGRELIDE .5 mg Capsule3Preferred Brand17%17%None
ANAGRELIDE 1 mg Capsule4Non-Preferred Drug33%N/ANone
ANASTROZOLE 1 mg Tablet2Generic$7.00$21.00None
ANORO ELLIPTA 62.5/25 ug PowderUmeclidinium Bromide And Vilanterol Trifenatate3Preferred Brand17%17%
  • QL 6 per 30 days
APREPITANT 125 mg Capsule4Non-Preferred Drug33%N/A
  • PA
  • QL 2 per 28 days
APREPITANT 40 mg Capsule4Non-Preferred Drug33%N/A
  • PA
  • QL 4 per 28 days
APREPITANT 80 mg Capsule4Non-Preferred Drug33%N/A
  • PA
  • QL 4 per 28 days
APREPITANT Kit4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 28 days
APRI 28 DAY KitDesogestrel And Ethinyl Estradiol3Preferred Brand17%17%None
ARANELLE KitNorethindrone And Ethinyl Estradiol3Preferred Brand17%17%None
ARANESP 10 ug/.4mL Injection, SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 100 ug/.5mL Injection, SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 100 ug/mL SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 150 ug/.3mL Injection, SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 200 ug/.4mL Injection, SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 200 ug/mL SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 25 ug/.42mL Injection, SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 25 ug/mL SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 300 ug/.6mL Injection, SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 40 ug/.4mL Injection, SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 40 ug/mL SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 500 ug/mL Injection, SolutionDarbepoetin Alfa5Specialty Tier25%N/A
  • PA
ARANESP 60 ug/.3mL Injection, SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARANESP 60 ug/mL SolutionDarbepoetin Alfa4Non-Preferred Drug33%N/A
  • PA
ARCALYST 160 mg/2mL Injection, Powder, Lyophilized, For SolutionRilonacept5Specialty Tier25%N/A
  • PA
AREXVY KitRespiratory Syncytial Virus Vaccine Recombinant, Adjuvanted3Preferred Brand17%17%
  • PA
  • QL 1 per 1 days
ARFORMOTEROL TARTRATE 15 ug/2mL Solution4Non-Preferred Drug33%N/A
  • PA
  • QL 12 per 30 days
ARIKAYCE 590 mg/8.4mL SuspensionAmikacin5Specialty Tier25%N/A
  • PA
ARIPIPRAZOLE 1 mg/mL Solution4Non-Preferred Drug33%N/A
  • QL 75 per 30 days
ARIPIPRAZOLE 10 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARIPIPRAZOLE 10 mg Tablet, Orally Disintegrating4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg TabletAripiprazole Orally Disintegrating4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ARIPIPRAZOLE 15 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARIPIPRAZOLE 2 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARIPIPRAZOLE 20 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARIPIPRAZOLE 30 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARIPIPRAZOLE 5 mg Tablet4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ARISTADA 1064 mg/3.9mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARISTADA 441 mg/1.6mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARISTADA 662 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARISTADA 882 mg/3.2mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARISTADA INITIO 675 mg/2.4mL Injection, Suspension, Extended ReleaseAripiprazole Lauroxil5Specialty Tier25%N/ANone
ARMODAFINIL 150 mg Tablet4Non-Preferred Drug33%N/A
  • PA
  • QL 3 per 30 days
ARMODAFINIL 200 mg Tablet4Non-Preferred Drug33%N/A
  • PA
  • QL 3 per 30 days
ARMODAFINIL 250 mg Tablet4Non-Preferred Drug33%N/A
  • PA
  • QL 3 per 30 days
ARMODAFINIL 50 mg Tablet4Non-Preferred Drug33%N/A
  • PA
  • QL 6 per 30 days
ASENAPINE 10 mg TabletAsenapine Maleate4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ASENAPINE 2.5 mg Tablet4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ASENAPINE 5 mg TabletAsenapine Maleate4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ASHLYNA KitLevonorgestrel And Ethinyl Estradiol And Ethinyl Estradiol3Preferred Brand17%17%None
ASPRIN AND EXTENDED-RELEASE DIPYRIDAMOLE 25/200 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ASTAGRAF XL .5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules4Non-Preferred Drug33%N/A
  • PA
ASTAGRAF XL 1 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules4Non-Preferred Drug33%N/A
  • PA
ASTAGRAF XL 5 mg Capsule, Coated, Extended ReleaseTacrolimus Extended-Release Capsules4Non-Preferred Drug33%N/A
  • PA
ATAZANAVIR SULFATE 150 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATAZANAVIR SULFATE 200 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATAZANAVIR SULFATE 300 mg CapsuleAtazanavir4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATENOLOL 100 mg Tablet2Generic$7.00$21.00None
ATENOLOL 25 mg Tablet2Generic$7.00$21.00None
ATENOLOL 50 mg Tablet2Generic$7.00$21.00None
ATENOLOL AND CHLORTHALIDONE 100/25 mg Tablet3Preferred Brand17%17%None
ATENOLOL AND CHLORTHALIDONE 50/25 mg Tablet3Preferred Brand17%17%None
ATOMOXETINE 10 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 100 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATOMOXETINE 18 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 25 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 40 mg Capsule4Non-Preferred Drug33%N/A
  • QL 6 per 30 days
ATOMOXETINE 60 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATOMOXETINE 80 mg Capsule4Non-Preferred Drug33%N/A
  • QL 3 per 30 days
ATORVASTATIN CALCIUM 10 mg Tablet, Film Coated1Preferred Generic$2.00$6.00None
ATORVASTATIN CALCIUM 20 mg Tablet, Film Coated1Preferred Generic$2.00$6.00None
ATORVASTATIN CALCIUM 40 mg Tablet, Film Coated1Preferred Generic$2.00$6.00None
ATORVASTATIN CALCIUM 80 mg Tablet, Film Coated1Preferred Generic$2.00$6.00None
ATOVAQUONE 750 mg/5mL Suspension4Non-Preferred Drug33%N/A
  • QL 42 per 30 days
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE 250/100 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
ATOVAQUONE AND PROGUANIL HYDROCHLORIDE PEDIATRIC 62.5/25 mg Tablet, Film Coated4Non-Preferred Drug33%N/ANone
ATROPINE 10 mg/mL Solution/ DropsAtropine Sulfate3Preferred Brand17%17%None
ATROVENT HFA 17 ug Aerosol, MeteredIpratropium Bromide4Non-Preferred Drug33%N/ANone
AUBRA EQ KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand17%17%None
AUGTYRO 160 mg CapsuleRepotrectinib5Specialty Tier25%N/A
  • PA
  • QL 6 per 30 days
AUGTYRO 40 mg CapsuleRepotrectinib5Specialty Tier25%N/A
  • PA
  • QL 24 per 30 days
AUSTEDO 12 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUSTEDO 6 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUSTEDO 9 mg Tablet, CoatedDeutetrabenazine5Specialty Tier25%N/A
  • PA
  • QL 12 per 30 days
AUVELITY 45/105 mg Tablet, Multilayer, Extended ReleaseDextromethorphan Hydrobromide, Bupropion Hydrochloride5Specialty Tier25%N/ANone
AVIANE KitLevonorgestrel And Ethinyl Estradiol3Preferred Brand17%17%None
AVMAPKI FAKZYNJA CO-PACK KitAvutometinib Potassium And Defactinib Hydrochloride5Specialty Tier25%N/A
  • PA
  • QL 66 per 28 days
AYVAKIT 100 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 200 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 25 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 300 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AYVAKIT 50 mg Tablet, Film CoatedAvapritinib5Specialty Tier25%N/A
  • PA
  • QL 3 per 30 days
AZATHIOPRINE 50 mg Tablet3Preferred Brand17%17%
  • PA
AZELAIC ACID .15 g/g Gel4Non-Preferred Drug33%N/A
  • QL 5 per 30 days
AZELASTINE HYDROCHLORIDE .5 mg/mL Solution/ Drops3Preferred Brand17%17%None
AZELASTINE HYDROCHLORIDE 137 ug Spray, Metered3Preferred Brand17%17%None
AZITHROMYCIN 100 mg/5mL Powder, For Suspension3Preferred Brand17%17%None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 250 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN 500 mg/5mL Injection, Powder, Lyophilized, For SolutionAzithromycin Dihydrate4Non-Preferred Drug33%N/ANone
AZITHROMYCIN 600 mg Tablet, Film Coated2Generic$7.00$21.00None
AZITHROMYCIN DIHYDRATE 200 mg/5mL Powder, For Suspension3Preferred Brand17%17%None
AZTREONAM 1 g Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug33%N/ANone
AZURETTE KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol3Preferred 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.