MedicarePartD.guide

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2026 Blue Rx PDP Plus (PDP) formulary (drug list)

Contract S5593, plan 002 · West Virginia · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.

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322 drugs starting with C.

Drug nameTier30-day preferred pharmacy90-day mail orderUsage management
CABERGOLINE .5 mg Tablet2Generic25%25%None
CABOMETYX 20 mg TabletCabozantinib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CABOMETYX 40 mg TabletCabozantinib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CABOMETYX 60 mg TabletCabozantinib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CALCIPOTRIENE .05 mg/mL Solution2Generic25%25%
  • QL 6 per 28 days
CALCIPOTRIENE 50 ug/g Cream2Generic25%25%
  • QL 6 per 28 days
CALCIPOTRIENE 50 ug/g Ointment2Generic25%25%
  • QL 6 per 28 days
CALCIPOTRIENE AND BETAMETHASONE DIPROPIONATE 50/.643 ug/g/mg/g OintmentCalcipotriene, Betamethasone Dipropionate4Non-Preferred Drug25%25%
  • ST
  • QL 4 per 28 days
CALCIPOTRIENE AND BETAMETHASONE DIPROPIONATE 50/50 ug/g/mg/g Suspension5Specialty Tier25%25%
  • ST
  • QL 4 per 28 days
CALCITONIN SALMON 200 [iU] Spray, Metered2Generic25%25%
  • PA
CALCITRIOL .25 ug Capsule, Liquid Filled2Generic25%25%
  • PA
CALCITRIOL .5 ug Capsule, Liquid Filled2Generic25%25%
  • PA
CALCITRIOL 1 ug/mL Solution3Preferred Brand25%25%
  • PA
CALCITRIOL 3 ug/g Ointment4Non-Preferred Drug25%25%
  • ST
CALCIUM ACETATE 667 mg Capsule2Generic25%25%
  • PA
CALCIUM ACETATE 667 mg Tablet2Generic25%25%
  • PA
CALQUENCE 100 mg Tablet, Film CoatedAcalabrutinib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
CANDESARTAN 16 mg Tablet2Generic25%25%None
CANDESARTAN 32 mg Tablet2Generic25%25%None
CANDESARTAN 4 mg Tablet2Generic25%25%None
CANDESARTAN 8 mg Tablet2Generic25%25%None
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 16/12.5 mg Tablet2Generic25%25%None
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/12.5 mg Tablet2Generic25%25%None
CANDESARTAN CILEXETIL AND HYDROCHLOROTHIAZIDE 32/25 mg Tablet2Generic25%25%None
CAPLYTA 10.5 mg CapsuleLumateperone5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CAPLYTA 21 mg CapsuleLumateperone5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CAPLYTA 42 mg CapsuleLumateperone5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CAPRELSA 100 mg Tablet, Film CoatedVandetanib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
CAPRELSA 300 mg Tablet, Film CoatedVandetanib5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
CAPTOPRIL 100 mg Tablet1Preferred Generic25%25%None
CAPTOPRIL 12.5 mg Tablet1Preferred Generic25%25%None
CAPTOPRIL 25 mg Tablet1Preferred Generic25%25%None
CAPTOPRIL 50 mg Tablet1Preferred Generic25%25%None
CARBAMAZEPINE 100 mg Capsule, Extended Release2Generic25%25%None
CARBAMAZEPINE 100 mg Tablet, Chewable1Preferred Generic25%25%None
CARBAMAZEPINE 100 mg Tablet, Extended Release2Generic25%25%None
CARBAMAZEPINE 100 mg/5mL Suspension1Preferred Generic25%25%None
CARBAMAZEPINE 200 mg Capsule, Extended Release2Generic25%25%None
CARBAMAZEPINE 200 mg Tablet1Preferred Generic25%25%None
CARBAMAZEPINE 200 mg Tablet, Chewable4Non-Preferred Drug25%25%None
CARBAMAZEPINE 200 mg Tablet, Extended Release2Generic25%25%None
CARBAMAZEPINE 300 mg Capsule, Extended Release2Generic25%25%None
CARBAMAZEPINE 400 mg Tablet, Extended Release2Generic25%25%None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet2Generic25%25%None
CARBIDOPA AND LEVODOPA 10/100 mg Tablet, Orally Disintegrating2Generic25%25%None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet2Generic25%25%None
CARBIDOPA AND LEVODOPA 25/100 mg Tablet, Orally Disintegrating2Generic25%25%None
CARBIDOPA AND LEVODOPA 25/250 mg Tablet, Orally Disintegrating2Generic25%25%None
CARBIDOPA-LEVODOPA 25/250 mg TabletCarbidopa And Levodopa2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 12.5/50/200 mg Tablet, Film Coated2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 18.75/75/200 mg Tablet, Film Coated2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 25/100/200 mg Tablet, Film Coated2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 31.25/125/200 mg Tablet, Film Coated2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 37.5/150/200 mg Tablet, Film Coated2Generic25%25%None
CARBIDOPA, LEVODOPA AND ENTACAPONE 50/200/200 mg Tablet, Film Coated2Generic25%25%None
CARGLUMIC ACID 200 mg Tablet, For Suspension5Specialty Tier25%25%
  • PA
CARTEOLOL HYDROCHLORIDE 10 mg/mL Solution2Generic25%25%None
CARTIA XT 120 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
CARTIA XT 180 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
CARTIA XT 240 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
CARTIA XT 300 mg Capsule, Extended ReleaseDiltiazem Hydrochloride1Preferred Generic25%25%None
CARVEDILOL 12.5 mg Tablet, Film Coated1Preferred Generic25%25%None
CARVEDILOL 25 mg Tablet, Film Coated1Preferred Generic25%25%None
CARVEDILOL 3.125 mg Tablet, Film Coated1Preferred Generic25%25%None
CARVEDILOL 6.25 mg Tablet, Film Coated1Preferred Generic25%25%None
CARVEDILOL PHOSPHATE 10 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
CARVEDILOL PHOSPHATE 20 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
CARVEDILOL PHOSPHATE 40 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
CARVEDILOL PHOSPHATE 80 mg Capsule, Extended Release4Non-Preferred Drug25%25%None
CASPOFUNGIN ACETATE 5 mg/mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug25%25%None
CASPOFUNGIN ACETATE 7 mg/mL Injection, Powder, Lyophilized, For Solution4Non-Preferred Drug25%25%None
CAYSTON KitAztreonam5Specialty Tier25%25%
  • PA
CEFACLOR 500 mg Capsule2Generic25%25%None
CEFADROXIL 1000 mg Tablet3Preferred Brand25%25%None
CEFADROXIL 250 mg/5mL Powder, For Suspension2Generic25%25%None
CEFADROXIL 500 mg Capsule2Generic25%25%None
CEFADROXIL 500 mg/5mL Powder, For Suspension3Preferred Brand25%25%None
CEFAZOLIN 1 g Injection, Powder, For Solution2Generic25%25%None
CEFAZOLIN 10 g Injection, Powder, For Solution2Generic25%25%None
CEFAZOLIN 500 mg Injection, Powder, For Solution2Generic25%25%None
CEFDINIR 300 mg Capsule2Generic25%25%None
CEFEPIME 1 g Injection, Powder, For Solution4Non-Preferred Drug25%25%None
CEFEPIME 2 g Injection, Powder, For Solution4Non-Preferred Drug25%25%None
CEFIXIME 100 mg/5mL Powder, For Suspension2Generic25%25%None
CEFIXIME 200 mg/5mL Powder, For Suspension2Generic25%25%None
CEFIXIME 400 mg Capsule2Generic25%25%None
CEFOTETAN 1 g/10mL Injection, Powder, For SolutionCefotetan Disodium2Generic25%25%None
CEFOTETAN 2 g/20mL Injection, Powder, For SolutionCefotetan Disodium2Generic25%25%None
CEFOXITIN 1 g Injection, Powder, For Solution2Generic25%25%None
CEFOXITIN 10 g Injection, Powder, For Solution2Generic25%25%None
CEFOXITIN 2 g Injection, Powder, For Solution2Generic25%25%None
CEFPODOXIME PROXETIL 100 mg Tablet, Film Coated2Generic25%25%None
CEFPODOXIME PROXETIL 100 mg/5mL Granule, For Suspension2Generic25%25%None
CEFPODOXIME PROXETIL 200 mg Tablet, Film Coated2Generic25%25%None
CEFPODOXIME PROXETIL 50 mg/5mL Granule, For Suspension2Generic25%25%None
CEFPROZIL 125 mg/5mL Powder, For Suspension2Generic25%25%None
CEFPROZIL 250 mg Tablet2Generic25%25%None
CEFPROZIL 250 mg/5mL Powder, For Suspension2Generic25%25%None
CEFPROZIL 500 mg Tablet2Generic25%25%None
CEFTAROLINE FOSAMIL 400 mg/20mL Injection, Powder, Lyophilized, For Solution5Specialty Tier25%25%None
CEFTAROLINE FOSAMIL 600 mg/20mL Injection, Powder, Lyophilized, For Solution5Specialty Tier25%25%None
CEFTAZIDIME 1 g Injection, Powder, For Solution4Non-Preferred Drug25%25%None
CEFTAZIDIME 2 g Injection, Powder, For Solution4Non-Preferred Drug25%25%None
CEFTAZIDIME 6 g/30mL Injection, Powder, For Solution4Non-Preferred Drug25%25%None
CEFTRIAXONE SODIUM 1 g Injection, Powder, For Solution2Generic25%25%None
CEFTRIAXONE SODIUM 10 g Injection, Powder, For Solution2Generic25%25%None
CEFTRIAXONE SODIUM 2 g Injection, Powder, For Solution2Generic25%25%None
CEFTRIAXONE SODIUM 250 mg Injection, Powder, For Solution2Generic25%25%None
CEFTRIAXONE SODIUM 500 mg Injection, Powder, For Solution2Generic25%25%None
CEFUROXIME 1.5 g Injection, Powder, For Solution2Generic25%25%None
CEFUROXIME 750 mg Injection, Powder, For Solution2Generic25%25%None
CEFUROXIME AXETIL 250 mg Tablet2Generic25%25%None
CEFUROXIME AXETIL 500 mg Tablet2Generic25%25%None
CELECOXIB 100 mg Capsule2Generic25%25%
  • QL 62 per 31 days
CELECOXIB 200 mg Capsule2Generic25%25%
  • QL 62 per 31 days
CELECOXIB 400 mg Capsule2Generic25%25%
  • QL 62 per 31 days
CELECOXIB 50 mg Capsule2Generic25%25%
  • QL 62 per 31 days
CEPHALEXIN 125 mg/5mL For Suspension2Generic25%25%None
CEPHALEXIN 250 mg Capsule2Generic25%25%None
CEPHALEXIN 250 mg Tablet2Generic25%25%None
CEPHALEXIN 250 mg/5mL For Suspension2Generic25%25%None
CEPHALEXIN 500 mg Capsule2Generic25%25%None
CEPHALEXIN 500 mg Tablet2Generic25%25%None
CEPHALEXIN 750 mg Capsule2Generic25%25%None
CERDELGA 84 mg CapsuleEliglustat5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
CETIRIZINE HYDROCHLORIDE 1 mg/mL Solution1Preferred Generic25%25%
  • QL 31 per 31 days
CEVIMELINE HYDROCHLORIDE 30 mg Capsule4Non-Preferred Drug25%25%None
CHEMET 100 mg CapsuleSuccimer4Non-Preferred Drug25%25%None
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HYDROCHLORIDE 10/27.98 mg Tablet, Film Coated4Non-Preferred Drug25%25%
  • PA
CHLORDIAZEPOXIDE AND AMITRIPTYLINE HYDROCHLORIDE 5/14 mg Tablet, Film Coated4Non-Preferred Drug25%25%
  • PA
CHLORHEXIDINE GLUCONATE 1.2 mg/mL Rinse1Preferred Generic25%25%None
CHLOROQUINE PHOSPHATE 250 mg Tablet3Preferred Brand25%25%
  • QL 5 per 30 days
CHLOROQUINE PHOSPHATE 500 mg Tablet3Preferred Brand25%25%
  • QL 25 per 30 days
CHLORPROMAZINE HYDROCHLORIDE 10 mg Tablet, Coated4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 100 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 100 mg/mL Concentrate4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 200 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 25 mg Tablet, Coated4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 30 mg/mL Concentrate4Non-Preferred Drug25%25%None
CHLORPROMAZINE HYDROCHLORIDE 50 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
CHLORTHALIDONE 25 mg Tablet1Preferred Generic25%25%None
CHLORTHALIDONE 50 mg Tablet1Preferred Generic25%25%None
CHOLESTYRAMINE 4 g/5.5g Powder, For Suspension2Generic25%25%None
CHOLESTYRAMINE 4 g/9g Powder, For Suspension2Generic25%25%None
CICLOPIROX 1 g/100mL Shampoo2Generic25%25%
  • QL 12 per 28 days
CICLOPIROX 7.7 mg/g Gel2Generic25%25%
  • QL 45 per 28 days
CICLOPIROX 80 mg/mL Solution2Generic25%25%None
CICLOPIROX OLAMINE 7.7 mg/g Cream2Generic25%25%
  • QL 9 per 28 days
CICLOPIROX OLAMINE 7.7 mg/mL Suspension3Preferred Brand25%25%
  • QL 6 per 28 days
CILOSTAZOL 100 mg Tablet2Generic25%25%None
CILOSTAZOL 50 mg Tablet2Generic25%25%None
CILOXAN 3 mg/g OintmentCiprofloxacin Hydrochloride3Preferred Brand25%25%None
CIMDUO 300/300 mg Tablet, Film CoatedLamivudine And Tenofovir Disoproxil Fumarate5Specialty Tier25%25%
  • QL 31 per 31 days
CIMETIDINE 200 mg Tablet, Film Coated2Generic25%25%None
CIMETIDINE 300 mg Tablet, Film Coated2Generic25%25%None
CIMETIDINE 400 mg Tablet, Film Coated2Generic25%25%None
CIMETIDINE 800 mg Tablet, Film Coated2Generic25%25%None
CIMETIDINE HYDROCHLORIDE 300 mg/5mL Solution2Generic25%25%None
CINRYZE KitHuman C1-Esterase Inhibitor5Specialty Tier25%25%
  • PA
  • QL 2 per 28 days
CIPROFLOXACIN 250 mg Tablet, Film Coated1Preferred Generic25%25%None
CIPROFLOXACIN 500 mg Tablet, Film Coated1Preferred Generic25%25%None
CIPROFLOXACIN 750 mg Tablet, Film Coated1Preferred Generic25%25%None
CIPROFLOXACIN AND DEXAMETHASONE 3/1 mg/mL Suspension/ Drops3Preferred Brand25%25%None
CIPROFLOXACIN HYDROCHLORIDE 3 mg/mL Solution/ Drops1Preferred Generic25%25%None
CIPROFLOXACIN IN DEXTROSE 200 mg/100mL Injection, SolutionCiprofloxacin2Generic25%25%None
CITALOPRAM 10 mg Tablet, Film Coated1Preferred Generic25%25%None
CITALOPRAM 20 mg Tablet, Film Coated1Preferred Generic25%25%None
CITALOPRAM 40 mg Tablet, Film Coated1Preferred Generic25%25%None
CITALOPRAM HYDROBROMIDE 10 mg/5mL Solution3Preferred Brand25%25%None
CLARAVIS 10 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug25%25%None
CLARAVIS 20 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug25%25%None
CLARAVIS 30 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug25%25%None
CLARAVIS 40 mg Capsule, Liquid FilledIsotretinoin4Non-Preferred Drug25%25%None
CLARINEX-D 12 HOUR 2.5/120 mg Tablet, Extended ReleaseDesloratadine And Pseudoephedrine Sulfate4Non-Preferred Drug25%25%None
CLARITHROMYCIN 125 mg/5mL For Suspension2Generic25%25%None
CLARITHROMYCIN 250 mg Tablet, Film Coated2Generic25%25%None
CLARITHROMYCIN 250 mg/5mL For Suspension4Non-Preferred Drug25%25%None
CLARITHROMYCIN 500 mg Tablet, Film Coated2Generic25%25%None
CLARITHROMYCIN 500 mg Tablet, Film Coated, Extended Release2Generic25%25%None
CLEOCIN 100 mg SuppositoryClindamycin Phosphate4Non-Preferred Drug25%25%None
CLIMARA PRO .045/.015 mg/d PatchEstradiol And Levonorgestrel4Non-Preferred Drug25%25%None
CLINDACIN 10 mg/g Aerosol, FoamClindamycin Phosphate2Generic25%25%
  • QL 1 per 28 days
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate2Generic25%25%None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate2Generic25%25%None
CLINDAMYCIN 150 mg/mL Injection, SolutionClindamycin Phosphate2Generic25%25%None
CLINDAMYCIN AND BENZOYL PEROXIDE 10/50 mg/g Gel2Generic25%25%None
CLINDAMYCIN HYDROCHLORIDE 150 mg Capsule2Generic25%25%None
CLINDAMYCIN HYDROCHLORIDE 300 mg Capsule2Generic25%25%None
CLINDAMYCIN HYDROCHLORIDE 75 mg Capsule2Generic25%25%None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 12 mg/mL Injection, Solution2Generic25%25%None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 18 mg/mL Injection, Solution2Generic25%25%None
CLINDAMYCIN IN 5 PERCENT DEXTROSE 6 mg/mL Injection, Solution2Generic25%25%None
CLINDAMYCIN PALMITATE HYDROCHLORIDE (PEDIATRIC) 75 mg/5mL Solution2Generic25%25%None
CLINDAMYCIN PHOSPHATE 10 mg/g Aerosol, Foam4Non-Preferred Drug25%25%
  • QL 1 per 28 days
CLINDAMYCIN PHOSPHATE 10 mg/g GelClindamycin Phosphate Gel Usp, 1%2Generic25%25%
  • QL 6 per 28 days
CLINDAMYCIN PHOSPHATE 10 mg/mL Lotion2Generic25%25%
  • QL 6 per 28 days
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution2Generic25%25%
  • QL 6 per 28 days
CLINDAMYCIN PHOSPHATE 10 mg/mL Solution2Generic25%25%None
CLINDAMYCIN PHOSPHATE 20 mg/g Cream2Generic25%25%None
CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE 10/50 mg/g GelClindamycin, Benzoyl Peroxide2Generic25%25%None
CLINDAMYCIN PHOSPHATE AND BENZOYL PEROXIDE 25/10 mg/g GelClindamycin Phosphate, Benzoyl Peroxide2Generic25%25%None
CLINDAMYCIN PHOSPHATE AND TRETINOIN 10/.25 mg/g Gel2Generic25%25%
  • PA
  • QL 6 per 28 days
CLINDESSE 100 mg/5g CreamClindamycin Phosphate4Non-Preferred Drug25%25%None
CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/10 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/15 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/20 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX E 201/154/159/110/165/160/132/116/50/570/283/316/187/138/11/217/261/51/112/33/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX E 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/297/261/51/77/33/10 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX E 311/238/247/170/255/247/204/179/77/880/438/489/289/213/17/297/261/51/77/33/5 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX E 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/340/261/51/59/33/15 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose4Non-Preferred Drug25%25%
  • PA
CLINIMIX E 365/280/290/200/300/290/240/210/90/1035/515/575/340/250/20/340/261/51/59/33/20 mg/100mL/g/100mL InjectionLeucine, Phenylalanine, Lysine, Methionine, Isoleucine, Valine, Histidine, Threonine, Tryptophan, Alanine, Glycine, Arginine, Proline, Serine, Tyrosine, Sodium Acetate, Dibasic Potassium Phosphate, Magnesium Chloride, Sodium Chloride, Calcium Chloride, Dextrose4Non-Preferred Drug25%25%
  • PA
CLOBAZAM 10 mg Tablet3Preferred Brand25%25%
  • PA
  • QL 62 per 31 days
CLOBAZAM 2.5 mg/mL Suspension4Non-Preferred Drug25%25%
  • PA
  • QL 496 per 31 days
CLOBAZAM 20 mg Tablet3Preferred Brand25%25%
  • PA
  • QL 62 per 31 days
CLOBETASOL PROPIONATE .05 g/100mL Shampoo4Non-Preferred Drug25%25%
  • QL 118 per 28 days
CLOBETASOL PROPIONATE .05 g/mL Spray2Generic25%25%
  • QL 125 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Aerosol, Foam2Generic25%25%
  • QL 1 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Cream3Preferred Brand25%25%
  • QL 6 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Cream3Preferred Brand25%25%
  • QL 6 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Gel2Generic25%25%
  • QL 6 per 28 days
CLOBETASOL PROPIONATE .5 mg/g Ointment3Preferred Brand25%25%
  • QL 6 per 28 days
CLOBETASOL PROPIONATE .5 mg/mL Lotion2Generic25%25%
  • QL 118 per 28 days
CLOBETASOL PROPIONATE .5 mg/mL Solution2Generic25%25%
  • QL 5 per 28 days
CLOBETASOL PROPIONATE EMOLLIENT FORMULATION .5 mg/g Aerosol, FoamClobetasol Propionate3Preferred Brand25%25%
  • QL 1 per 28 days
CLOCORTOLONE PIVALATE .001 g/g Cream4Non-Preferred Drug25%25%None
CLODAN .5 mg/mL ShampooClobetasol Propionate2Generic25%25%
  • QL 118 per 28 days
CLOMIPRAMINE HYDROCHLORIDE 25 mg Capsule4Non-Preferred Drug25%25%
  • PA
CLOMIPRAMINE HYDROCHLORIDE 50 mg Capsule4Non-Preferred Drug25%25%
  • PA
CLOMIPRAMINE HYDROCHLORIDE 75 mg Capsule4Non-Preferred Drug25%25%
  • PA
CLONAZEPAM .125 mg Tablet, Orally Disintegrating2Generic25%25%
  • PA
  • QL 93 per 31 days
CLONAZEPAM .25 mg Tablet, Orally Disintegrating2Generic25%25%
  • PA
  • QL 93 per 31 days
CLONAZEPAM .5 mg Tablet2Generic25%25%
  • PA
  • QL 93 per 31 days
CLONAZEPAM .5 mg Tablet, Orally Disintegrating2Generic25%25%
  • PA
  • QL 93 per 31 days
CLONAZEPAM 1 mg Tablet2Generic25%25%
  • PA
  • QL 124 per 31 days
CLONAZEPAM 1 mg Tablet, Orally Disintegrating2Generic25%25%
  • PA
  • QL 124 per 31 days
CLONAZEPAM 2 mg Tablet2Generic25%25%
  • PA
  • QL 31 per 31 days
CLONAZEPAM 2 mg Tablet, Orally Disintegrating2Generic25%25%
  • PA
  • QL 31 per 31 days
CLONIDINE HYDROCHLORIDE .1 mg Tablet1Preferred Generic25%25%None
CLONIDINE HYDROCHLORIDE .1 mg Tablet, Extended Release4Non-Preferred Drug25%25%
  • PA
CLONIDINE HYDROCHLORIDE .2 mg Tablet1Preferred Generic25%25%None
CLONIDINE HYDROCHLORIDE .3 mg Tablet1Preferred Generic25%25%None
CLONIDINE TRANSDERMAL SYSTEM .1 mg/d PatchClonidine4Non-Preferred Drug25%25%None
CLONIDINE TRANSDERMAL SYSTEM .2 mg/d PatchClonidine4Non-Preferred Drug25%25%None
CLONIDINE TRANSDERMAL SYSTEM .3 mg/d PatchClonidine4Non-Preferred Drug25%25%None
CLOPIDOGREL 75 mg Tablet, Film CoatedClopidogrel Bisulfate1Preferred Generic25%25%None
CLORAZEPATE DIPOTASSIUM 15 mg Tablet2Generic25%25%
  • PA
  • QL 186 per 31 days
CLORAZEPATE DIPOTASSIUM 3.75 mg Tablet2Generic25%25%
  • PA
  • QL 93 per 31 days
CLORAZEPATE DIPOTASSIUM 7.5 mg Tablet2Generic25%25%
  • PA
  • QL 93 per 31 days
CLOTRIMAZOLE 10 mg Lozenge2Generic25%25%None
CLOTRIMAZOLE 10 mg/g Cream2Generic25%25%
  • QL 45 per 28 days
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/g Cream2Generic25%25%
  • QL 45 per 28 days
CLOTRIMAZOLE AND BETAMETHASONE DIPROPIONATE 10/.5 mg/mL Lotion2Generic25%25%
  • QL 6 per 28 days
CLOTRIMAZOLE TOPICAL SOLUTION USP, 1% 10 mg/mL Solution2Generic25%25%
  • QL 3 per 28 days
CLOZAPINE 100 mg Tablet2Generic25%25%
  • QL 279 per 31 days
CLOZAPINE 100 mg Tablet, Orally Disintegrating2Generic25%25%
  • QL 279 per 31 days
CLOZAPINE 12.5 mg Tablet, Orally Disintegrating2Generic25%25%
  • QL 93 per 31 days
CLOZAPINE 150 mg Tablet, Orally Disintegrating4Non-Preferred Drug25%25%
  • QL 186 per 31 days
CLOZAPINE 200 mg Tablet2Generic25%25%
  • QL 124 per 31 days
CLOZAPINE 200 mg Tablet, Orally Disintegrating4Non-Preferred Drug25%25%
  • QL 124 per 31 days
CLOZAPINE 25 mg Tablet2Generic25%25%
  • QL 279 per 31 days
CLOZAPINE 25 mg Tablet, Orally Disintegrating2Generic25%25%
  • QL 279 per 31 days
CLOZAPINE 50 mg Tablet2Generic25%25%
  • QL 93 per 31 days
COARTEM 20/120 mg TabletArtemether And Lumefantrine4Non-Preferred Drug25%25%None
COBENFY 100/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
COBENFY 125/30 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
COBENFY 50/20 mg Capsule, Coated PelletsXanomeline And Trospium Chloride5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
COBENFY KitXanomeline And Trospium Chloride5Specialty Tier25%25%
  • PA
  • QL 112 per 365 days
COLCHICINE .6 mg Tablet, Film Coated2Generic25%25%
  • QL 62 per 31 days
COLESEVELAM HCL 625 mg Tablet, Film Coated4Non-Preferred Drug25%25%None
COLESEVELAM HYDROCHLORIDE 3.75 g Powder, For Suspension4Non-Preferred Drug25%25%None
COLESTIPOL HYDROCHLORIDE 1 g Tablet, Film Coated2Generic25%25%None
COLESTIPOL HYDROCHLORIDE 5 g/5g Granule, For Suspension2Generic25%25%None
COLISTIMETHATE 150 mg Injection, Powder, For SolutionColistimethate Sodium4Non-Preferred Drug25%25%None
COMBIGAN 2/5 mg/mL Solution/ DropsBrimonidine Tartrate, Timolol Maleate3Preferred Brand25%25%None
COMBIVENT RESPIMAT 20/100 ug Spray, MeteredIpratropium Bromide And Albuterol3Preferred Brand25%25%
  • QL 4 per 30 days
COMETRIQ 20 mg CapsuleCabozantinib5Specialty Tier25%25%
  • PA
  • QL 84 per 28 days
COMETRIQ KitCabozantinib5Specialty Tier25%25%
  • PA
  • QL 112 per 28 days
COMETRIQ KitCabozantinib5Specialty Tier25%25%
  • PA
  • QL 56 per 28 days
COMPRO 25 mg SuppositoryProchlorperazine3Preferred Brand25%25%None
CONSTULOSE 10 g/15mL SolutionLactulose2Generic25%25%None
COPAXONE 20 mg/mL Injection, SolutionGlatiramer Acetate5Specialty Tier25%25%
  • PA
  • QL 31 per 31 days
COPAXONE 40 mg/mL Injection, SolutionGlatiramer Acetate5Specialty Tier25%25%
  • PA
  • QL 12 per 28 days
COPIKTRA 15 mg CapsuleDuvelisib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
COPIKTRA 25 mg CapsuleDuvelisib5Specialty Tier25%25%
  • PA
  • QL 62 per 31 days
COSENTYX 150 mg/mL InjectionSecukinumab5Specialty Tier25%25%
  • PA
  • QL 2 per 28 days
COSENTYX 150 mg/mL InjectionSecukinumab5Specialty Tier25%25%
  • PA
  • QL 2 per 28 days
COSENTYX 300 mg/2mL InjectionSecukinumab5Specialty Tier25%25%
  • PA
  • QL 2 per 28 days
COSENTYX 75 mg/.5mL InjectionSecukinumab5Specialty Tier25%25%
  • PA
  • QL 0.5 per 28 days
COTELLIC 20 mg Tablet, Film CoatedCobimetinib5Specialty Tier25%25%
  • PA
  • QL 63 per 28 days
CREON 15000/3000/9500 [USP'U] Capsule, Delayed ReleasePancrelipase3Preferred Brand25%25%None
CREON 24000/76000/120000 [USP'U] Capsule, Delayed Release PelletsPancrelipase3Preferred Brand25%25%None
CREON 30000/6000/19000 [USP'U] Capsule, Delayed Release PelletsPancrelipase3Preferred Brand25%25%None
CREON 36000/180000/114000 [USP'U] Capsule, Delayed Release PelletsPancrelipase3Preferred Brand25%25%None
CREON 60000/12000/38000 [USP'U] Capsule, Delayed Release PelletsPancrelipase3Preferred Brand25%25%None
CRESEMBA 100 mg CapsuleIsavuconazonium Sulfate5Specialty Tier25%25%None
CRESEMBA 40 mg CapsuleIsavuconazonium Sulfate5Specialty Tier25%25%None
CROMOLYN SODIUM 100 mg/5mL Solution, Concentrate4Non-Preferred Drug25%25%None
CROMOLYN SODIUM 20 mg/2mL Solution4Non-Preferred Drug25%25%
  • PA
CROMOLYN SODIUM 40 mg/mL Solution/ Drops2Generic25%25%None
CRYSELLE KitNorgestrel And Ethinyl Estradiol2Generic25%25%None
CYCLOBENZAPRINE HYDROCHLORIDE 10 mg Tablet, Film Coated2Generic25%25%
  • QL 93 per 31 days
CYCLOBENZAPRINE HYDROCHLORIDE 5 mg Tablet, Film Coated2Generic25%25%
  • QL 155 per 31 days
CYCLOBENZAPRINE HYDROCHLORIDE 7.5 mg Tablet, Film Coated2Generic25%25%
  • QL 93 per 31 days
CYCLOPHOSPHAMIDE 25 mg Capsule3Preferred Brand25%25%
  • PA
CYCLOPHOSPHAMIDE 50 mg Capsule3Preferred Brand25%25%
  • PA
CYCLOPHOSPHAMIDE 50 mg Tablet3Preferred Brand25%25%
  • PA
CYCLOSERINE 250 mg Capsule4Non-Preferred Drug25%25%None
CYCLOSPORINE .5 mg/mL Emulsion3Preferred Brand25%25%
  • QL 6 per 30 days
CYCLOSPORINE 100 mg Capsule, Gelatin Coated2Generic25%25%
  • PA
CYCLOSPORINE 100 mg/mL Solution5Specialty Tier25%25%
  • PA
CYCLOSPORINE 25 mg Capsule, Gelatin Coated2Generic25%25%
  • PA
CYCLOSPORINE MODIFIED 100 mg Capsule, Liquid FilledCyclosporine2Generic25%25%
  • PA
CYCLOSPORINE MODIFIED 50 mg Capsule, Liquid FilledCyclosporine2Generic25%25%
  • PA
CYCLOSPORINE, MODFIED 25 mg Capsule, Liquid FilledCyclosporine2Generic25%25%
  • PA
CYPROHEPTADINE HYDROCHLORIDE 2 mg/5mL Syrup2Generic25%25%
  • PA
CYPROHEPTADINE HYDROCHLORIDE 4 mg Tablet2Generic25%25%
  • PA
CYRED EQ KitDesogestrel And Ethinyl Estradiol2Generic25%25%None
CYSTADROPS 3.5 mg/mL SolutionCysteamine Hydrochloride5Specialty Tier25%25%
  • PA
  • QL 2 per 28 days
CYSTAGON 150 mg CapsuleCysteamine Bitartrate3Preferred Brand25%25%None
CYSTAGON 50 mg CapsuleCysteamine Bitartrate3Preferred Brand25%25%None
CYSTARAN 6.5 mg/mL SolutionCysteamine Hydrochloride5Specialty Tier25%25%
  • PA
  • QL 6 per 28 days

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.