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

Contract S5593, plan 003 · West Virginia · 3,788 drugs on file · formulary ID 00026017. Each drug links to its cost in every CMS PDP Region 06 plan.

283 drugs starting with P.

Drug name	Tier	30-day preferred pharmacy	90-day mail order	Usage management
PACERONE 100 mg TabletAmiodarone Hydrochloride	2Generic	$5.00	$12.50	None
PACERONE 200 mg TabletAmiodarone Hydrochloride	2Generic	$5.00	$12.50	None
PACERONE 400 mg TabletAmiodarone Hydrochloride	2Generic	$5.00	$12.50	None
PALIPERIDONE 1.5 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
PALIPERIDONE 3 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
PALIPERIDONE 6 mg Tablet, Extended Release	4Non-Preferred Drug	25%	25%	QL 62 per 31 days
PALIPERIDONE 9 mg Tablet, Film Coated, Extended Release	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
PALYNZIQ 10 mg/.5mL Injection, SolutionPegvaliase-Pqpz	5Specialty Tier	25%	N/A	PA QL 15 per 30 days
PALYNZIQ 2.5 mg/.5mL Injection, SolutionPegvaliase-Pqpz	5Specialty Tier	25%	N/A	PA QL 4 per 30 days
PALYNZIQ 20 mg/mL Injection, SolutionPegvaliase-Pqpz	5Specialty Tier	25%	N/A	PA QL 9 per 30 days
PANRETIN 60 mg/60g GelAlitretinoin	5Specialty Tier	25%	N/A	PA
PANTOPRAZOLE SODIUM 20 mg Tablet, Delayed Release	1Preferred Generic	$0.00	$0.00	None
PANTOPRAZOLE SODIUM 40 mg Tablet, Delayed ReleasePantoprazole	1Preferred Generic	$0.00	$0.00	None
PARICALCITOL 1 ug Capsule, Liquid Filled	2Generic	$5.00	$12.50	PA
PARICALCITOL 2 ug Capsule, Liquid Filled	2Generic	$5.00	$12.50	PA
PARICALCITOL 4 ug Capsule, Liquid Filled	2Generic	$5.00	$12.50	PA
PAROXETINE 10 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	PA
PAROXETINE 10 mg/5mL Suspension	4Non-Preferred Drug	25%	25%	PA
PAROXETINE 20 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	PA
PAROXETINE 30 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	PA
PAROXETINE 40 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	PA
PAROXETINE HYDROCHLORIDE 12.5 mg Tablet, Film Coated, Extended Release	3Preferred Brand	25%	25%	PA
PAROXETINE HYDROCHLORIDE 25 mg Tablet, Film Coated, Extended Release	3Preferred Brand	25%	25%	PA
PAROXETINE HYDROCHLORIDE 37.5 mg Tablet, Film Coated, Extended Release	3Preferred Brand	25%	25%	PA
PAXLOVID KitNirmatrelvir And Ritonavir	3Preferred Brand	25%	25%	QL 27 per 365 days
PAXLOVID KitNirmatrelvir And Ritonavir	3Preferred Brand	25%	25%	QL 18 per 365 days
PAXLOVID KitNirmatrelvir And Ritonavir	3Preferred Brand	25%	25%	QL 99 per 365 days
PAZOPANIB 200 mg Tablet	5Specialty Tier	25%	N/A	PA QL 124 per 31 days
PEDIARIX 25/10/25/25/8/10/40/8/32 [iU]/.5mL/ug/.5mL Injection, SuspensionDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) And Inactivated Poliovirus Vaccine Combined	3Preferred Brand	25%	25%	None
PEDVAXHIB 7.5 ug/.5mL Injection, SuspensionHaemophilus B Conjugate Vaccine (Meningococcal Protein Conjugate)	3Preferred Brand	25%	25%	None
PEG-3350 AND ELECTROLYTES 236/22.74/6.74/5.86/2.97 g/4L Powder, For SolutionPolyethylene Glycol 3350, Sodium Sulfate Anhydrous, Sodium Bicarbonate, Sodium Chloride, Potassium Chloride	1Preferred Generic	$0.00	$0.00	None
PEG-3350, ELECTROLYTES, AND ASCORBATE KitPolyethylene Glycol 3350, Sodium Sulfate, Sodium Chloride, Potassium Chloride, Sodium Ascorbate, And Ascorbic Acid	4Non-Preferred Drug	25%	25%	None
PEGASYS 180 ug/.5mL Injection, SolutionPeginterferon Alfa-2A	5Specialty Tier	25%	N/A	PA
PEGASYS 180 ug/mL Injection, SolutionPeginterferon Alfa-2A	5Specialty Tier	25%	N/A	PA
PEMAZYRE 13.5 mg TabletPemigatinib	5Specialty Tier	25%	N/A	PA QL 14 per 21 days
PEMAZYRE 4.5 mg TabletPemigatinib	5Specialty Tier	25%	N/A	PA QL 14 per 21 days
PEMAZYRE 9 mg TabletPemigatinib	5Specialty Tier	25%	N/A	PA QL 14 per 21 days
PENBRAYA KitMeningococcal Groups A, B, C, W, And Y Vaccine	3Preferred Brand	25%	25%	None
PENCICLOVIR 10 mg/g Cream	3Preferred Brand	25%	25%	QL 5 per 28 days
PENICILLAMINE 250 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	None
PENICILLIN G POTASSIUM 2000000 [iU]/50mL Injection, SolutionPenicillin G	4Non-Preferred Drug	25%	25%	None
PENICILLIN G POTASSIUM 20000000 [iU] Injection, Powder, For Solution	2Generic	$5.00	$12.50	None
PENICILLIN G POTASSIUM 3000000 [iU]/50mL Injection, SolutionPenicillin G	4Non-Preferred Drug	25%	25%	None
PENICILLIN G SODIUM 5000000 [USP'U] Injection, Powder, For Solution	5Specialty Tier	25%	N/A	None
PENICILLIN V POTASSIUM 125 mg/5mL Powder, For Solution	1Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM 250 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM 250 mg/5mL Powder, For Solution	1Preferred Generic	$0.00	$0.00	None
PENICILLIN V POTASSIUM 500 mg Tablet, Film Coated	1Preferred Generic	$0.00	$0.00	None
PENMENVY KitMeningococcal (Groups A, B, C, W And Y)	3Preferred Brand	25%	25%	None
PENTACEL KitDiphtheria And Tetanus Toxoids And Acellular Pertussis Adsorbed, Inactivated Poliovirus And Haemophilus B Conjugate (Tetanus Toxoid Conjugate) Vaccine	3Preferred Brand	25%	25%	None
PENTAMIDINE ISETHIONATE 300 mg/300mg Inhalant	4Non-Preferred Drug	25%	25%	PA
PENTAMIDINE ISETHIONATE 300 mg/300mg Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	25%	25%	None
PENTOXIFYLLINE 400 mg Tablet, Extended Release	2Generic	$5.00	$12.50	None
PERAMPANEL .5 mg/mL Suspension	5Specialty Tier	25%	N/A	QL 744 per 31 days
PERAMPANEL 10 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 31 per 31 days
PERAMPANEL 12 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 31 per 31 days
PERAMPANEL 2 mg Tablet, Film Coated	4Non-Preferred Drug	25%	25%	QL 31 per 31 days
PERAMPANEL 4 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 31 per 31 days
PERAMPANEL 6 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 31 per 31 days
PERAMPANEL 8 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	QL 31 per 31 days
PERINDOPRIL ERBUMINE 2 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PERINDOPRIL ERBUMINE 4 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PERINDOPRIL ERBUMINE 8 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PERIOGARD ALCOHOL FREE 1.2 mg/mL RinseChlorhexidine Gluconate	1Preferred Generic	$0.00	$0.00	None
PERMETHRIN 50 mg/g CreamPermethrin Cream 5% W/W	2Generic	$5.00	$12.50	None
PERPHENAZINE 16 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PERPHENAZINE 2 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PERPHENAZINE 4 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PERPHENAZINE 8 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 2/10 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 2/25 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/10 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/25 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
PERPHENAZINE AND AMITRIPTYLINE HYDROCHLORIDE 4/50 mg Tablet, Film Coated	2Generic	$5.00	$12.50	PA
PHEBURANE KitSodium Phenylbutyrate	5Specialty Tier	25%	N/A	PA QL 62 per 31 days
PHENELZINE SULFATE 15 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PHENOBARBITAL 100 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 15 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 16.2 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 30 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 32.4 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 60 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 64.8 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL 97.2 mg Tablet	2Generic	$5.00	$12.50	PA
PHENOBARBITAL ORAL SOLUTION 20 mg/5mL SolutionPhenobarbital Oral	2Generic	$5.00	$12.50	PA
PHENYTEK 200 mg Capsule, Extended ReleaseExtended Phenytoin Sodium	3Preferred Brand	25%	25%	None
PHENYTEK 300 mg Capsule, Extended ReleasePhenytoin Sodium	3Preferred Brand	25%	25%	None
PHENYTOIN 125 mg/5mL Suspension	2Generic	$5.00	$12.50	None
PHENYTOIN 50 mg Tablet, Chewable	2Generic	$5.00	$12.50	None
PHENYTOIN SODIUM 100 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PIFELTRO 100 mg Tablet, Film CoatedDoravirine	5Specialty Tier	25%	N/A	QL 62 per 31 days
PILOCARPINE HYDROCHLORIDE 10 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution	2Generic	$5.00	$12.50	None
PILOCARPINE HYDROCHLORIDE 20 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution	2Generic	$5.00	$12.50	None
PILOCARPINE HYDROCHLORIDE 40 mg/mL Solution/ DropsPilocarpine Hydrochloride Ophthalmic Solution	2Generic	$5.00	$12.50	None
PILOCARPINE HYDROCHLORIDE 5 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PILOCARPINE HYDROCHLORIDE 7.5 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PIMECROLIMUS 10 mg/g Cream	3Preferred Brand	25%	25%	QL 1 per 28 days
PIMOZIDE 1 mg Tablet	4Non-Preferred Drug	25%	25%	None
PIMOZIDE 2 mg Tablet	4Non-Preferred Drug	25%	25%	None
PIMTREA KitDesogestrel/Ethinyl Estradiol And Ethinyl Estradiol	2Generic	$5.00	$12.50	None
PINDOLOL 10 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PINDOLOL 5 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PIOGLITAZONE 15 mg Tablet	1Preferred Generic	$0.00	$0.00	QL 31 per 31 days
PIOGLITAZONE 30 mg Tablet	1Preferred Generic	$0.00	$0.00	QL 31 per 31 days
PIOGLITAZONE 45 mg Tablet	1Preferred Generic	$0.00	$0.00	QL 31 per 31 days
PIOGLITAZONE HYDROCHLORIDE AND METFORMIN HYDROCHLORIDE 15/500 mg Tablet, Film Coated	2Generic	$5.00	$12.50	QL 93 per 31 days
PIOGLITAZONE HYDROCHLORIDE AND METFORMIN HYDROCHLORIDE 15/850 mg Tablet, Film Coated	2Generic	$5.00	$12.50	QL 93 per 31 days
PIPERACILLIN AND TAZOBACTAM 2/.25 g/10mL Injection, Powder, For Solution	4Non-Preferred Drug	25%	25%	None
PIPERACILLIN AND TAZOBACTAM 3/.375 g/15mL Injection, Powder, For Solution	4Non-Preferred Drug	25%	25%	None
PIPERACILLIN AND TAZOBACTAM 4.5/36 g/180mL Injection, Powder, Lyophilized, For Solution	4Non-Preferred Drug	25%	25%	None
PIPERACILLIN AND TAZOBACTAM 4/.5 g/20mL Injection, Powder, For Solution	4Non-Preferred Drug	25%	25%	None
PIQRAY 150 mg TabletAlpelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
PIQRAY 200 mg TabletAlpelisib	5Specialty Tier	25%	N/A	PA QL 28 per 28 days
PIQRAY KitAlpelisib	5Specialty Tier	25%	N/A	PA QL 56 per 28 days
PIRFENIDONE 267 mg Capsule	5Specialty Tier	25%	N/A	PA QL 279 per 31 days
PIRFENIDONE 267 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	PA QL 93 per 31 days
PIRFENIDONE 534 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	PA QL 93 per 31 days
PIRFENIDONE 801 mg Tablet, Film Coated	5Specialty Tier	25%	N/A	PA QL 93 per 31 days
PIROXICAM 10 mg Capsule	2Generic	$5.00	$12.50	None
PIROXICAM 20 mg Capsule	2Generic	$5.00	$12.50	None
PITAVASTATIN 1 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PITAVASTATIN 2 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PITAVASTATIN 4 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PLEGRIDY 125 ug/.5mL Injection, SolutionPeginterferon Beta-1A	5Specialty Tier	25%	N/A	PA QL 1 per 28 days
PLEGRIDY PEN 125 ug/.5mL Injection, SolutionPeginterferon Beta-1A	5Specialty Tier	25%	N/A	PA QL 1 per 28 days
PLENAMINE 1.18/1.04/1.04/960/749/749/749/250/2.17/1.47/1.04/894/894/749/592/434/39 g/100mL/mg/100mL SolutionLysine Acetate, Leucine, Phenylalanine, Valine, Isoleucine, Methionine, Threonine, Tryptophan, Alanine, Arginine, Glycine, Histidine, Proline, Glutamic Acid, Serine, Aspartic Acid, And Tyrosine	3Preferred Brand	25%	25%	PA
PODOFILOX 5 mg/mL Solution	2Generic	$5.00	$12.50	None
POLYETHYLENE GLYCOL 3350, SODIUM CHLORIDE, SODIUM BICARBONATE AND POTASSIUM CHLORIDE WITH LEMON FLAVOR 420/11.2/5.72/1.48 g/4L Powder, For Solution	1Preferred Generic	$0.00	$0.00	None
POLYMYXIN B 500000 [USP'U] Injection, Powder, For SolutionPolymyxin B Sulfate	2Generic	$5.00	$12.50	None
POLYMYXIN B SULFATE AND TRIMETHOPRIM 10000/1 [USP'U]/mL/mg/mL Solution	1Preferred Generic	$0.00	$0.00	None
POMALIDOMIDE 1 mg Capsule	5Specialty Tier	25%	N/A	PA QL 21 per 28 days
POMALIDOMIDE 2 mg Capsule	5Specialty Tier	25%	N/A	PA QL 21 per 28 days
POMALIDOMIDE 3 mg Capsule	5Specialty Tier	25%	N/A	PA QL 21 per 28 days
POMALIDOMIDE 4 mg Capsule	5Specialty Tier	25%	N/A	PA QL 21 per 28 days
PORTIA KitLevonorgestrel And Ethinyl Estradiol	2Generic	$5.00	$12.50	None
POSACONAZOLE 100 mg Tablet, Delayed Release	5Specialty Tier	25%	N/A	PA
POTASSIUM CHLORIDE 1.5 g/15mL Solution	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 10 meq Tablet, Film Coated, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 1125 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 14.9 g/1000mL Injection, Solution	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 149 mg/mL Injection, Solution, Concentrate	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 150/5 mg/100mL/g/100mL Injection, SolutionPotassium Chloride, Dextrose Monohydrate	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 1500 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 1500 mg Tablet, Film Coated, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 2 meq/mL Injection, Solution, Concentrate	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 29.8 g/1000mL Injection, Solution	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 3 g/15mL Solution	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 600 mg Capsule, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 600 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 7.46 g/1000mL Injection, Solution	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE 750 mg Capsule, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE 750 mg Tablet, Extended Release	1Preferred Generic	$0.00	$0.00	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 150/5/200 mg/100mL/g/100mL Injection, SolutionPotassium Chloride, Dextrose Monohydrate And Sodium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/.745 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/1.49 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/2.24 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/4.5/2.98 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/9/1.49 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE 50/9/2.98 g/1000mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN LACTATED RINGERS AND DEXTROSE 5/600/310/179/20 g/100mL/mg/100mL Injection, SolutionDextrose Monohydrate, Sodium Chloride, Sodium Lactate, Potassium Chloride, Calcium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 450/150 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 900/150 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CHLORIDE IN SODIUM CHLORIDE 900/300 mg/100mL Injection, SolutionSodium Chloride And Potassium Chloride	2Generic	$5.00	$12.50	None
POTASSIUM CITRATE 10 meq Tablet, Extended Release	2Generic	$5.00	$12.50	None
POTASSIUM CITRATE 5 meq Tablet, Extended Release	2Generic	$5.00	$12.50	None
POTASSIUM CITRATE EXTENDED RELEASE 15 meq TabletPotassium Citrate	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE .125 mg Tablet	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE .25 mg Tablet	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE .5 mg Tablet	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE .75 mg Tablet	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE 1 mg Tablet	2Generic	$5.00	$12.50	None
PRAMIPEXOLE DIHYDROCHLORIDE 1.5 mg Tablet	2Generic	$5.00	$12.50	None
PRASUGREL 10 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PRASUGREL 5 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PRAVASTATIN SODIUM 10 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM 20 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM 40 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PRAVASTATIN SODIUM 80 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PRAZIQUANTEL 600 mg Tablet, Film Coated	4Non-Preferred Drug	25%	25%	None
PRAZOSIN HYDROCHLORIDE 1 mg Capsule	1Preferred Generic	$0.00	$0.00	None
PRAZOSIN HYDROCHLORIDE 2 mg Capsule	1Preferred Generic	$0.00	$0.00	None
PRAZOSIN HYDROCHLORIDE 5 mg Capsule	1Preferred Generic	$0.00	$0.00	None
PREDNISOLONE 15 mg/5mL SolutionPrednisolone Oral	2Generic	$5.00	$12.50	None
PREDNISOLONE ACETATE 10 mg/mL Suspension/ Drops	2Generic	$5.00	$12.50	None
PREDNISOLONE SODIUM PHOSPHATE 10 mg/5mL Solution	2Generic	$5.00	$12.50	None
PREDNISOLONE SODIUM PHOSPHATE 10 mg/mL Solution/ Drops	2Generic	$5.00	$12.50	None
PREDNISOLONE SODIUM PHOSPHATE 20 mg/5mL Solution	2Generic	$5.00	$12.50	None
PREDNISOLONE SODIUM PHOSPHATE 5 mg/5mL Solution	2Generic	$5.00	$12.50	None
PREDNISOLONE SODIUM PHOSPHATE ORAL SOLUTION 25 mg/5mL SolutionPrednisolone Sodium Phosphate	2Generic	$5.00	$12.50	None
PREDNISONE 1 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREDNISONE 10 mg Tablet	2Generic	$5.00	$12.50	None
PREDNISONE 10 mg Tablet	2Generic	$5.00	$12.50	None
PREDNISONE 10 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREDNISONE 2.5 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREDNISONE 20 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREDNISONE 5 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREDNISONE 5 mg Tablet	2Generic	$5.00	$12.50	None
PREDNISONE 5 mg Tablet	2Generic	$5.00	$12.50	None
PREDNISONE 5 mg/5mL Solution	2Generic	$5.00	$12.50	None
PREDNISONE 50 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PREGABALIN 100 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 150 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 20 mg/mL Solution	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 200 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 225 mg Capsule	2Generic	$5.00	$12.50	PA QL 62 per 31 days
PREGABALIN 25 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 300 mg Capsule	2Generic	$5.00	$12.50	PA QL 62 per 31 days
PREGABALIN 50 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREGABALIN 75 mg Capsule	2Generic	$5.00	$12.50	PA QL 93 per 31 days
PREMARIN VAGINAL .625 mg/g CreamConjugated Estrogens	3Preferred Brand	25%	25%	None
PREVALITE 4 g/5.5g Powder, For SuspensionCholestyramine	2Generic	$5.00	$12.50	None
PREVYMIS 120 mg PelletLetermovir	5Specialty Tier	25%	N/A	PA QL 124 per 31 days
PREVYMIS 20 mg PelletLetermovir	5Specialty Tier	25%	N/A	PA QL 124 per 31 days
PREVYMIS 240 mg Tablet, Film CoatedLetermovir	5Specialty Tier	25%	N/A	QL 31 per 31 days
PREVYMIS 480 mg Tablet, Film CoatedLetermovir	5Specialty Tier	25%	N/A	QL 31 per 31 days
PREZCOBIX 675/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat	5Specialty Tier	25%	N/A	None
PREZCOBIX 800/150 mg Tablet, Film CoatedDarunavir Ethanolate And Cobicistat	5Specialty Tier	25%	N/A	None
PREZISTA 100 mg/mL SuspensionDarunavir	5Specialty Tier	25%	N/A	None
PREZISTA 150 mg Tablet, Film CoatedDarunavir	5Specialty Tier	25%	N/A	None
PREZISTA 75 mg Tablet, Film CoatedDarunavir	4Non-Preferred Drug	25%	25%	None
PRIFTIN 150 mg Tablet, Film CoatedRifapentine	3Preferred Brand	25%	25%	None
PRIMAQUINE PHOSPHATE 15 mg Tablet, Film Coated	3Preferred Brand	25%	25%	None
PRIMIDONE 125 mg Tablet	3Preferred Brand	25%	25%	None
PRIMIDONE 250 mg Tablet	2Generic	$5.00	$12.50	None
PRIMIDONE 50 mg Tablet	2Generic	$5.00	$12.50	None
PRIORIX KitMeasels, Mumps, And Rubella Vaccine, Live	3Preferred Brand	25%	25%	None
PRIVIGEN 20 g/200mL LiquidHuman Immunoglobulin G	5Specialty Tier	25%	N/A	PA
PROBENECID 500 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PROBENECID AND COLCHICINE 500/.5 mg Tablet	2Generic	$5.00	$12.50	None
PROCHLORPERAZINE 25 mg Suppository	3Preferred Brand	25%	25%	None
PROCHLORPERAZINE MALEATE 10 mg Tablet	2Generic	$5.00	$12.50	None
PROCHLORPERAZINE MALEATE 5 mg Tablet	2Generic	$5.00	$12.50	None
PROCRIT 10000 [iU]/mL Injection, SolutionErythropoietin	3Preferred Brand	25%	25%	PA
PROCRIT 2000 [iU]/mL Injection, SolutionErythropoietin	3Preferred Brand	25%	25%	PA
PROCRIT 20000 [iU]/mL Injection, SolutionErythropoietin	5Specialty Tier	25%	N/A	PA
PROCRIT 3000 [iU]/mL Injection, SolutionErythropoietin	3Preferred Brand	25%	25%	PA
PROCRIT 4000 [iU]/mL Injection, SolutionErythropoietin	3Preferred Brand	25%	25%	PA
PROCRIT 40000 [iU]/mL Injection, SolutionErythropoietin	5Specialty Tier	25%	N/A	PA
PROCTO-MED HC 25 mg/g CreamHydrocortisone	2Generic	$5.00	$12.50	None
PROCTOSOL-HC 25 mg/g CreamHydrocortisone	2Generic	$5.00	$12.50	None
PROCTOZONE-HC 25 mg/g CreamHydrocortisone 2.5%	2Generic	$5.00	$12.50	None
PROCYSBI 300 mg Granule, Delayed ReleaseCysteamine Bitartrate	5Specialty Tier	25%	N/A	PA
PROCYSBI 75 mg Granule, Delayed ReleaseCysteamine Bitartrate	5Specialty Tier	25%	N/A	PA
PROGESTERONE 100 mg Capsule	3Preferred Brand	25%	25%	None
PROGESTERONE 200 mg Capsule	3Preferred Brand	25%	25%	None
PROGRAF .2 mg Granule, For SuspensionTacrolimus	4Non-Preferred Drug	25%	25%	PA
PROGRAF 1 mg Granule, For SuspensionTacrolimus	4Non-Preferred Drug	25%	25%	PA
PROLASTIN-C LIQUID 1000 mg/20mL Injection, SolutionAlpha1-Proteinase Inhibitor (Human)	5Specialty Tier	25%	N/A	PA
PROLIA 60 mg/mL InjectionDenosumab	4Non-Preferred Drug	25%	25%	PA QL 1 per 180 days
PROMETHAZINE HYDROCHLORIDE 12.5 mg Suppository	2Generic	$5.00	$12.50	None
PROMETHAZINE HYDROCHLORIDE 12.5 mg Tablet	4Non-Preferred Drug	25%	25%	PA
PROMETHAZINE HYDROCHLORIDE 25 mg Suppository	2Generic	$5.00	$12.50	None
PROMETHAZINE HYDROCHLORIDE 25 mg Tablet	4Non-Preferred Drug	25%	25%	PA
PROMETHAZINE HYDROCHLORIDE 50 mg Tablet	4Non-Preferred Drug	25%	25%	PA
PROMETHAZINE HYDROCHLORIDE 6.25 mg/5mL Syrup	2Generic	$5.00	$12.50	PA
PROPAFENONE HYDROCHLORIDE 150 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PROPAFENONE HYDROCHLORIDE 225 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPAFENONE HYDROCHLORIDE 225 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PROPAFENONE HYDROCHLORIDE 300 mg Tablet, Film Coated	2Generic	$5.00	$12.50	None
PROPAFENONE HYDROCHLORIDE 325 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPAFENONE HYDROCHLORIDE 425 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPRANOLOL HYDROCHLORIDE 10 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HYDROCHLORIDE 120 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPRANOLOL HYDROCHLORIDE 160 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPRANOLOL HYDROCHLORIDE 20 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HYDROCHLORIDE 20 mg/5mL Solution	1Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HYDROCHLORIDE 40 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HYDROCHLORIDE 40 mg/5mL Solution	1Preferred Generic	$0.00	$0.00	None
PROPRANOLOL HYDROCHLORIDE 60 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPRANOLOL HYDROCHLORIDE 80 mg Capsule, Extended Release	2Generic	$5.00	$12.50	None
PROPRANOLOL HYDROCHLORIDE 80 mg Tablet	1Preferred Generic	$0.00	$0.00	None
PROPYLTHIOURACIL 50 mg Tablet	2Generic	$5.00	$12.50	None
PROQUAD 1000/20000/1000/9772 [TCID_50]/.5mL/[PFU]/.5mL Injection, Powder, Lyophilized, For SuspensionMeasles, Mumps, Rubella And Varicella Virus Vaccine Live	3Preferred Brand	25%	25%	None
PROSOL 1.44/1.35/1.18/1.08/1.08/1/980/760/320/2.76/2.06/1.96/1.34/1.02/1.02/600/50 g/100mL/mg/100mL Injection, SolutionValine, Lysine, Histidine, Isoleucine, Leucine, Phenylalanine, Threonine, Methionine, Tryptophan, Alanine, Glycine, Arginine, Proline, Glutamic Acid, Serine, Aspartic Acid And Tyrosine	4Non-Preferred Drug	25%	25%	PA
PROTRIPTYLINE HYDROCHLORIDE 10 mg Tablet, Film Coated	4Non-Preferred Drug	25%	25%	None
PROTRIPTYLINE HYDROCHLORIDE 5 mg Tablet, Film Coated	4Non-Preferred Drug	25%	25%	None
PULMOZYME 1 mg/mL SolutionDornase Alfa	5Specialty Tier	25%	N/A	PA
PYRAZINAMIDE 500 mg Tablet	4Non-Preferred Drug	25%	25%	None
PYRIDOSTIGMINE BROMIDE 180 mg Tablet, Extended Release	2Generic	$5.00	$12.50	None
PYRIDOSTIGMINE BROMIDE 30 mg Tablet	3Preferred Brand	25%	25%	None
PYRIDOSTIGMINE BROMIDE 60 mg Tablet	2Generic	$5.00	$12.50	None
PYRIDOSTIGMINE BROMIDE 60 mg/5mL Solution	5Specialty Tier	25%	N/A	None
PYRIMETHAMINE 25 mg Tablet	5Specialty Tier	25%	N/A	PA

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.