Alphabetical Listing. This list is subject to change. For an up-to-date listing please visit Pg. 2

Transcription

1 898/7

2

3 A abacavir oral tablet 00 mg abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg ABREVA TOPICAL CREAM 0 % acarbose oral tablet 00 mg, 5 mg, 50 mg acebutolol oral capsule 00 mg, 00 mg acetaminophen-codeine oral solution 0- mg/5 ml acetaminophen-codeine oral tablet 00-5 mg, 00-0 mg, mg acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 5 mg, 50 mg acetic acid otic (ear) solution % acetylcysteine solution 00 mg/ml (0 %), 00 mg/ml (0 %) acitretin oral capsule 0 mg, 7.5 mg, 5 mg ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML (PA) Acyclovir caps, inj, susp, tabs acyclovir oral capsule 00 mg acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet 00 mg, 800 mg acyclovir topical ointment 5 % (QL) adapalene topical cream 0. % adapalene topical gel 0. %, 0. % adapalene topical gel with pump 0. % ADCIRCA ORAL TABLET 0 MG (ST, QL) adefovir oral tablet 0 mg (PA) ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, MG,.5 MG (PA, QL) afeditab cr oral tablet extended release 0 mg, 60 mg AFINITOR ORAL TABLET 0 MG,.5 MG, 7.5 MG (PA, QL) AFINITOR ORAL TABLET 5 MG (PA, QL) AGGRENOX ORAL CAPSULE, ER MULTIPHASE HR 5-00 MG (PA) AGONEAZE TOPICAL KIT.5-.5 % AKYNZEO ORAL CAPSULE MG (PA, QL) albuterol sulfate inhalation solution for nebulization 0.6 mg/ ml,.5 mg/ ml,.5 mg / ml (0.08 %),.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup mg/5 ml albuterol sulfate oral tablet mg, mg alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % alendronate oral tablet 0 mg, 5 mg, 5 mg, 70 mg (QL) alendronate oral tablet 0 mg (QL) alfuzosin oral tablet extended release hr 0 mg ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG allopurinol oral tablet 00 mg, 00 mg almotriptan malate oral tablet.5 mg, 6.5 mg (ST, QL) ALOCRIL OPHTHALMIC (EYE) DROPS % ALOMIDE OPHTHALMIC (EYE) DROPS 0. % alosetron oral tablet 0.5 mg, mg alprazolam oral tablet 0.5 mg, 0.5 mg, mg, mg ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % (ST) ALTABAX TOPICAL OINTMENT % (ST) altavera (8) oral tablet mg alyacen /5 (8) oral tablet -5 mg-mcg alyacen 7/7/7 (8) oral tablet 0.5/0.75/ mg- 5 mcg amantadine hcl oral capsule 00 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 00 mg amcinonide topical cream 0. % (ST) amethia lo oral tablets,dose pack, month 0.0 mg-0 mcg (8)/0 mcg (7) amethia oral tablets,dose pack, month 0.5 mg-0 mcg (8)/0 mcg (7) amethyst oral tablet 90-0 mcg amiloride oral tablet 5 mg amiodarone oral tablet 00 mg AMITIZA ORAL CAPSULE MCG, 8 MCG amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg amlodipine oral tablet 0 mg,.5 mg, 5 mg amlodipine-benazepril oral capsule 0-0 mg, 0-0 mg,.5-0 mg, 5-0 mg, 5-0 mg, 5-0 mg ammonium lactate topical cream % ammonium lactate topical lotion % amnesteem oral capsule 0 mg, 0 mg, 0 mg amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 00 mg/5 ml amoxicillin oral tablet 875 mg amoxicillin oral tablet,chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet 50-5 mg, mg, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 50 mg, 500 mg AMPYRA ORAL TABLET EXTENDED RELEASE HR 0 MG (PA, QL) ANADROL-50 ORAL TABLET 50 MG (PA) anagrelide oral capsule 0.5 mg, mg anastrozole oral tablet mg ANGELIQ ORAL TABLET MG, 0.5- MG ANODYNE LPT TOPICAL KIT.5-.5 % ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION (QL) ANZEMET ORAL TABLET 00 MG, 50 MG (QL) APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (ST) APIDRA SUBCUTANEOUS SOLUTION 00 UNIT/ML (ST) APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML (PA) apraclonidine ophthalmic (eye) drops 0.5 % aprepitant oral capsule 5 mg, 0 mg, 80 mg apri oral tablet mg APTIOM ORAL TABLET 00 MG, 00 MG, 600 MG, 800 MG APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 00 MCG/ML, 0 MCG/ML, 60 MCG/ML (PA, QL) ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0. ML, 00 MCG/0.5 ML, 50 MCG/0. ML, 00 MCG/0. ML, 5 MCG/0. ML, 00 MCG/0.6 ML, 0 MCG/0. ML, 500 MCG/ML, 60 MCG/0. ML (PA, QL) ARCALYST SUBCUTANEOUS RECON SOLN 0 MG (PA) ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG (QL) aripiprazole oral tablet 0 mg, 5 mg, mg, 0 mg, 0 mg, 5 mg (QL) armodafinil oral tablet 50 mg, 00 mg, 50 mg, 50 mg ashlyna oral tablets,dose pack, month 0.5 mg-0 mcg (8)/0 mcg (7) ASMANEX HFA INHALATION HFA AEROSOL INHALER 00 MCG/ACTUATION, 00 MCG/ACTUATION (QL) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (0 DOSES), 0 MCG (7 DOSES), 0 MCG (0 DOSES), 0 MCG ( DOSES), 0 MCG (0 DOSES), 0 MCG (60 DOSES) (QL) aspirin-dipyridamole oral capsule, er multiphase hr 5-00 mg atenolol oral tablet 00 mg, 5 mg, 50 mg Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) This list is subject to change. For an up-to-date listing please visit Pg.

4 atomoxetine oral capsule 0 mg, 00 mg, 8 mg, 5 mg, 0 mg, 60 mg, 80 mg atorvastatin oral tablet 0 mg, 0 mg, 0 mg, 80 mg (QL) atovaquone oral suspension 750 mg/5 ml atovaquone-proguanil oral tablet mg, mg atropine ophthalmic (eye) drops % ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION (QL) AUBAGIO ORAL TABLET MG, 7 MG (PA, QL) aubra oral tablet 0.-0 mg-mcg AVALIDE ORAL TABLET MG AVANDIA ORAL TABLET MG, MG (QL) aviane oral tablet 0.-0 mg-mcg AXERT ORAL TABLET.5 MG (ST, QL) AZASITE OPHTHALMIC (EYE) DROPS % azathioprine oral tablet 50 mg azelastine nasal aerosol,spray 7 mcg (0. %) (QL) azelastine nasal spray,non-aerosol 0.5 % (05.5 mcg) (ST) azelastine ophthalmic (eye) drops 0.05 % azithromycin oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 500 mg, 600 mg AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION % azurette (8) oral tablet mgx /0.0 mg x 5 B bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram baclofen oral tablet 0 mg, 0 mg balsalazide oral capsule 750 mg balziva (8) oral tablet 0.-5 mg-mcg BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 00 MG, 00 MG BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) bekyree (8) oral tablet mgx /0.0 mg x 5 BELSOMRA ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG (ST, QL) BELVIQ ORAL TABLET 0 MG (PA) benazepril oral tablet 0 mg, 0 mg, 0 mg, 5 mg benztropine oral tablet 0.5 mg, mg, mg BEPREVE OPHTHALMIC (EYE) DROPS.5 % (ST) BERINERT INTRAVENOUS KIT 500 UNIT (0 ML) (PA) BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % BETASERON SUBCUTANEOUS KIT 0. MG (PA, QL) betaxolol ophthalmic (eye) drops 0.5 % betaxolol oral tablet 0 mg, 0 mg (ST) bethanechol chloride oral tablet 0 mg, 5 mg, 5 mg, 50 mg bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg BILTRICIDE ORAL TABLET 600 MG bimatoprost ophthalmic (eye) drops 0.0 % bisoprolol fumarate oral tablet 0 mg, 5 mg C bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg blisovi fe oral tablet mg-0 mcg ()/75 mg () blisovi fe.5/0 (8) oral tablet.5 mg-0 mcg ()/75 mg (7) blisovi fe /0 (8) oral tablet mg-0 mcg ()/75 mg (7) BREO ELLIPTA INHALATION BLISTER WITH DEVICE 00-5 MCG/DOSE, 00-5 MCG/DOSE (QL) briellyn oral tablet 0.-5 mg-mcg BRILINTA ORAL TABLET 60 MG, 90 MG brimonidine ophthalmic (eye) drops 0.5 %, 0. % bromfenac ophthalmic (eye) drops 0.09 % bromocriptine oral capsule 5 mg bromocriptine oral tablet.5 mg BROVANA INHALATION SOLUTION FOR NEBULIZATION 5 MCG/ ML (QL) budesonide inhalation suspension for nebulization 0.5 mg/ ml, 0.5 mg/ ml (QL) budesonide oral capsule,delayed,extend.release mg bumetanide oral tablet 0.5 mg, mg, mg BUPHENYL ORAL TABLET 500 MG buprenorphine hcl sublingual tablet mg, 8 mg BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (QL) buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg (QL) bupropion hcl (smoking deter) oral tablet extended release hr 50 mg bupropion hcl oral tablet 00 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release hr 00 mg, 00 mg (QL) bupropion hcl oral tablet extended release hr 50 mg, 00 mg (QL) buspirone oral tablet 0 mg, 5 mg, 5 mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet 50-5 mg butalbital-acetaminophen-caff oral tablet mg butorphanol tartrate nasal spray,non-aerosol 0 mg/ml (QL) BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (QL) BYDUREON SUBCUTANEOUS PEN INJECTOR MG/0.65 ML (QL) BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON MG (QL) BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(50 MCG/ML). ML, 5 MCG/DOSE (50 MCG/ML). ML (QL) BYSTOLIC ORAL TABLET 0 MG,.5 MG, 0 MG, 5 MG (ST) cabergoline oral tablet 0.5 mg (QL) calcipotriene scalp solution % calcipotriene topical cream % calcipotriene topical ointment % calcipotriene-betamethasone topical ointment % calcitonin (salmon) nasal spray,non-aerosol 00 unit/actuation calcitriol oral capsule 0.5 mcg, 0.5 mcg calcitriol oral solution mcg/ml calcitriol topical ointment mcg/gram calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg camila oral tablet 0.5 mg camrese lo oral tablets,dose pack, month 0.0 mg-0 mcg (8)/0 mcg (7) camrese oral tablets,dose pack, month 0.5 mg-0 mcg (8)/0 mcg (7) candesartan oral tablet 6mg, mg, mg, 8mg capecitabine oral tablet 50 mg, 500 mg (QL) CAPRELSA ORAL TABLET 00 MG, 00 MG (QL) captopril oral tablet 00 mg,.5 mg, 5 mg, 50 mg (ST) Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) Pg. This list is subject to change. For an up-to-date listing please visit

5 CARAFATE ORAL SUSPENSION 00 MG/ML CARBAGLU ORAL TABLET, DISPERSIBLE 00 MG carbamazepine oral capsule, er multiphase hr 00 mg, 00 mg, 00 mg carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet 00 mg carbamazepine oral tablet extended release hr 00 mg, 00 mg, 00 mg carbamazepine oral tablet,chewable 00 mg carbidopa oral tablet 5 mg carbidopa-levodopa oral tablet 0-00 mg, 5-00 mg, 5-50 mg carbidopa-levodopa oral tablet extended release 5-00 mg, mg carbidopa-levodopa oral tablet,disintegrating 0-00 mg, 5-00 mg, 5-50 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg carbinoxamine maleate oral liquid mg/5 ml carbinoxamine maleate oral tablet mg carisoprodol oral tablet 50 mg carteolol ophthalmic (eye) drops % cartia xt oral capsule,extended release hr 0 mg, 80 mg, 0 mg, 00 mg carvedilol oral tablet.5 mg, 5 mg,.5 mg, 6.5 mg CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML (QL) caziant (8) oral tablet 0./.5/.5-5 mg-mcg CEDAX ORAL CAPSULE 00 MG cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension for reconstitution 50 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefdinir oral capsule 00 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefditoren pivoxil oral tablet 00 mg, 00 mg cefixime oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml cefotaxime injection recon soln 0 gram, 500 mg cefoxitin intravenous recon soln 0 gram cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 00 mg cefprozil oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftibuten oral capsule 00 mg ceftriaxone injection recon soln 0 gram, 50 mg CEFTRIAXONE INJECTION RECON SOLN 00 GRAM cefuroxime axetil oral tablet 50 mg, 500 mg CELEBREX ORAL CAPSULE 00 MG, 00 MG, 00 MG, 50 MG (PA) celecoxib oral capsule 00 mg, 00 mg, 00 mg, 50 mg CELONTIN ORAL CAPSULE 00 MG cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml CERDELGA ORAL CAPSULE 8 MG (PA) CESAMET ORAL CAPSULE MG cetirizine oral solution mg/ml cetirizine oral tablet 0mg CETROTIDE SUBCUTANEOUS KIT 0.5 MG cevimeline oral capsule 0 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET MG (ST) CHANTIX ORAL TABLET 0.5 MG, MG (ST) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG () (ST) chateal oral tablet mg CHEMET ORAL CAPSULE 00 MG CHILDREN'S FLONASE SENSIMIST NASAL SPRAY,SUSPENSION 7.5 MCG/ACTUATION chlorhexidine gluconate mucous membrane mouthwash 0. % chloroquine phosphate oral tablet 50 mg, 500 mg chlorothiazide oral tablet 50 mg, 500 mg chlorpromazine oral tablet 0 mg, 00 mg, 00 mg, 5 mg, 50 mg chlorpropamide oral tablet 00 mg, 50 mg chlorthalidone oral tablet 5 mg, 50 mg chlorzoxazone oral tablet 500 mg CHOLBAM ORAL CAPSULE 50 MG CHOLBAM ORAL CAPSULE 50 MG (QL) cholestyramine (with sugar) oral powder gram cholestyramine (with sugar) oral powder in packet gram cholestyramine light oral powder gram cholestyramine light oral powder in packet gram CHORIONIC GONADOTROPIN, HUMAN INTRAMUSCULAR RECON SOLN 0,000 UNIT (PA, QL) CIALIS ORAL TABLET.5 MG (PA, QL) CIALIS ORAL TABLET 5 MG (PA, QL) ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % cilostazol oral tablet 00 mg, 50 mg cimetidine hcl oral solution 00 mg/5 ml cimetidine oral tablet 00 mg, 00 mg, 00 mg, 800 mg CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 00 MG (00 MG X VIALS) (PA, QL) CIMZIA SUBCUTANEOUS SYRINGE KIT 00 MG/ ML (00 MG/ML X ) (PA, QL) CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) (PA) CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.- % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops 0. % ciprofloxacin hcl oral tablet 00 mg, 50 mg, 500 mg, 750 mg citalopram oral solution 0 mg/5 ml citalopram oral tablet 0 mg, 0 mg, 0 mg (QL) claravis oral capsule 0 mg, 0 mg, 0 mg, 0 mg clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release hr 500 mg cleansing wash topical cleanser 0--0 % clemastine oral tablet.68 mg clindamycin hcl oral capsule 50 mg, 00 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin pediatric oral recon soln 75 mg/5 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % clindamycin-benzoyl peroxide topical gel -5 % clindamycin-benzoyl peroxide topical gel with pump -5 % clindamycin-tretinoin topical gel % clobetasol scalp solution 0.05 % (QL) clobetasol topical cream 0.05 % (QL) clobetasol topical foam 0.05 % (QL) clobetasol topical gel 0.05 %(QL) clobetasol topical lotion 0.05 % (QL) clobetasol topical ointment 0.05 % (QL) Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) This list is subject to change. For an up-to-date listing please visit Pg.

6 clobetasol topical shampoo 0.05 % (QL) clobetasol-emollient topical cream 0.05 % (QL) clobetasol-emollient topical foam 0.05 % (QL) CLOCORTOLONE PIVALATE TOPICAL CREAM 0. % (ST) clomipramine oral capsule 5 mg, 50 mg, 75 mg (ST) clonazepam oral tablet 0.5 mg, mg, mg clonidine hcl oral tablet 0. mg, 0. mg, 0. mg clonidine transdermal patch weekly 0. mg/ hr, 0. mg/ hr, 0. mg/ hr (QL) clopidogrel oral tablet 00 mg, 75 mg clotrimazole mucous membrane troche 0 mg clotrimazole topical cream % clotrimazole topical solution % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % clozapine oral tablet 00 mg, 00 mg, 5 mg, 50 mg COARTEM ORAL TABLET 0-0 MG codeine sulfate oral tablet 5 mg, 0 mg, 60 mg (QL) COLCHICINE ORAL CAPSULE 0.6 MG COLCHICINE ORAL TABLET 0.6 MG colestipol oral granules 5 gram colestipol oral packet 5 gram colestipol oral tablet gram colocort rectal enema 00 mg/60 ml COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML COMBIGAN OPHTHALMIC (EYE) DROPS % (ST) COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION (QL) compro rectal suppository 5 mg constulose oral solution 0 gram/5 ml CONTRAVE ORAL TABLET EXTENDED RELEASE 8-90 MG (PA) CORDRAN TOPICAL CREAM 0.05 % (ST) COREG CR ORAL CAPSULE, ER MULTIPHASE HR 0 MG, 0 MG, 0 MG, 80 MG (ST) CORLANOR ORAL TABLET 5 MG, 7.5 MG cortisone oral tablet 5 mg CORTISPORIN TOPICAL OINTMENT % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 50 MG/ML (PA, QL) COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 50 MG/ML (PA, QL) COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML (PA, QL) COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML (PA, QL) CRESEMBA ORAL CAPSULE 86MG (PA) CRESTOR ORAL TABLET 0 MG, 0 MG, 0 MG, 5 MG (PA, QL) CRIXIVAN ORAL CAPSULE 00 MG, 00 MG cromolyn inhalation solution for nebulization 0 mg/ ml cromolyn ophthalmic (eye) drops % cromolyn oral concentrate 00 mg/5 ml cryselle (8) oral tablet 0.-0 mg-mcg cyclafem /5 (8) oral tablet -5 mg-mcg cyclafem 7/7/7 (8) oral tablet 0.5/0.75/ mg- 5 mcg cyclobenzaprine oral tablet 0 mg, 5 mg CYCLOSERINE ORAL CAPSULE 50 MG CYCLOSET ORAL TABLET 0.8 MG cyclosporine modified oral capsule 00 mg, 5 mg, 50 mg cyclosporine modified oral solution 00 mg/ml cyclosporine oral capsule 00 mg, 5 mg cyproheptadine oral syrup mg/5 ml cyproheptadine oral tablet mg cyred oral tablet mg CYSTADANE ORAL POWDER GRAM/.7 ML CYSTAGON ORAL CAPSULE 50 MG, 50 MG (PA) D DALIRESP ORAL TABLET 500 MCG danazol oral capsule 00 mg, 00 mg, 50 mg dantrolene oral capsule 00 mg, 5 mg, 50 mg dapsone oral tablet 00 mg, 5 mg darifenacin oral tablet extended release hr 5 mg, 7.5 mg (ST) dasetta /5 (8) oral tablet -5 mg-mcg dasetta 7/7/7 (8) oral tablet 0.5/0.75/ mg- 5 mcg daysee oral tablets,dose pack, month 0.5 mg-0 mcg (8)/0 mcg (7) DAYTRANA TRANSDERMAL PATCH HOUR 0 MG/9 HR, 5 MG/9 HR, 0 MG/9 HR, 0 MG/9 HR (QL) DEBACTEROL MUCOUS MEMBRANE SOLUTION 0-50 % deblitane oral tablet 0.5 mg DECARA ORAL CAPSULE 50,000 UNIT deltasone oral tablet 0 mg delyla (8) oral tablet 0.-0 mg-mcg demeclocycline oral tablet 50 mg, 00 mg DENAVIR TOPICAL CREAM % (ST) DEPEN TITRATABS ORAL TABLET 50 MG DEPO-PROVERA INTRAMUSCULAR SOLUTION 00 MG/ML DERMACINRX EMPRICAINE TOPICAL KIT.5-.5 % dermacinrx prizopak topical kit.5-.5 % DERMACINRX SILAZONE TOPICAL KIT 0. % desipramine oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg (ST) desloratadine oral tablet 5 mg (QL) desloratadine oral tablet,disintegrating.5 mg (QL) desloratadine oral tablet,disintegrating 5 mg (QL) desmopressin nasal solution 0. mg/ml (refrigerate) desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0. mg desog-e.estradiol/e.estradiol oral tablet mgx /0.0 mg x 5 desogestrel-ethinyl estradiol oral tablet mg desonide topical cream 0.05 % (ST) desonide topical ointment 0.05 % (ST) desoximetasone topical cream 0.05 %, 0.5 % (ST) desoximetasone topical gel 0.05 % (ST) desoximetasone topical ointment 0.5 % (ST) DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 00 MG, 50 MG (ST, QL) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG, 50 MG (ST, QL) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG (ST, QL) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 50 MG (ST, QL) desvenlafaxine succinate oral tablet extended release hr 00 mg, 50 mg (QL) desvenlafaxine succinate oral tablet extended release hr 5 mg (ST, QL) dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral solution 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, mg, mg, 6 mg dexamethasone sodium phosphate ophthalmic (eye) drops 0. % DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 0 MG (PA, QL) DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS 60 MG (PA) dexmethylphenidate oral tablet 0 mg,.5 mg, 5 mg dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg dextroamphetamine oral tablet 0 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release hr 0 mg, 5 mg, 0 mg, 5 mg, 0 mg, 5 mg dextroamphetamine-amphetamine oral tablet 0 mg,.5 mg, 5 mg, 0 mg, 0 mg, 5 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) Pg. 5 This list is subject to change. For an up-to-date listing please visit

7 diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml ( mg/ml) diazepam oral tablet 0 mg, mg, 5 mg diazepam rectal kit mg,.5 mg, mg diclofenac potassium oral tablet 50 mg diclofenac sodium ophthalmic (eye) drops 0. % diclofenac sodium oral tablet extended release hr 00 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg diclofenac sodium oral tablet,delayed release (dr/ec) 50 mg, 75 mg diclofenac sodium topical gel % (QL) diclofenac sodium topical gel % (QL) dicloxacillin oral capsule 50 mg, 500 mg DICLOZOR TOPICAL KIT % (QL) dicyclomine oral capsule 0 mg dicyclomine oral solution 0 mg/5 ml dicyclomine oral tablet 0 mg didanosine oral capsule,delayed release(dr/ec) 5 mg, 00 mg, 50 mg, 00 mg DIFFERIN TOPICAL GEL 0. % OTC DIFICID ORAL TABLET 00MG (PA) diflorasone topical cream 0.05 % (ST) diflorasone topical ointment 0.05 % (ST) diflunisal oral tablet 500 mg digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg dihydroergotamine injection solution mg/ml (QL) diltiazem hcl oral capsule,ext.rel h degradable 0 mg diltiazem hcl oral capsule,extended release hr 0 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release hr 0 mg diltiazem hcl oral capsule,extended release hr 0 mg, 80 mg, 0 mg, 00 mg diltiazem hcl oral tablet 0 mg, 0 mg, 60 mg, 90 mg DIPENTUM ORAL CAPSULE 50 MG (ST) diphenhydramine hcl injection solution 50 mg/ml diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg dipyridamole oral tablet 5 mg, 50 mg, 75 mg disopyramide phosphate oral capsule 00 mg, 50 mg disulfiram oral tablet 50 mg, 500 mg divalproex oral capsule, delayed rel sprinkle 5 mg divalproex oral tablet extended release hr 50 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 500 mg dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg DOLOPHINE ORAL TABLET 5 MG (QL) donepezil oral tablet 0 mg, 5 mg donepezil oral tablet,disintegrating 0 mg, 5 mg dorzolamide ophthalmic (eye) drops % dorzolamide-timolol ophthalmic (eye) drops.-6.8 mg/ml doxazosin oral tablet mg, mg, mg, 8 mg (QL) doxepin oral capsule 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg doxepin oral concentrate 0 mg/ml doxepin topical cream 5 % doxercalciferol intravenous solution mcg/ ml doxercalciferol oral capsule 0.5 mcg, mcg,.5 mcg doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral suspension for reconstitution 5 mg/5 ml doxycycline monohydrate oral tablet 00 mg, 50 mg, 75 mg dronabinol oral capsule 0 mg,.5 mg, 5 mg E drospirenone-e.estradiol-lm.fa oral tablet mg () () drospirenone-ethinyl estradiol oral tablet -0.0 mg, -0.0 mg DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG DUAVEE ORAL TABLET MG DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 MCG/ACTUATION (QL) duloxetine oral capsule,delayed release(dr/ec) 0 mg, 0 mg, 60 mg (QL) DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % (ST) dutasteride oral capsule 0.5 mg DYRENIUM ORAL CAPSULE 00 MG, 50 MG e.e.s. 00 oral tablet 00 mg econazole topical cream % (ST) EDARBI ORAL TABLET 0 MG, 80 MG (ST) EDECRIN ORAL TABLET 5 MG (PA) EDURANT ORAL TABLET 5 MG effer-k oral tablet, effervescent 5 meq EFFIENT ORAL TABLET 0 MG, 5 MG eletriptan hbr oral tablet 0 mg, 0 mg (ST, QL) ELIDEL TOPICAL CREAM % (ST, QL) ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG (PA, QL) ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG (PA, QL) ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG (PA, QL) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) (PA, QL) elinest oral tablet 0.-0 mg-mcg ELIQUIS ORAL TABLET.5 MG, 5 MG ELLA ORAL TABLET 0 MG ELMIRON ORAL CAPSULE 00 MG EMADINE OPHTHALMIC (EYE) DROPS 0.05 % EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 00- MG, MG, 0-. MG, 50- MG, 60-. MG, 80-. MG (QL) EMCYT ORAL CAPSULE 0 MG (PA) emoquette oral tablet mg EMSAM TRANSDERMAL PATCH HOUR MG/ HR, 6 MG/ HR, 9 MG/ HR EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML ENABLEX ORAL TABLET EXTENDED RELEASE HR 5 MG, 7.5 MG (ST) enalapril maleate oral tablet 0 mg,.5 mg, 0 mg, 5 mg ENBREL SUBCUTANEOUS RECON SOLN 5 MG ( ML) (PA, QL) ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) (PA, QL) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) (PA, QL) endocet oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg (QL) ENDOMETRIN VAGINAL INSERT 00 MG enoxaparin subcutaneous solution 00 mg/ ml enoxaparin subcutaneous syringe 00 mg/ml, 0 mg/0.8 ml, 50 mg/ml, 0 mg/0. ml, 0 mg/0. ml, 60 mg/0.6 ml, 80 mg/0.8 ml enpresse oral tablet 50-0 (6)/75-0 (5)/5-0(0) enskyce oral tablet mg entacapone oral tablet 00 mg entecavir oral tablet 0.5 mg, mg (PA) ENTRESTO ORAL TABLET -6 MG, 9-5 MG, 97-0 MG (QL) enulose oral solution 0 gram/5 ml EPIDUO TOPICAL GEL WITH PUMP % (PA) epinastine ophthalmic (eye) drops 0.05 % EPINEPHRINE INJECTION AUTO-INJECTOR 0.5 MG/0. ML (QL) EPINEPHRINE INJECTION AUTO-INJECTOR 0. MG/0. ML (QL) epinephrine injection solution mg/ml (QL) Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) This list is subject to change. For an up-to-date listing please visit Pg. 6

8 F epinephrine injection syringe 0. mg/ml (QL) eplerenone oral tablet 5 mg, 50 mg EPOGEN INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML (PA, QL) eprosartan oral tablet 600 mg EPZICOM ORAL TABLET MG ergoloid oral tablet mg ERIVEDGE ORAL CAPSULE 50 MG (QL) errin oral tablet 0.5 mg ERTACZO TOPICAL CREAM % (ST) erythromycin ethylsuccinate oral tablet 00 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral tablet 50 mg, 500 mg erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % erythromycin with ethanol topical swab % erythromycin-benzoyl peroxide topical gel -5 % ESBRIET ORAL CAPSULE 67 MG (PA, QL) ESBRIET ORAL TABLET 67 MG, 80 MG (PA, QL) escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 0 mg, 0 mg, 5 mg (QL) esomeprazole magnesium oral capsule,delayed release(dr/ec) 0 mg (QL) esomeprazole magnesium oral capsule,delayed release(dr/ec) 0 mg estarylla oral tablet mg-mcg ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, mg estradiol transdermal patch semiweekly 0.05 mg/ hr, mg/ hr, 0.05 mg/ hr, mg/ hr, 0. mg/ hr (QL) estradiol transdermal patch weekly 0.05 mg/ hr (QL) estradiol transdermal patch weekly mg/ hr, 0.05 mg/ hr, 0.06 mg/ hr, mg/ hr, 0. mg/ hr estradiol vaginal tablet 0 mcg estradiol valerate intramuscular oil 0 mg/ml, 0 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg ESTRING VAGINAL RING MG (7.5 MCG / HOUR) estropipate oral tablet 0.75 mg,.5 mg, mg eszopiclone oral tablet mg, mg, mg (QL) ethacrynic acid oral tablet 5 mg ethambutol oral tablet 00 mg, 00 mg ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml etidronate disodium oral tablet 00 mg, 00 mg etodolac oral capsule 00 mg, 00 mg (ST) etodolac oral tablet 00 mg, 500 mg (ST) etodolac oral tablet extended release hr 00 mg, 500 mg, 600 mg (ST) EURAX TOPICAL CREAM 0 % EURAX TOPICAL LOTION 0 % EXELDERM TOPICAL CREAM % (ST) EXELDERM TOPICAL SOLUTION % (ST) exemestane oral tablet 5 mg (ST) EXTAVIA SUBCUTANEOUS KIT 0. MG (PA, QL) EXTAVIA SUBCUTANEOUS RECON SOLN 0. MG (PA, QL) ezetimibe oral tablet 0 mg FACTIVE ORAL TABLET 0 MG falmina (8) oral tablet 0.-0 mg-mcg famciclovir oral tablet 5 mg, 50 mg, 500 mg (QL) famotidine oral suspension 0 mg/5 ml (8 mg/ml) famotidine oral tablet 0 mg, 0 mg FANAPT ORAL TABLET MG, 0 MG, MG, MG, MG, 6 MG, 8 MG (QL) FANAPT ORAL TABLETS,DOSE PACK MG()-MG()- MG()-6MG() (QL) FARESTON ORAL TABLET 60 MG FARXIGA ORAL TABLET 0 MG, 5 MG (QL) FARYDAK ORAL CAPSULE 0 MG (PA, QL) FARYDAK ORAL CAPSULE 5 MG, 0 MG (PA, QL) fayosim oral tablets,dose pack, month 0.5 mg-0 mcg/ 0.5 mg-5 mcg felbamate oral suspension 600 mg/5 ml felbamate oral tablet 00 mg, 600 mg felodipine oral tablet extended release hr 0 mg,.5 mg, 5 mg FEMRING VAGINAL RING 0.05 MG/ HR, 0. MG/ HR femynor oral tablet mg-mcg fenofibrate micronized oral capsule mg, 00 mg, 67 mg fenofibrate nanocrystallized oral tablet 5 mg, 8 mg fenofibrate oral tablet 60 mg, 5 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 5 mg, 5 mg fenofibric acid oral tablet 05 mg, 5 mg fenoprofen oral tablet 600 mg (ST) fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg (PA, QL) fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr (QL) FERRIPROX ORAL TABLET 500 MG FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK 0 MG ()- 0 MG (6) (ST, QL) FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG, 0 MG, 0 MG, 80 MG (ST, QL) FINACEA TOPICAL GEL 5 % (ST) finasteride oral tablet mg finasteride oral tablet 5 mg flavoxate oral tablet 00 mg flecainide oral tablet 00 mg, 50 mg, 50 mg FLONASE SENSIMIST NASAL SPRAY,SUSPENSION 7.5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION, 50 MCG/ACTUATION (QL) FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION, 0 MCG/ACTUATION, MCG/ACTUATION (QL) fluconazole oral suspension for reconstitution 0 mg/ml, 0 mg/ml fluconazole oral tablet 00mg, 50mg, 00mg 50mg flucytosine oral capsule 50 mg, 500 mg fludrocortisone oral tablet 0. mg flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) (QL) fluocinolone acetonide oil otic (ear) drops 0.0 % fluocinolone and shower cap scalp oil 0.0 % fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical oil 0.0 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical cream 0.05 % (QL) fluocinonide topical gel 0.05 % (QL) fluocinonide topical ointment 0.05 % (QL) fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluoride (sodium) oral drops 0.5 mg (. mg sod.fluorid)/ml fluoride (sodium) oral tablet,chewable 0.5 mg(0.55 mg sod. fluoride), 0.5 mg (. mg sodium fluorid), mg (. mg sod. fluoride) fluorometholone ophthalmic (eye) drops,suspension 0. % Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) Pg. 7 This list is subject to change. For an up-to-date listing please visit

9 G fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % fluoxetine oral capsule 0 mg, 0 mg fluoxetine oral capsule 0 mg fluoxetine oral solution 0 mg/5 ml ( mg/ml) fluoxetine oral tablet 0 mg, 0 mg (QL) fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral tablet mg, 0 mg,.5 mg, 5 mg flurandrenolide topical cream 0.05 % (ST) flurbiprofen oral tablet 00 mg, 50 mg flurbiprofen sodium ophthalmic (eye) drops 0.0 % flutamide oral capsule 5 mg fluticasone nasal spray,suspension 50 mcg/actuation (QL) fluticasone topical cream 0.05 % fluticasone topical lotion 0.05 % fluticasone topical ointment % FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED - MCG/ACTUATION, - MCG/ACTUATION, 55- MCG/ACTUATION fluvastatin oral capsule 0 mg, 0 mg (QL) fluvoxamine oral tablet 00 mg, 5 mg, 50 mg (QL) fondaparinux subcutaneous syringe 0 mg/0.8 ml,.5 mg/0.5 ml, 5 mg/0. ml, 7.5 mg/0.6 ml FORTEO SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE MCG/. ML (PA, QL) fosinopril oral tablet 0 mg, 0 mg, 0 mg FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG frovatriptan oral tablet.5 mg (ST, QL) furosemide oral solution 0 mg/ml furosemide oral tablet 0 mg, 0 mg, 80 mg FUZEON SUBCUTANEOUS RECON SOLN 90 MG (QL) fyavolv oral tablet mg-mcg, -5 mg-mcg FYCOMPA ORAL TABLET 0 MG, MG, MG, MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 00 mg, 00 mg gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg galantamine oral capsule,ext rel. pellets hr 6 mg, mg, 8 mg galantamine oral solution mg/ml galantamine oral tablet mg, mg, 8 mg GANIRELIX SUBCUTANEOUS SYRINGE 50 MCG/0.5 ML gatifloxacin ophthalmic (eye) drops 0.5 % gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 0 gram gemfibrozil oral tablet 600 mg generlac oral solution 0 gram/5 ml gentak ophthalmic (eye) ointment 0. % ( mg/gram) gentamicin ophthalmic (eye) drops 0. % gentamicin ophthalmic (eye) ointment 0. % ( mg/gram) gentamicin topical cream 0. % gentamicin topical ointment 0. % genteal ophthalmic (eye) drops gianvi (8) oral tablet -0.0 mg gildagia oral tablet 0.-5 mg-mcg GILENYA ORAL CAPSULE 0.5 MG (PA, QL) GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG (PA, QL) glatopa subcutaneous syringe 0 mg/ml (PA, QL) H GLEEVEC ORAL TABLET 00 MG, 00 MG (PA, QL) glimepiride oral tablet mg, mg, mg glipizide oral tablet 0 mg, 5 mg glipizide oral tablet extended release hr 0 mg,.5 mg, 5 mg glipizide-metformin oral tablet.5-50 mg, mg, mg GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN MG/ML GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG GLUCAGON HCL INJECTION RECON SOLN MG glyburide micronized oral tablet.5 mg, mg, 6 mg glyburide oral tablet.5 mg,.5 mg, 5 mg glyburide-metformin oral tablet.5-50 mg, mg, mg glycopyrrolate oral tablet mg, mg GLYSET ORAL TABLET 00 MG, 5 MG, 50 MG (PA) GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR 00/0.5 UNIT/ML, 50/0.75 UNIT/ML, 900/.5 UNIT/ML (PA) granisetron hcl oral tablet mg griseofulvin microsize oral suspension 5 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 5 mg, 50 mg guanfacine oral tablet mg, mg guanfacine oral tablet extended release hr mg, mg, mg, mg guanidine oral tablet 5 mg GYNAZOLE- VAGINAL CREAM % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % HALOG TOPICAL CREAM 0. % (ST) HALOG TOPICAL OINTMENT 0. % (ST) haloperidol decanoate intramuscular solution 00 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, mg, 0 mg, 5 mg heartburn treatment hour oral capsule,delayed release(dr/ec) 5 mg heather oral tablet 0.5 mg heparin (porcine) in 5 % dex intravenous parenteral solution,500 unit/50 ml, 0,000 unit/500 ml (0 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml HEPSERA ORAL TABLET 0 MG (PA) HETLIOZ ORAL CAPSULE 0 MG (PA, QL) HEXALEN ORAL CAPSULE 50 MG HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS INSULIN PEN, HALF-UNIT 00 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML, 00 UNIT/ML ( ML) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 00 UNIT/ML (50-50) HUMALOG MIX 75-5 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (75-5) HUMALOG MIX 75-5 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (75-5) HUMALOG SUBCUTANEOUS CARTRIDGE 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML (PA, QL) HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0.8 ML (PA, QL) Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) This list is subject to change. For an up-to-date listing please visit Pg. 8

10 I HUMULIN 70/0 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-0) HUMULIN 70/0 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-0) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R U-00 INJECTION SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML hydralazine oral tablet 0 mg, 00 mg, 5 mg, 50 mg hydrochlorothiazide oral capsule.5 mg hydrochlorothiazide oral tablet.5 mg, 5 mg, 50 mg hydrocodone-acetaminophen oral solution mg/5 ml (QL) hydrocodone-acetaminophen oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg (QL) hydrocodone-homatropine oral syrup 5-.5 mg/5 ml hydrocodone-ibuprofen oral tablet mg (QL) hydrocortisone butyrate topical cream 0. % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone oral tablet 0 mg, 0 mg, 5 mg hydrocortisone rectal enema 00 mg/60 ml hydrocortisone topical cream %,.5 % hydrocortisone topical cream with perineal applicator %,.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment %,.5 % hydrocortisone valerate topical cream 0. % (ST) hydrocortisone valerate topical ointment 0. % (ST) hydromet oral syrup 5-.5 mg/5 ml hydromorphone oral liquid mg/ml (QL) hydromorphone oral tablet mg, mg, 8 mg (QL) hydromorphone oral tablet extended release hr mg, 6 mg, mg, 8 mg (QL) hydroxychloroquine oral tablet 00 mg hydroxyurea oral capsule 500 mg hydroxyzine hcl oral solution 0 mg/5 ml hydroxyzine hcl oral tablet 0 mg, 5 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 5 mg, 50 mg hyoscyamine sulfate oral tablet 0.5 mg hyoscyamine sulfate oral tablet extended release hr 0.75 mg hyoscyamine sulfate sublingual tablet 0.5 mg 0 GRAM /00 ML (0 %), 5 GRAM /50 ML (0 %) (PA) HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %) (PA) HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL. HR 00 MG, 0 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG (QL) ibandronate oral tablet 50 mg (QL) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG (PA, QL) ibuprofen oral tablet 00 mg, 600 mg, 800 mg ibuprofen-oxycodone oral tablet 00-5 mg (QL) ICLUSIG ORAL TABLET 5 MG, 5 MG (PA, QL) imatinib oral tablet 00 mg, 00 mg (PA, QL) IMBRUVICA ORAL CAPSULE 0 MG (PA, QL) imipramine hcl oral tablet 0 mg, 5 mg, 50 mg imiquimod topical cream in packet 5 % IMPAVIDO ORAL CAPSULE 50 MG INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML (PA) indapamide oral tablet.5 mg,.5 mg indomethacin oral capsule 5 mg, 50 mg J indomethacin oral capsule, extended release 75 mg INFLECTRA INTRAVENOUS RECON SOLN 00 MG (PA) INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG (QL) INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) (PA, QL) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML (PA, QL) introvale oral tablets,dose pack, month 0.5 mg-0 mcg INVANZ INJECTION RECON SOLN GRAM INVANZ INTRAVENOUS RECON SOLN GRAM INVIRASE ORAL CAPSULE 00 MG (QL) INVIRASE ORAL TABLET 500 MG (QL) INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG (QL) INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC HR 50-,000 MG, MG, 50-,000 MG, MG (QL) INVOKANA ORAL TABLET 00 MG (QL) INVOKANA ORAL TABLET 00 MG ipratropium bromide inhalation solution 0.0 % ipratropium bromide nasal spray,non-aerosol 0.0 %, 0.06 % (QL) ipratropium-albuterol inhalation solution for nebulization 0.5 mg- mg(.5 mg base)/ ml (QL) irbesartan oral tablet 50 mg, 00 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 00 MG isibloom oral tablet mg ISOLYTE S PH 7. INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 00 mg, 00 mg isosorbide dinitrate oral tablet 0 mg, 0 mg, 0 mg, 5 mg (ST) isosorbide dinitrate oral tablet extended release 0 mg isosorbide mononitrate oral tablet 0 mg, 0 mg isosorbide mononitrate oral tablet extended release hr 0 mg, 0 mg, 60 mg isradipine oral capsule.5 mg, 5 mg itraconazole oral capsule 00mg (QL) ivermectin oral tablet mg JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG (PA, QL) jantoven oral tablet mg, 0 mg, mg,.5 mg, mg, mg, 5 mg, 6 mg, 7.5 mg JANUMET ORAL TABLET 50-,000 MG, MG (QL) JANUMET XR ORAL TABLET, ER MULTIPHASE HR 00-,000 MG, 50-,000 MG, MG (QL) JANUVIA ORAL TABLET 00 MG, 5 MG, 50 MG (QL) JARDIANCE ORAL TABLET 0 MG, 5 MG (QL) jencycla oral tablet 0.5 mg JENTADUETO ORAL TABLET.5-,000 MG, MG, MG (QL) JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC HR.5-,000 MG, 5-,000 MG (QL) jinteli oral tablet -5 mg-mcg jolessa oral tablets,dose pack, month 0.5 mg-0 mcg jolivette oral tablet 0.5 mg juleber oral tablet mg junel.5/0 () oral tablet.5-0 mg-mcg junel /0 () oral tablet -0 mg-mcg junel fe.5/0 (8) oral tablet.5 mg-0 mcg ()/75 mg (7) junel fe /0 (8) oral tablet mg-0 mcg ()/75 mg (7) junel fe oral tablet mg-0 mcg ()/75 mg () Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) Pg. 9 This list is subject to change. For an up-to-date listing please visit

11 K L kaitlib fe oral tablet,chewable 0.8mg-5mcg() and 75 mg () KALETRA ORAL SOLUTION MG/5 ML (QL) KALETRA ORAL TABLET 00-5 MG, MG (QL) KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG (PA, QL) KALYDECO ORAL TABLET 50 MG (PA, QL) kariva (8) oral tablet mgx /0.0 mg x 5 k-effervescent oral tablet, effervescent 5 meq kelnor /5 (8) oral tablet -5 mg-mcg KERYDIN TOPICAL SOLUTION WITH APPLICATOR 5 % (ST) ketoconazole oral tablet 00 mg ketoconazole topical cream % ketoconazole topical shampoo % ketoprofen oral capsule 50 mg, 75 mg (ST) ketorolac ophthalmic (eye) drops 0. % ketorolac ophthalmic (eye) drops 0.5 % ketorolac oral tablet 0 mg (QL) kimidess (8) oral tablet mgx /0.0 mg x 5 kionex oral powder klor-con 0 oral tablet extended release 0 meq klor-con 8 oral tablet extended release 8 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con/ef oral tablet, effervescent 5 meq k-phos-neutral oral tablet 50 mg kurvelo oral tablet mg KUVAN ORAL POWDER IN PACKET 500 MG (PA) KUVAN ORAL TABLET,SOLUBLE 00 MG (PA) l norgest/e.estradiol-e.estrad oral tablets,dose pack, month 0.0 mg-0 mcg (8)/0 mcg (7), 0.5 mg-0 mcg (8)/0 mcg (7) labetalol oral tablet 00 mg, 00 mg, 00 mg LACRISERT OPHTHALMIC (EYE) INSERT 5 MG lactulose oral solution 0 gram/5 ml lamivudine oral solution 0 mg/ml (PA) lamivudine oral tablet 00 mg, 50 mg, 00 mg lamivudine-zidovudine oral tablet mg lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg lansoprazole oral capsule,delayed release(dr/ec) 5 mg, 0 mg LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML larin.5/0 () oral tablet.5-0 mg-mcg larin /0 () oral tablet -0 mg-mcg larin fe oral tablet mg-0 mcg ()/75 mg () larin fe.5/0 (8) oral tablet.5 mg-0 mcg ()/75 mg (7) larin fe /0 (8) oral tablet mg-0 mcg ()/75 mg (7) larissia oral tablet 0.-0 mg-mcg LASTACAFT OPHTHALMIC (EYE) DROPS 0.5 % (ST) latanoprost ophthalmic (eye) drops % LATUDA ORAL TABLET 0 MG, 0 MG, 0 MG, 60 MG, 80 MG (ST, QL) layolis fe oral tablet,chewable 0.8mg-5mcg() and 75 mg () leflunomide oral tablet 0 mg, 0 mg (QL) LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), MG/DAY(0 MG X - MG X ), 0 MG/DAY (0 MG X ), MG/DAY(0 MG X - MG X ) (QL) LENVIMA ORAL CAPSULE 8 MG/DAY (0 MG X - MG X), 8 MG/DAY ( MG X ) (QL) lessina oral tablet 0.-0 mg-mcg LETAIRIS ORAL TABLET 0 MG, 5 MG (QL) letrozole oral tablet.5 mg leucovorin calcium oral tablet 0mg 5mg, 5mg, 5mg LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit mg/0. ml LEVA SET TOPICAL KIT.5-.5 % levalbuterol hcl inhalation solution for nebulization 0. mg/ ml, 0.6 mg/ ml,.5 mg/0.5 ml,.5 mg/ ml LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 5 MCG/ACTUATION LEVATOL ORAL TABLET 0 MG LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) (ST) LEVEMIR SUBCUTANEOUS SOLUTION 00 UNIT/ML levetiracetam oral solution 00 mg/ml, 500 mg/5 ml (5 ml) levetiracetam oral tablet,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release hr 500 mg, 750 mg levobunolol ophthalmic (eye) drops 0.5 % levocarnitine (with sugar) oral solution 00 mg/ml levocarnitine oral tablet 0 mg levocetirizine oral solution.5 mg/5 ml levocetirizine oral tablet 5 mg (QL) levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 50 mg/0 ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg levonest (8) oral tablet 50-0 (6)/75-0 (5)/5-0(0) levonorgestrel-ethinyl estrad oral tablet 0.-0 mg-mcg, mg, 90-0 mcg levonorgestrel-ethinyl estrad oral tablets,dose pack, month 0.5 mg-0 mcg levonorg-eth estrad triphasic oral tablet 50-0 (6)/75-0 (5)/5-0(0) levora-8 oral tablet mg levorphanol tartrate oral tablet mg (QL) levothyroxine oral tablet 00 mcg, mcg, 5 mcg, 7 mcg, 50 mcg, 75 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC). GRAM lidocaine hcl laryngotracheal solution % lidocaine hcl mucous membrane jelly % (QL) lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution % (0 mg/ml) lidocaine topical adhesive patch,medicated 5 % lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % (QL) lidocaine-prilocaine topical kit.5-.5 % lidopril topical kit.5-.5 % LIDOPRIL XR TOPICAL KIT.5-.5 % LIDO-PRILO CAINE PACK TOPICAL KIT.5-.5 % lillow oral tablet mg lindane topical shampoo % linezolid oral suspension for reconstitution 00 mg/5 ml linezolid oral tablet 600 mg LINZESS ORAL CAPSULE 5 MCG, 90 MCG, 7 MCG liothyronine oral tablet 5 mcg, 5 mcg, 50 mcg LIPROZONEPAK TOPICAL KIT.5-.5 % lisinopril oral tablet 0 mg,.5 mg, 0 mg, 0 mg, 0 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg lithium carbonate oral capsule 50 mg, 00 mg, 600 mg lithium carbonate oral tablet 00 mg lithium carbonate oral tablet extended release 00 mg, 50 mg Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) This list is subject to change. For an up-to-date listing please visit Pg. 0

12 M lithium citrate oral solution 8 meq/5 ml LIVALO ORAL TABLET MG, MG, MG (PA, QL) LIVIXIL PAK TOPICAL KIT.5-.5 % LOCOID LIPOCREAM TOPICAL CREAM 0. % LOCOID TOPICAL CREAM 0. % LODOSYN ORAL TABLET 5 MG lomedia fe oral tablet mg-0 mcg ()/75 mg () loperamide oral capsule mg LOPERAMIDE ORAL LIQUID MG/7.5 ML loperamide oral tablet mg lopreeza oral tablet mg, -0.5 mg loratadine oral tablet 0mg lorazepam intensol oral concentrate mg/ml lorazepam oral concentrate mg/ml lorazepam oral tablet 0.5 mg, mg, mg loryna (8) oral tablet -0.0 mg losartan oral tablet 00 mg, 5 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, 00-5 mg, mg LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % (ST) LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % (ST) LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % (ST) LOTRISONE TOPICAL CREAM % LOTRONEX ORAL TABLET 0.5 MG, MG (PA) lovastatin oral tablet 0 mg, 0 mg, 0 mg (QL) LOVAZA ORAL CAPSULE GRAM low-ogestrel (8) oral tablet 0.-0 mg-mcg loxapine succinate oral capsule 0 mg, 5 mg, 5 mg, 50 mg LP LITE PAK TOPICAL KIT.5-.5 % lubricant ophthalmic (eye) ointment LUMIGAN OPHTHALMIC (EYE) DROPS 0.0 % (ST) LUMIZYME INTRAVENOUS RECON SOLN 50 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG (PA, QL) LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG (PA, QL) LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG (PA, QL) LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG (PA, QL) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG (PA, QL) LUPRON DEPOT-PED ( MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG, 0 MG (PA, QL) LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) (PA, QL) lutera (8) oral tablet 0.-0 mg-mcg LYNPARZA ORAL CAPSULE 50 MG (PA, QL) LYNPARZA ORAL TABLET 00 MG, 50 MG (PA) LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML LYSODREN ORAL TABLET 500 MG lyza oral tablet 0.5 mg malathion topical lotion 0.5 % maprotiline oral tablet 5 mg, 50 mg, 75 mg marlissa oral tablet mg MARPLAN ORAL TABLET 0 MG MATULANE ORAL CAPSULE 50 MG MAVYRET ORAL TABLET 00-0 MG MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % meclizine oral tablet.5 mg, 5 mg meclofenamate oral capsule 00 mg (ST) meclofenamate oral capsule 50 mg (ST) MEDOLOR PAK TOPICAL KIT.5-.5 % medroxyprogesterone intramuscular suspension 50 mg/ml (QL) medroxyprogesterone intramuscular syringe 50 mg/ml medroxyprogesterone oral tablet 0 mg,.5 mg, 5 mg mefenamic acid oral capsule 50 mg mefloquine oral tablet 50 mg megestrol oral suspension 00 mg/0 ml (0 mg/ml) megestrol oral tablet 0 mg, 0 mg MEKINIST ORAL TABLET 0.5 MG, MG (PA, QL) meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg memantine oral solution mg/ml memantine oral tablet 0 mg, 5 mg MEMANTINE ORAL TABLETS,DOSE PACK 5-0 MG MENEST ORAL TABLET 0. MG, 0.65 MG,.5 MG (ST) MENTAX TOPICAL CREAM % (ST) meperidine oral solution 50 mg/5 ml (QL) meperidine oral tablet 00 mg, 50 mg (QL) meprobamate oral tablet 00 mg mercaptopurine oral tablet 50 mg mesalamine oral tablet,delayed release (dr/ec). gram MESALAMINE ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG mesalamine rectal enema gram/60 ml mesalamine with cleansing wipe rectal enema kit gram/60 ml metadate er oral tablet extended release 0 mg metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 0 mg metaxall oral tablet 800 mg (ST) metaxalone oral tablet 800 mg (ST) metformin oral tablet,000 mg, 500 mg, 850 mg metformin oral tablet extended release hr 500 mg, 750 mg methadone oral concentrate 0 mg/ml (QL) methadone oral solution 0 mg/5 ml, 5 mg/5 ml (QL) methadone oral tablet 0 mg, 5 mg (QL) methadone oral tablet,soluble 0 mg (QL) methadose oral concentrate 0 mg/ml (QL) methadose oral tablet,soluble 0 mg (QL) methamphetamine oral tablet 5 mg methazolamide oral tablet 5 mg, 50 mg methenamine hippurate oral tablet gram methimazole oral tablet 0 mg, 5 mg METHITEST ORAL TABLET 0 MG methocarbamol oral tablet 500 mg, 750 mg methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 mg/ml methotrexate sodium injection solution 5 mg/ml methotrexate sodium oral tablet.5 mg methoxsalen oral capsule,liqd-filled,rapid rel 0 mg (QL) methscopolamine oral tablet.5 mg, 5 mg methyclothiazide oral tablet 5 mg methyldopa oral tablet 50 mg, 500 mg methylphenidate hcl oral capsule, er biphasic mg, 0 mg, 0 mg, 0 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg, 0 mg, 0 mg, 60 mg methylphenidate hcl oral solution 0 mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 0 mg, 0 mg, 5 mg Marketplace Formulary ( Tier Plans) - Version = Most Preferred Generic Drugs (tier ) = Non-Preferred Brand and Generic Drugs (tier ) = Brand and Generic Specialty Drugs (tier ) Pg. This list is subject to change. For an up-to-date listing please visit