2018 處方藥一覽表 ( 承保藥品清單 ) Imperial Health Plan of California Senior Value (HMO- SNP) 請閱讀 : 本文件內含本計畫承保藥品的相關資訊 HPMS 核准的處方藥一覽表檔案遞交 ID 18497, 版本編號 20 本處方藥一覽表

Transcription

1 2018 處方藥一覽表 Los Angeles Senior Value HMO-SNP PBP 010 Los Angeles San Francisco Senior Value HMO-SNP PBP 005 San Francisco Imperial Health Plan of California 2018 處方藥一覽表 1

2 2018 處方藥一覽表 ( 承保藥品清單 ) Imperial Health Plan of California Senior Value (HMO- SNP) 請閱讀 : 本文件內含本計畫承保藥品的相關資訊 HPMS 核准的處方藥一覽表檔案遞交 ID 18497, 版本編號 20 本處方藥一覽表最近更新日期為 2018 年 10 月 23 日 如需最新資訊或有其他疑問, 請聯絡 Imperial Health Plan of California 會員服務部門 ( 聽障專線 : 711),10 月 1 日至 2 月 14 日期間為星期一至星期日, 上午 8 點至晚上 8 點, 假日除外 ;2 月 15 日至 9 月 30 日則是星期一至星期五上午 8 點至下午 5 點, 假日除外, 或造訪 H5496_024 藥物表格 SNP CHT_NM Imperial Health Plan of California 2018 處方藥一覽表 2

3 目錄 Imperial Health Plan of California 處方藥一覽表是什麼?... 4 處方藥一覽表 ( 藥品清單 ) 會變更嗎?... 4 如何使用處方藥一覽表?... 4 什麼是副廠藥品?... 5 我的承保是否有任何限制?... 5 我要如何向 Imperial Health Plan of California 要求例外處理?... 6 在與自己的醫師討論變更藥品或要求例外之前, 我該做什麼?... 7 如需更多資訊... 7 Imperial Health Plan of California... 8 藥品索引 現有會員注意事項 : 本處方藥一覽表自去年起已有變更 請詳閱此文件以確定您服用的藥品仍包含在內 當本藥品清單 ( 處方藥一覽表 ) 提到 我們 或 我們的 時, 均指 Imperial Health Plan of California 提到 計畫 或 本計畫 時, 是指 Imperial Health Plan of California 本文件包含我們的計畫之藥物清單 ( 處方藥一覽表 ), 最近更新日期為 2018 年 10 月 23 日 若需要最新的處方藥一覽表, 請與我們聯絡 我們的聯絡資訊與處方藥一覽表最近的更新日期併列於封面與封底 一般來說, 您必須使用網絡藥房才能享用您的處方藥福利 福利 處方藥一覽表 藥房網絡和 / 或自付額 / 共同保險可能在 2018 年 1 月 1 日變更, 並在一年中不定時變動 Imperial Health Plan of California 2018 處方藥一覽表 3

4 Imperial Health Plan of California 處方藥一覽表 是什麼? 處方藥一覽表是 Imperial Health Plan of California 向醫療保健醫療服務提供者團隊諮詢後選出的承保藥品清單, 涵蓋所有我們認為高品質治療方案之處方治療必需的藥品 只要藥品為醫療所需 於 Imperial Health Plan of California 網絡藥房領取處方以及遵守其他計畫規定,Imperial Health Plan of California 通常承保於處方藥一覽表列示的藥品 如需更多有關如何領取處方藥的資訊, 請檢閱您的承保證書 處方藥一覽表 ( 藥品清單 ) 會變更嗎? 一般而言, 若您使用我們 2018 年處方藥一覽表上在年初受承保的藥品, 我們將不會在 2018 承保年度終止或減低承保, 除非有全新 價格較低的副廠藥品上市, 或是對於藥品的安全性或效用有新的負面資訊公開時 其他類型的處方藥一覽表變更 ( 例如自我們的處方藥一覽表中移除藥品 ) 將不會對目前服用該藥品的會員造成影響 對於那些在剩餘承保年份中繼續使用此藥品的會員, 分攤費用將維持不變 除非是在能夠為您省下額外金錢, 或我們可以確定您安全無虞的狀況以外, 否則我們認為您必須能夠繼續在您剩餘的承保年份中取得您選擇我們計畫時之處方藥一覽表中的藥品 若我們自我們的處方藥一覽表移除藥品, 或對某藥品新增事先授權 數量限制和 ( 或 ) 階段療法限制 ( 或將某藥品移到較高的費用分攤層級 ), 我們必須在變更生效至少 60 天前, 或在會員要求續配處方時, 通知受影響的會員 且自當日起, 會員即可拿到此藥品 60 天的用量 若食品藥物管理局 (Food and Drug Administration, FDA ) 認為我們的處方藥一覽表上的某藥品不安全, 或是製藥廠將此藥下架, 我們會立刻將此藥品從我們的處方藥一覽表上移除, 並通知服用此藥品的會員 隨附處方藥一覽表, 最近更新日期為 2018 年 10 月 23 日 若要取得 Imperial Health Plan of California 承保藥物的最新資訊, 請聯絡我們 我們的聯絡資訊列於封面與封底 若為計畫年度期間對於處方藥一覽表的非維持變更,Imperial Health Plan of California 可能會寄勘誤表給您加以變更 此外, 您亦可造訪我們的網站取得勘誤表的連結 如何使用處方藥一覽表? 有兩個方法可以在處方藥一覽表中找到您的藥物 : 醫療狀況 Imperial Health Plan of California 2018 處方藥一覽表 4

5 處方藥一覽表從第 8 頁開始 本處方藥一覽表中藥物的分類方式, 是按藥物用以治療的醫療狀況類型而分為類別 例如, 用於治療心臟病況的藥品列於 心血管 分類下 若您知道您的藥品用途, 請在第 8 頁開始的清單上找尋類別名稱 然後在該類別下找出您的藥品 按英文字母順序排列的清單 若您不知該查找哪個類別, 請在 140 頁開始的索引中查找您的藥品 索引依英文字母順序列出本文件所包含的所有藥物 原廠藥品與副廠藥品皆列於索引中 在索引中找出您的藥物 您會在藥物旁邊看到頁碼, 該頁碼可引導您找到藥物的承保資訊 翻到索引中列出的頁數, 在清單的第一欄找到您的藥品名稱 什麼是副廠藥品? Imperial Health Plan of California 同時承保原廠藥品和副廠藥品 副廠藥品是 FDA 核准與原廠藥品具備相同活性成分的藥品 一般而言, 副廠藥品的費用低於原廠藥品 我的承保是否有任何限制? 某些承保藥物可能在承保方面有額外要求或限制 這些要求和限制可能包括 : 事先授權 :Imperial Health Plan of California 要求您或您的醫師必須在針對特定藥品開藥前取得事先授權 這表示您拿處方籤配藥前, 需得到 Imperial Health Plan of California 的核准 如果您未獲得核准,Imperial Health Plan of California 就可能不會承保該藥物 數量限制 : 對於某些藥品,Imperial Health Plan of California 會限制 Imperial Health Plan of California 所承保的藥品數量 例如,Imperial Health Plan of California 對於 celecoxib 提供每處方 60 顆膠囊 這可能是對標準一個月或三個月供應量之外所額外提供的量 階段療法 : 某些狀況下,Imperial Health Plan of California 會要求您在我們承保治療相同病況的其他藥品前, 先試用某些藥品治療您的醫療狀況 例如, 如果藥物 A 及藥物 B 均可治療您的醫療狀況,Imperial Health Plan of California 就可能要求您先嘗試藥物 A 後, 才會承保藥物 B 如果 A 藥物對您無效, 則 Imperial Health Plan of California 將承保 B 藥物 您可以在第 8 頁開始的處方藥一覽表中找出您的藥品是否有額外要求或限制 您也可以瀏覽我們的網站, 取得特定承保藥品限制的詳細資訊 我們已將關於事先授權與階段療法限制的文件公告於網路上 您也可要求我們寄一份給您 我們的聯絡資訊與處方藥一覽表最近的更新日期併列於封面與封底 Imperial Health Plan of California 2018 處方藥一覽表 5

6 您可以要求 Imperial Health Plan of California 針對這些藥品的限制或限額, 或對可能治療您醫療狀況之其他 類似藥品清單提供例外 請參閱第 6 頁的 我要如何向 Imperial Health Plan of California 要求例外處理? 章節, 瞭解如何要求例外處理 如果我的藥品不在處方藥一覽表上該怎麼辦? 如果您的藥品不包含在處方藥一覽表 ( 承保藥品清單 ) 中, 您必須先聯絡會員服務部, 詢問該藥品是否承保 如果您發現 Imperial Health Plan of California 不承保您的藥品, 您有兩種選擇 : 您可向會員服務部索取 Imperial Health Plan of California 承保之類似藥品的清單 您收到此清單時, 請將清單拿給您的醫師並請醫師開立 Imperial Health Plan of California 所承保之類似藥品 您可要求 Imperial Health Plan of California 做出例外處理並承保您的藥物 請參閱下列資訊瞭解如何要求例外處理 我要如何向 Imperial Health Plan of California 要 求例外處理? 您可要求 Imperial Health Plan of California 對於我們的承保規則做出例外處理 在數種類型的例外情況中, 您可以要求我們做出處理 您可以要求我們承保某藥品, 即便此藥品不在我們的處方藥一覽表上 一經核准, 此藥品將以預先決定的費用分攤等級承保, 您不得要求我們以較低的費用分攤等級提供此藥品 若處方藥一覽表上某藥品不屬於專科層級, 您可以要求以較低的費用分攤等級承保此藥品 一經核准, 這將會降低您必須對藥品付出的金額 您可以要求我們取消對您藥品的承保限制或限額 例如 : 對於某些藥品,Imperial Health Plan of California 會限制對此藥品所承保的數量 若您的藥品有數量上的限制, 可以要求我們取消此限制並承保較大的數量 一般而言, 只有在本計畫有數種處方藥一覽表上所含的替代藥品 費用分攤較低藥品或額外的使用限制對治療您的病況無效和 / 或可能對您造成負面的醫療效果時,Imperial Health Plan of California 才會核准您要求的例外處理 您必須與我們聯絡以索取處方藥一覽表或使用限制例外的初步承保決定 您索取處方藥一覽表或使用限制例外的初步承保決定時, 必須遞交一份為您開立處方者或佐證您要求的醫師所提供的聲明 通常, 我們必須在收到您的開立處方者之佐證聲明的 72 小時內做出決定 若您的醫師認為等候長達 72 小時才做決定對您的健康可能造成嚴重危害, 您可以要求加快 ( 加速 ) 例外審核 若您的加快要求得到授予, 我們必須在收到您醫師或其他開立處方者的佐證聲明後 24 小時內向您告知我們的決定 Imperial Health Plan of California 2018 處方藥一覽表 6

7 在與自己的醫師討論變更藥品或要求例外之 前, 我該做什麼? 身為我們計畫的新會員或續保會員, 您可能正在服用我們處方藥一覽表所包含的藥品, 但您取得該藥物之能力受到限制 例如, 您可能需取得我們的事先授權, 才能領取您的處方藥 您必須先與醫師討論才能決定是否該換用我們所承保的適當藥品, 或要求處方藥一覽表的例外處理, 讓我們承保您所服用的藥品 與您的醫師討論並決定對您來說正確的行動時, 我們可能在特定狀況下, 於您成為本計畫會員最初的 90 天內承保您的藥品 對於每項不屬於我們處方藥一覽表中的藥品, 或您取得此藥品的能力受到限制時, 當您到網絡藥房配藥, 我們將承保暫時性的 30 天用藥量 ( 除非您的處方天數更短 ) 您最初 30 天的用藥量用完後, 我們將不再對這些藥品付費, 即便您成為本計畫會員不到 90 天 若您居住在長期照護機構, 我們將依用藥保險允許您續配處方上的藥品, 直到我們為您提供 91 天的過渡期用藥 ( 除非您的處方天數更短 ) 您成為我們的計畫會員的最初 90 天, 我們將負擔這些藥物超過一次的續配處方 如果您需要不屬於本處方藥一覽表上的藥品或您取得藥品的能力受到限制, 但您已成為本計畫會員超過 90 天, 則在您申請處方藥一覽表例外處理期間, 我們將支付該藥品 31 天的緊急情況用量 ( 除非您的處方天數更短 ) 受益人所接受的照護等級變更, 導致其需從某間設施或治療中心轉移到另一間接受照護時, 可申請例外處理 受益人於 Part D 計畫生效日三個月範圍外可能有資格取得一次性暫時配藥例外處理的情況舉例如下 : 1. 受益人出院, 且獲得根據該院處方藥一覽表所定的藥品出院清單 2. 受益人結束專業護理機構 Medicare Part A 療養 ( 其中的付款包含所有藥房收費 ), 且需要轉回其 Part D 計畫處方藥一覽表 3. 受益人放棄善終護理狀態, 轉回接受標準 Medicare Part A 與 B 福利給付 4. 受益人從慢性精神科醫院出院, 並有極為個人化的藥物療程 如需更多資訊 如需更多有關 Imperial Health Plan of California 處方藥品承保的詳細資訊, 請參閱您的承保證書及其他計畫資料 如果您有 Imperial Health Plan of California 的相關疑問, 請聯絡我們 我們的聯絡資訊與處方藥一覽表最近的更新日期併列於封面與封底 Imperial Health Plan of California 2018 處方藥一覽表 7

8 若您對 Medicare 處方藥品承保有任何一般疑問, 請與 Medicare 聯絡, 聯絡專線 : MEDICARE ( ), 每天 24 小時 / 每週 7 天 聽障服務專線 (TTY) 使用者請撥打 或瀏覽 Imperial Health Plan of California 此頁開始的處方藥一覽表提供 Imperial Health Plan of California 承保藥物的承保資訊 若您無法在本清單上找到您的藥物, 請到在第 146 頁開始的索引查詢 表格的第一欄會列出藥品名稱 原廠藥物以大寫字母表示 ( 如 HUMIRA), 副廠藥物則以斜體小寫字母表示 ( 如 celecoxib) 要求 / 限制欄位的資訊會告訴您 Imperial Health Plan of California 對您的藥品是否有任何特殊要求 下表說明本藥品清單表格中使用的縮寫 縮寫 LA QL 縮寫意義 該處方可能只能在特定的藥房取得 如需更多資訊, 請撥打 , 服務時間每週七天, 每天 24 小時 聽障專線 (TTY/TDD) 使用者請撥打 數量限制 後方會列出指定天數的數量限制 PA 此藥品需要事先授權 若要申請例外處理, 請撥打 , 服務時間每週七天, 每天 24 小時 聽障專線 (TTY/TDD) 使用者請撥打 NEW PA B/D PA ST 此藥品需要事先授權, 且僅適用於新開始 若要申請例外處理, 請撥打 , 服務時間每週七天, 每天 24 小時 聽障專線 (TTY/TDD) 使用者請撥打 此藥品可能視情況屬於 Medicare Part B 或 Part D 的承保範圍 可能需要提交說明該藥品的使用和情況等資訊, 以利判定 適用階段療法規範 藥物名稱層級規定 / 限制 ANALGESICS Analgesics acetaminophen w/ codeine soln mg/5ml 2 QL 4500 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 8

9 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 butalbital-acetaminophen tab mg 4 PA butalbital-acetaminophen tab mg 4 QL 180 PER 30 ; PA butalbital-acetaminophen-caff w/ cod cap mg 4 ; PA butalbital-acetaminophen-caff w/ cod cap mg 2 QL 360 PER 30 ; PA butalbital-acetaminophen-caffeine cap mg 4 PA butalbital-acetaminophen-caffeine cap mg 4 ; PA butalbital-acetaminophen-caffeine tab mg 4 ; PA butalbital-aspirin-caff w/ codeine cap mg 2 ; PA butalbital-aspirin-caffeine cap mg 4 QL 180 PER 30 ; PA diclofenac w/ misoprostol tab delayed release mg 2 diclofenac w/ misoprostol tab delayed release mg 2 ergotamine w/ caffeine tab mg 2 hydrocodone-acetaminophen soln mg/15ml 2 QL 3600 PER 30 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 QL 360 PER 30 hydrocodone-ibuprofen tab mg 2 Imperial Health Plan of California 2018 處方藥一覽表 9

10 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone-aspirin tab mg 2 oxycodone-ibuprofen tab mg 2 tramadol-acetaminophen tab mg 2 QL 240 PER 30 Nonsteroidal Anti-inflammatory Drugs diclofenac sodium gel 1% 2 diclofenac sodium soln 1.5% 4 indomethacin cap cr 75 mg 1 PA oxaprozin tab 600 mg 4 Opioid Analgesics, Long-acting buprenorphine hcl inj 0.3 mg/ml (base equiv) 3 BUTRANS DIS10MCG/HR 3 BUTRANS DIS15MCG/HR 3 BUTRANS DIS20MCG/HR 3 BUTRANS DIS5MCG/HR 3 BUTRANS DIS7.5/HR 3 fentanyl td patch 72hr 100 mcg/hr 2 fentanyl td patch 72hr 12 mcg/hr 2 fentanyl td patch 72hr 25 mcg/hr 2 fentanyl td patch 72hr 37.5 mcg/hr 2 fentanyl td patch 72hr 50 mcg/hr 2 QL 150 PER 30 ; B/D PA QL 4 PER 28 QL 4 PER 28 QL 4 PER 28 QL 4 PER 28 QL 4 PER 28 Imperial Health Plan of California 2018 處方藥一覽表 10

11 fentanyl td patch 72hr 62.5 mcg/hr 2 fentanyl td patch 72hr 75 mcg/hr 2 fentanyl td patch 72hr 87.5 mcg/hr 2 hydromorphone hcl tab er 24hr deter 12 mg 2 hydromorphone hcl tab er 24hr deter 16 mg 5 hydromorphone hcl tab er 24hr deter 32 mg 5 hydromorphone hcl tab er 24hr deter 8 mg 2 HYSINGLA ER TAB100 MG 3 HYSINGLA ER TAB120 MG 3 HYSINGLA ER TAB20 MG 3 HYSINGLA ER TAB30 MG 3 HYSINGLA ER TAB40 MG 3 HYSINGLA ER TAB60 MG 3 HYSINGLA ER TAB80 MG 3 levorphanol tartrate tab 2 mg 2 METHADONE INJ10MG/ML 4 ; B/D PA methadone hcl soln 10 mg/5ml 2 QL 600 PER 30 methadone hcl soln 5 mg/5ml 2 QL 1200 PER 30 methadone hcl tab 10 mg 2 methadone hcl tab 5 mg 2 morphine sulfate beads cap sr 24hr 120 mg 2 morphine sulfate beads cap sr 24hr 30 mg 2 morphine sulfate beads cap sr 24hr 45 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 11

12 morphine sulfate beads cap sr 24hr 60 mg 2 morphine sulfate beads cap sr 24hr 75 mg 2 morphine sulfate beads cap sr 24hr 90 mg 2 morphine sulfate cap sr 24hr 10 mg 2 morphine sulfate cap sr 24hr 100 mg 5 morphine sulfate cap sr 24hr 20 mg 2 morphine sulfate cap sr 24hr 30 mg 2 morphine sulfate cap sr 24hr 50 mg 2 morphine sulfate cap sr 24hr 60 mg 2 morphine sulfate cap sr 24hr 80 mg 2 morphine sulfate oral soln 20 mg/5ml 4 QL 900 PER 30 morphine sulfate tab cr 100 mg 2 morphine sulfate tab cr 15 mg 2 morphine sulfate tab cr 200 mg 2 morphine sulfate tab cr 30 mg 2 morphine sulfate tab cr 60 mg 2 MORPHINE SULINJ10MG/ML 4 B/D PA MORPHINE SULINJ2MG/ML 4 QL 900 PER 30 ; B/D PA MORPHINE SULINJ4MG/ML 4 QL 450 PER 30 ; B/D PA MORPHINE SULINJ8MG/ML 4 B/D PA OXYCONTIN TAB10MG CR 3 QL 90 PER 30 QL 90 PER 30 OXYCONTIN TAB15MG CR 3 Imperial Health Plan of California 2018 處方藥一覽表 12

13 OXYCONTIN TAB20MG CR 3 QL 90 PER 30 OXYCONTIN TAB30MG CR 3 QL 90 PER 30 OXYCONTIN TAB40MG CR 3 QL 90 PER 30 OXYCONTIN TAB60MG CR 3 QL 90 PER 30 OXYCONTIN TAB80MG CR 3 tramadol hcl tab sr 24hr 100 mg 2 tramadol hcl tab sr 24hr 200 mg 2 tramadol hcl tab sr 24hr biphasic release 300 mg 2 Opioid Analgesics, Short-acting butorphanol tartrate nasal soln 10 mg/ml 2 fentanyl citrate lozenge on a handle 1200 mcg 5 fentanyl citrate lozenge on a handle 1600 mcg 5 fentanyl citrate lozenge on a handle 200 mcg 5 fentanyl citrate lozenge on a handle 400 mcg 5 fentanyl citrate lozenge on a handle 600 mcg 5 fentanyl citrate lozenge on a handle 800 mcg 5 hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 morphine sulfate inj pf 0.5 mg/ml 4 morphine sulfate inj pf 1 mg/ml 4 morphine sulfate oral soln 10 mg/5ml 4 QL 10 PER 30 ; PA ; PA ; PA ; PA ; PA ; PA QL 180 PER 30 ; B/D PA QL 180 PER 30 ; B/D PA QL 1800 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 13

14 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 2 QL 180 PER 30 morphine sulfate tab 15 mg 2 morphine sulfate tab 30 mg 2 nalbuphine hcl inj 10 mg/ml 4 ; B/D PA nalbuphine hcl inj 20 mg/ml 4 ; B/D PA oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2 oxycodone hcl soln 5 mg/5ml 2 QL 1800 PER 30 oxycodone hcl tab 10 mg 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab 5 mg 2 tramadol hcl tab 50 mg 2 QL 240 PER 30 ANESTHETICS Local Anesthetics lidocaine hcl gel 2% 4 lidocaine hcl local preservative free (pf) inj 0.5% 4 B/D PA lidocaine hcl soln 4% 4 lidocaine hcl viscous soln 2% 2 QL 36 PER 30 lidocaine oint 5% 4 lidocaine patch 5% 4 lidocaine-prilocaine cream % 4 QL 90 PER 30 ; PA ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Imperial Health Plan of California 2018 處方藥一覽表 14

15 藥物名稱層級規定 / 限制 Alcohol Deterrents/Anti-craving acamprosate calcium tab delayed release 333 mg 2 disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naltrexone hcl tab 50 mg 2 Opioid Dependence Treatments buprenorphine hcl sl tab 2 mg (base equiv) 2 buprenorphine hcl sl tab 8 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl tab mg (base equiv) 2 ; PA buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2 ; PA SUBOXONE MIS12-3MG 3 SUBOXONE MIS2-0.5MG 3 QL 90 PER 30 SUBOXONE MIS4-1MG 3 QL 45 PER 30 SUBOXONE MIS8-2MG 3 QL 90 PER 30 VIVITROL INJ380MG 5 PA Opioid Reversal Agents naloxone hcl soln prefilled syringe 2 mg/2ml 3 Smoking Cessation Agents bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2 CHANTIX PAK0.5& 1MG 3 CHANTIX TAB0.5MG 3 CHANTIX TAB1MG 3 NICOTROL NS SPR10MG/ML 3 ANTIBACTERIALS Aminoglycosides GENTAMICIN OIN0.1% 2 gentamicin sulfate cream 0.1% 2 QL 90 PER 30 QL 40 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 15

16 gentamicin sulfate inj 40 mg/ml 2 B/D PA gentamicin sulfate iv soln 10 mg/ml 4 B/D PA gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 2 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 4 B/D PA TOBRADEX OIN % 4 tobramycin ophth soln 0.3% 2 tobramycin sulfate inj 10 mg/ml (base equivalent) 4 B/D PA tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) 4 B/D PA Antibacterials colistimethate sodium for inj 150 mg 4 B/D PA neomycin-polymyxin b gu irrigation soln 2 SYNERCID INJ500MG 5 B/D PA Antibacterials, Other acetic acid otic soln 2% 2 bacitracin intramuscular for soln unit 4 bacitracin ophth oint 500 unit/gm 2 chloramphenicol sodium succinate for iv inj 1 gm 4 B/D PA clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin hcl cap 75 mg 2 clindamycin phosphate foam 1% 4 clindamycin phosphate gel 1% 4 clindamycin phosphate in d5w iv soln 300 mg/50ml 4 clindamycin phosphate in d5w iv soln 600 mg/50ml 4 clindamycin phosphate in d5w iv soln 900 mg/50ml 4 clindamycin phosphate inj 600 mg/4ml 4 B/D PA clindamycin phosphate lotion 1% 4 clindamycin phosphate soln 1% 4 clindamycin phosphate swab 1% 4 clindamycin phosphate vaginal cream 2% 2 clindamycin phosphate-tretinoin gel % 2 daptomycin for iv soln 500 mg 2 B/D PA linezolid for susp 100 mg/5ml 5 linezolid iv soln 600 mg/300ml (2 mg/ml) 5 PA Imperial Health Plan of California 2018 處方藥一覽表 16

17 linezolid tab 600 mg 5 QL 28 PER 14 ; PA methenamine hippurate tab 1 gm 2 metronidazole cap 375 mg 2 metronidazole cream 0.75% 4 metronidazole gel 0.75% 4 metronidazole gel 1% 4 metronidazole in nacl 0.79% iv soln 500 mg/100ml 4 B/D PA metronidazole lotion 0.75% 4 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 metronidazole vaginal gel 0.75% 2 mupirocin calcium cream 2% 4 mupirocin oint 2% 4 nitrofurantoin macrocrystalline cap 100 mg 2 PA nitrofurantoin macrocrystalline cap 25 mg 2 PA nitrofurantoin macrocrystalline cap 50 mg 4 PA nitrofurantoin monohydrate macrocrystalline cap 100 mg 2 nitrofurantoin susp 25 mg/5ml 2 PA SULFAMYLON CRE85MG/GM 4 TIGECYCLINE INJ50MG 2 PA tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 2 TYGACIL INJ50MG 5 PA QL 40 PER 30 vancomycin hcl cap 125 mg 5 ; PA vancomycin hcl cap 250 mg 5 QL 80 PER 30 ; PA vancomycin hcl for inj 10 gm 4 PA vancomycin hcl for inj 1000 mg 4 PA vancomycin hcl for inj 500 mg 4 PA Beta-lactam, Cephalosporins cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 Imperial Health Plan of California 2018 處方藥一覽表 17

18 cefaclor monohydrate tab sr 12hr 500 mg 2 cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 4 B/D PA cefazolin sodium for inj 10 gm 4 B/D PA cefazolin sodium for inj 500 mg 4 B/D PA cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefepime hcl for inj 1 gm 4 B/D PA cefepime hcl for inj 2 gm 4 B/D PA cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefoxitin sodium for inj 10 gm 4 B/D PA cefoxitin sodium for iv soln 1 gm 4 B/D PA cefoxitin sodium for iv soln 2 gm 4 B/D PA cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 ceftriaxone sodium for inj 10 gm 4 ceftriaxone sodium for inj 250 mg 4 B/D PA ceftriaxone sodium for inj 500 mg 4 B/D PA ceftriaxone sodium for iv soln 1 gm 4 ceftriaxone sodium for iv soln 2 gm 4 B/D PA cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 1.5 gm 4 B/D PA cefuroxime sodium for inj 7.5 gm 4 B/D PA Imperial Health Plan of California 2018 處方藥一覽表 18

19 cefuroxime sodium for inj 750 mg 4 B/D PA cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin cap 750 mg 2 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 SUPRAX CAP400MG 4 TEFLARO INJ400MG 5 B/D PA TEFLARO INJ600MG 5 B/D PA Beta-lactam, Other AZACTAM/DEX INJ1GM 4 PA AZACTAM/DEX INJ2GM 4 PA aztreonam for inj 1 gm 4 LA; QL 84 PER 28 CAYSTON INH75MG 5 ; PA imipenem-cilastatin intravenous for soln 250 mg 2 B/D PA imipenem-cilastatin intravenous for soln 500 mg 2 B/D PA INVANZ INJ1GM 4 meropenem iv for soln 500 mg 4 B/D PA Beta-lactam, Penicillins AMOX/K CLAV CHW200MG 2 amoxicillin & k clavulanate chew tab mg 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab sr 12hr mg 2 amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 amoxicillin (trihydrate) for susp 200 mg/5ml 1 Imperial Health Plan of California 2018 處方藥一覽表 19

20 amoxicillin (trihydrate) for susp 250 mg/5ml 1 amoxicillin (trihydrate) for susp 400 mg/5ml 1 amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 3 (2-1) gm 4 B/D PA ampicillin & sulbactam sodium for iv soln 15 (10-5) gm 4 B/D PA ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 4 B/D PA ampicillin sodium for inj 125 mg 4 B/D PA ampicillin sodium for iv soln 10 gm 4 B/D PA BICILLIN C-RINJ BICILLIN C-RINJ900/300 4 BICILLIN L-AINJ BICILLIN L-AINJ BICILLIN L-AINJ dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 4 B/D PA nafcillin sodium for inj 10 gm 5 B/D PA PENICILL GK/INJDEX 2MU 4 PENICILL GK/INJDEX 3MU 4 penicillin g potassium for inj unit 4 B/D PA penicillin g procaine intramuscular susp unit/ml 4 penicillin g sodium for inj unit 4 B/D PA penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj gm ( gm) 4 B/D PA piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4 B/D PA piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) 2 PA ZOSYN SOL2-0.25GM 4 PA ZOSYN SOL G 4 PA Macrolides Imperial Health Plan of California 2018 處方藥一覽表 20

21 AZASITE SOL1% 4 azithromycin for susp 100 mg/5ml 2 QL 30 PER 5 azithromycin for susp 200 mg/5ml 2 QL 90 PER 5 azithromycin iv for soln 500 mg 4 B/D PA azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab sr 24hr 500 mg 2 ERYTHROCIN INJ500MG 4 B/D PA ERYTHROM ETHTAB400MG 2 erythromycin ethylsuccinate tab 400 mg 2 erythromycin gel 2% 4 erythromycin ophth oint 5 mg/gm 2 erythromycin pads 2% 4 erythromycin soln 2% 4 erythromycin stearate tab 250 mg 4 erythromycin tab 250 mg 4 erythromycin tab 500 mg 4 erythromycin tab delayed release 250 mg 4 erythromycin tab delayed release 333 mg 4 erythromycin tab delayed release 500 mg 4 ZMAX SUS2GM 4 Quinolones ciprofloxacin 200 mg/100ml in d5w 4 ciprofloxacin hcl ophth soln 0.3% 2 ciprofloxacin hcl tab 100 mg (base equiv) 4 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 4 B/D PA Imperial Health Plan of California 2018 處方藥一覽表 21

22 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 2 levofloxacin in d5w iv soln 500 mg/100ml 4 B/D PA levofloxacin iv soln 25 mg/ml 4 B/D PA levofloxacin ophth soln 0.5% 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 QL 14 PER 14 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 MOXEZA SOL0.5% 3 ofloxacin ophth soln 0.3% 2 ofloxacin otic soln 0.3% 2 ofloxacin tab 300 mg 2 ofloxacin tab 400 mg 2 VIGAMOX DRO0.5% 3 QL 14 PER 14 Sulfonamides silver sulfadiazine cream 1% 1 SULFACET SODOIN10% OP 2 sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium ophth soln 10% 2 sulfadiazine tab 500 mg 2 sulfamethoxazole-trimethoprim iv soln mg/5ml 4 B/D PA sulfamethoxazole-trimethoprim susp mg/5ml 1 sulfamethoxazole-trimethoprim tab mg 1 sulfamethoxazole-trimethoprim tab mg 1 Tetracyclines demeclocycline hcl tab 150 mg 4 demeclocycline hcl tab 300 mg 4 doxycycline hyclate cap 100 mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate for inj 100 mg 4 B/D PA doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 100 mg 2 doxycycline hyclate tab delayed release 150 mg 2 doxycycline hyclate tab delayed release 50 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 22

23 doxycycline hyclate tab delayed release 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate for susp 25 mg/5ml 2 minocycline hcl cap 100 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl tab 100 mg 4 minocycline hcl tab 50 mg 4 minocycline hcl tab 75 mg 4 minocycline hcl tab sr 24hr 135 mg 4 minocycline hcl tab sr 24hr 45 mg 4 minocycline hcl tab sr 24hr 90 mg 4 ANTICONVULSANTS Anticonvulsants, Other BRIVIACT INJ50MG/5ML 5 BRIVIACT SOL10MG/ML 5 BRIVIACT TAB100MG 5 BRIVIACT TAB10MG 5 BRIVIACT TAB25MG 5 BRIVIACT TAB50MG 5 QL 600 PER 30 QL 600 PER 30 QL 240 PER 30 QL 90 PER 30 BRIVIACT TAB75MG 5 levetiracetam inj 500 mg/5ml (100 mg/ml) 4 B/D PA levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 1000 mg 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab sr 24hr 500 mg 2 levetiracetam tab sr 24hr 750 mg 2 QL 180 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 23

24 ROWEEPRA TAB1000MG 2 ROWEEPRA TAB750MG 2 QL 90 PER 30 SPRITAM TAB1000MG 4 SPRITAM TAB250MG 4 QL 360 PER 30 SPRITAM TAB500MG 4 QL 180 PER 30 SPRITAM TAB750MG 5 Calcium Channel Modifying Agents CELONTIN CAP300MG 4 ethosuximide cap 250 mg 2 ethosuximide soln 250 mg/5ml 2 LYRICA CAP100MG 3 zonisamide cap 100 mg 2 zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam orally disintegrating tab 0.5 mg 4 clonazepam orally disintegrating tab 1 mg 4 clonazepam tab 1 mg 2 DIASTAT ACDLGEL DIASTAT ACDLGEL5-10MG 4 DIASTAT PED GEL2.5M GEL 4 diazepam conc 5 mg/ml 2 diazepam oral soln 1 mg/ml 2 diazepam tab 10 mg 2 diazepam tab 2 mg 2 QL 180 PER 30 QL 1200 PER 30 QL 600 PER 30 QL 600 PER 30 QL 40 PER 30 QL 240 PER 30 QL 1200 PER 30 QL 180 PER 30 QL 90 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 24

25 diazepam tab 5 mg 2 QL 240 PER 30 gabapentin cap 100 mg 2 QL 360 PER 30 gabapentin cap 300 mg 2 QL 360 PER 30 gabapentin cap 400 mg 2 QL 270 PER 30 gabapentin oral soln 250 mg/5ml 2 QL 2160 PER 30 gabapentin tab 600 mg 2 QL 180 PER 30 gabapentin tab 800 mg 2 GABITRIL TAB12MG 4 QL 90 PER 30 GABITRIL TAB16MG 5 QL 90 PER 30 QL 480 PER 30 ONFI SUS2.5MG/ML 5 ONFI TAB10MG 5 ONFI TAB20MG 5 QL 90 PER 30 PHENOBARB TAB100MG 2 PHENOBARB TAB15MG 2 PHENOBARB TAB30MG 2 QL 195 PER 30 PHENOBARB TAB60MG 2 phenobarbital elixir 20 mg/5ml 2 QL 1500 PER 30 phenobarbital tab 16.2 mg 2 QL 360 PER 30 phenobarbital tab 32.4 mg 2 QL 180 PER 30 phenobarbital tab 64.8 mg 2 QL 90 PER 30 phenobarbital tab 97.2 mg 2 primidone tab 250 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 25

26 primidone tab 50 mg 2 LA; QL 180 PER 30 SABRIL POW500MG 5 SABRIL TAB500MG 5 LA; QL 180 PER 30 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 tiagabine hcl tab 12 mg 4 QL 90 PER 30 tiagabine hcl tab 16 mg 4 QL 90 PER 30 valproate sodium inj 100 mg/ml 4 B/D PA Glutamate Reducing Agents felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 FYCOMPA SUS0.5MG/ML 5 FYCOMPA TAB10MG 4 FYCOMPA TAB12MG 5 FYCOMPA TAB2MG 4 FYCOMPA TAB4MG 4 FYCOMPA TAB6MG 4 FYCOMPA TAB8MG 4 lamotrigine kitstart 35 4 lamotrigine kitstart 49 4 lamotrigine kitstart 98 4 lamotrigine orally disintegrating tab 100 mg 4 topiramate sprinkle cap 25 mg 2 TROKENDI XR CAP100MG 4 TROKENDI XR CAP200MG 5 TROKENDI XR CAP25MG 4 TROKENDI XR CAP50MG 4 Sodium Channel Agents QL 720 PER 30 QL 90 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 26

27 APTIOM TAB200MG 5 QL 180 PER 30 APTIOM TAB400MG 5 QL 90 PER 30 APTIOM TAB600MG 5 APTIOM TAB800MG 5 QL 45 PER 30 BANZEL SUS40MG/ML 5 QL 2400 PER 30 BANZEL TAB200MG 5 QL 240 PER 30 BANZEL TAB400MG 5 QL 240 PER 30 carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 400 mg 2 DILANTIN CAP30MG 3 EQUETRO CAP300MG 4 QL 180 PER 30 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 4 B/D PA oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4 oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 OXTELLAR XR TAB150MG 4 QL 480 PER 30 OXTELLAR XR TAB300MG 4 QL 240 PER 30 OXTELLAR XR TAB600MG 4 PEGANONE TAB250MG 4 phenytoin chew tab 50 mg 1 phenytoin sodium extended cap 100 mg 1 phenytoin sodium extended cap 200 mg 1 phenytoin sodium extended cap 300 mg 1 phenytoin sodium inj 50 mg/ml 4 B/D PA phenytoin susp 125 mg/5ml 1 VIMPAT INJ200MG/20 5 QL 1200 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 27

28 VIMPAT SOL10MG/ML 5 QL 1200 PER 30 VIMPAT TAB100MG 5 VIMPAT TAB150MG 5 VIMPAT TAB200MG 5 VIMPAT TAB50MG 4 ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates tab 1 mg 2 Cholinesterase Inhibitors donepezil hydrochloride orally disintegrating tab 10 mg 4 donepezil hydrochloride orally disintegrating tab 5 mg 4 donepezil hydrochloride tab 10 mg 2 donepezil hydrochloride tab 23 mg 2 donepezil hydrochloride tab 5 mg 2 galantamine hydrobromide cap sr 24hr 16 mg 4 galantamine hydrobromide cap sr 24hr 24 mg 4 galantamine hydrobromide cap sr 24hr 8 mg 4 galantamine hydrobromide oral soln 4 mg/ml 4 galantamine hydrobromide tab 12 mg 4 galantamine hydrobromide tab 4 mg 4 galantamine hydrobromide tab 8 mg 4 rivastigmine tartrate cap 1.5 mg 4 rivastigmine tartrate cap 3 mg 4 QL 180 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 28

29 rivastigmine tartrate cap 4.5 mg 4 rivastigmine tartrate cap 6 mg 4 rivastigmine td patch 24hr 13.3 mg/24hr 2 rivastigmine td patch 24hr 4.6 mg/24hr 2 rivastigmine td patch 24hr 9.5 mg/24hr 2 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hccap14mg er 2 memantine hccap21mg er 2 memantine hccap28mg er 2 memantine hccap7mg er 2 memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 10 mg 1 memantine hcl tab 5 mg 1 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 4 NAMZARIC CAP 3 NAMZARIC CAP14-10MG 3 NAMZARIC CAP21-10MG 3 NAMZARIC CAP28-10MG 3 NAMZARIC CAP7-10MG 3 ANTIDEPRESSANTS Antidepressants olanzapine-fluoxetine hcl cap mg 4 olanzapine-fluoxetine hcl cap mg 4 olanzapine-fluoxetine hcl cap 3-25 mg 4 QL 360 PER 30 QL 90 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 29

30 olanzapine-fluoxetine hcl cap 6-25 mg 4 QL 90 PER 30 olanzapine-fluoxetine hcl cap 6-50 mg 4 perphenazine-amitriptyline tab 2-10 mg 4 perphenazine-amitriptyline tab 2-25 mg 4 perphenazine-amitriptyline tab 4-10 mg 4 perphenazine-amitriptyline tab 4-25 mg 4 perphenazine-amitriptyline tab 4-50 mg 4 Antidepressants, Other ABILIFY MAININJ400MG 5 ARISTADA INJ1064MG 5 bupropion hcl tab 100 mg 2 bupropion hcl tab 75 mg 2 bupropion hcl tab sr 12hr 100 mg 2 bupropion hcl tab sr 12hr 150 mg 2 bupropion hcl tab sr 12hr 200 mg 2 bupropion hcl tab sr 24hr 150 mg 2 bupropion hcl tab sr 24hr 300 mg 2 FORFIVO XL TAB450MG 4 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 QL 1 PER 28 QL 3.9 PER 56 QL 180 PER 30 QL 90 PER 30 QL 45 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 30

31 mirtazapine tab 7.5 mg 2 QUETIAPINE TAB300MG ER 3 QUETIAPINE TAB50MG ER 3 quetiapine fumarate tab 300 mg 2 QL 90 PER 30 quetiapine fumarate tab 400 mg 2 SEROQUEL XR TAB300MG 3 SEROQUEL XR TAB50MG 3 Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 5 EMSAM DIS6MG/24HR 5 EMSAM DIS9MG/24HR 5 MARPLAN TAB10MG 4 phenelzine sulfate tab 15 mg 2 tranylcypromine sulfate tab 10 mg 2 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors) QL 600 PER 30 citalopram hydrobromide oral soln 10 mg/5ml 1 citalopram hydrobromide tab 10 mg (base equiv) 1 citalopram hydrobromide tab 20 mg (base equiv) 1 citalopram hydrobromide tab 40 mg (base equiv) 1 DESVENLAFAX TAB100MG ER 2 DESVENLAFAX TAB100MG ER 4 DESVENLAFAX TAB25MG ER 2 QL 240 PER 30 QL 240 PER 30 DESVENLAFAX TAB50MG ER 4 Imperial Health Plan of California 2018 處方藥一覽表 31

32 DESVENLAFAX TAB50MG ER 2 QL 240 PER 30 duloxetine hcl enteric coated pellets cap 40 mg 2 QL 90 PER 30 FETZIMA CAP120MG 4 FETZIMA CAP20MG 4 QL 180 PER 30 FETZIMA CAP40MG 4 FETZIMA CAP80MG 4 FETZIMA CAPTITRATIO 4 QL 28 PER 28 fluoxetine hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 2 fluoxetine hcl cap 40 mg 2 fluoxetine hcl cap delayed release 90 mg 1 QL 5 PER 30 fluoxetine hcl solution 20 mg/5ml 1 QL 600 PER 30 fluoxetine hcl tab 10 mg 1 QL 240 PER 30 fluoxetine hcl tab 20 mg 1 fluvoxamine maleate cap sr 24hr 100 mg 2 fluvoxamine maleate cap sr 24hr 150 mg 2 fluvoxamine maleate tab 100 mg 2 QL 90 PER 30 fluvoxamine maleate tab 25 mg 2 QL 360 PER 30 fluvoxamine maleate tab 50 mg 2 QL 180 PER 30 KHEDEZLA TAB100MG ER 4 QL 240 PER 30 KHEDEZLA TAB50MG ER 4 Imperial Health Plan of California 2018 處方藥一覽表 32

33 maprotiline hcl tab 25 mg 2 QL 270 PER 30 maprotiline hcl tab 50 mg 2 QL 135 PER 30 maprotiline hcl tab 75 mg 2 nefazodone hcl tab 100 mg 2 QL 180 PER 30 nefazodone hcl tab 150 mg 2 nefazodone hcl tab 200 mg 2 QL 90 PER 30 nefazodone hcl tab 250 mg 2 QL 72 PER 30 nefazodone hcl tab 50 mg 2 QL 360 PER 30 PRISTIQ TAB100MG 4 trazodone hcl tab 100 mg 2 trazodone hcl tab 150 mg 2 trazodone hcl tab 300 mg 2 trazodone hcl tab 50 mg 2 TRINTELLIX TAB10MG 4 TRINTELLIX TAB20MG 4 TRINTELLIX TAB5MG 4 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 2 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 2 QL 90 PER 30 venlafaxine hcl tab 100 mg 2 QL 90 PER 30 venlafaxine hcl tab 75 mg 2 QL 150 PER 30 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 4 QL 90 PER 30 VIIBRYD KITSTARTER 4 VIIBRYD TAB10MG 4 VIIBRYD TAB20MG 4 Imperial Health Plan of California 2018 處方藥一覽表 33

34 VIIBRYD TAB40MG 4 Tricyclics amitriptyline hcl tab 10 mg 2 amitriptyline hcl tab 100 mg 2 amitriptyline hcl tab 150 mg 2 amitriptyline hcl tab 25 mg 2 amitriptyline hcl tab 50 mg 2 amitriptyline hcl tab 75 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 clomipramine hcl cap 25 mg 2 clomipramine hcl cap 50 mg 2 clomipramine hcl cap 75 mg 2 desipramine hcl tab 10 mg 4 desipramine hcl tab 100 mg 4 desipramine hcl tab 150 mg 4 desipramine hcl tab 25 mg 4 desipramine hcl tab 50 mg 4 desipramine hcl tab 75 mg 4 doxepin hcl cap 25 mg 2 imipramine hcl tab 10 mg 2 imipramine hcl tab 25 mg 2 imipramine hcl tab 50 mg 2 nortriptyline hcl cap 10 mg 2 nortriptyline hcl cap 25 mg 2 nortriptyline hcl cap 50 mg 2 nortriptyline hcl cap 75 mg 2 nortriptyline hcl soln 10 mg/5ml 2 protriptyline hcl tab 10 mg 2 protriptyline hcl tab 5 mg 2 trimipramine maleate cap 100 mg 4 trimipramine maleate cap 25 mg 4 trimipramine maleate cap 50 mg 4 ANTIEMETICS Imperial Health Plan of California 2018 處方藥一覽表 34

35 藥物名稱層級規定 / 限制 Antiemetics, Other chlorpromazine hcl inj 50 mg/2ml 4 B/D PA meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 prochlorperazine suppos 25 mg 2 Emetogenic Therapy Adjuncts ALOXI INJ0.25MG/5 5 B/D PA QL 4 PER 30 aprepitant capsule 125 mg 2 ; B/D PA aprepitant capsule 40 mg 2 ; B/D PA aprepitant capsule 80 mg 2 QL 4 PER 30 ; B/D PA aprepitant capsule therapy pack 80 & 125 mg 2 ; B/D PA dronabinol cap 10 mg 5 ; B/D PA dronabinol cap 2.5 mg 2 ; B/D PA dronabinol cap 5 mg 2 ; B/D PA EMEND SUS125MG 4 B/D PA granisetron hcl tab 1 mg 4 ; B/D PA ondansetron hcl inj 4 mg/2ml (2 mg/ml) 4 ondansetron hcl oral soln 4 mg/5ml 2 B/D PA ondansetron hcl tab 24 mg 2 ; B/D PA ondansetron hcl tab 4 mg 2 ; B/D PA ondansetron hcl tab 8 mg 2 ; B/D PA ondansetron orally disintegrating tab 4 mg 2 B/D PA ondansetron orally disintegrating tab 8 mg 2 B/D PA ANTIFUNGALS Antifungals ABELCET INJ5MG/ML 5 PA AMBISOME INJ50MG 5 B/D PA amphotericin b for inj 50 mg 4 PA Imperial Health Plan of California 2018 處方藥一覽表 35

36 CANCIDAS INJ50MG 5 B/D PA CANCIDAS INJ70MG 5 B/D PA CASPOFUNGIN INJ50MG 5 B/D PA CASPOFUNGIN INJ70MG 5 B/D PA ciclopirox gel 0.77% 4 ciclopirox olamine cream 0.77% (base equiv) 4 ciclopirox olamine susp 0.77% (base equiv) 4 ciclopirox shampoo 1% 4 ciclopirox solution 8% 4 clotrimazole cream 1% 2 clotrimazole soln 1% 2 clotrimazole troche 10 mg 4 econazole nitrate cream 1% 4 ERAXIS INJ100MG 5 PA EXELDERM CRE1% 4 EXELDERM SOL1% 4 fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 4 B/D PA fluconazole in nacl 0.9% inj 400 mg/200ml 4 B/D PA fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 fluconazole tab 50 mg 2 flucytosine cap 250 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 griseofulvin ultramicrosize tab 250 mg 2 itraconazole cap 100 mg 2 ketoconazole cream 2% 2 ketoconazole shampoo 2% 4 ketoconazole tab 200 mg 2 miconazole nitrate vaginal suppos 200 mg 4 QL 3 PER 3 naftifine hcl cream 2% 2 NATACYN SUS5% OP 4 Imperial Health Plan of California 2018 處方藥一覽表 36

37 NOXAFIL SUS40MG/ML 5 QL 630 PER 30 NOXAFIL TAB100MG 5 nystatin cream unit/gm 2 nystatin oint unit/gm 2 nystatin susp unit/ml 4 nystatin tab unit 2 nystatin topical powder unit/gm 2 nystatin-triamcinolone cream unit/gm-% 4 nystatin-triamcinolone oint unit/gm-% 4 oxiconazole nitrate cream 1% 2 terbinafine hcl tab 250 mg 2 terconazole vaginal cream 0.4% 4 terconazole vaginal cream 0.8% 4 terconazole vaginal suppos 80 mg 4 voriconazole for inj 200 mg 4 PA voriconazole for susp 40 mg/ml 5 QL 300 PER 30 ; PA voriconazole tab 200 mg 5 ; PA voriconazole tab 50 mg 5 ; PA ANTIGOUT AGENTS Antigout Agents allopurinol tab 300 mg 2 COLCHICINE TAB0.6MG 4 colchicine w/ probenecid tab mg 2 COLCRYS TAB0.6MG 4 probenecid tab 500 mg 2 ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs celecoxib cap 100 mg 4 celecoxib cap 200 mg 4 Imperial Health Plan of California 2018 處方藥一覽表 37

38 celecoxib cap 400 mg 4 celecoxib cap 50 mg 4 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 mg 2 diclofenac sodium tab delayed release 50 mg 2 diclofenac sodium tab delayed release 75 mg 2 diclofenac sodium tab sr 24hr 100 mg 2 diflunisal tab 500 mg 2 etodolac cap 200 mg 4 etodolac cap 300 mg 4 etodolac tab 400 mg 4 etodolac tab 500 mg 4 etodolac tab sr 24hr 400 mg 4 etodolac tab sr 24hr 500 mg 4 etodolac tab sr 24hr 600 mg 4 fenoprofen calcium tab 600 mg 2 FLECTOR DIS1.3% 4 ; PA flurbiprofen tab 100 mg 2 flurbiprofen tab 50 mg 2 ibu tab 600 mg 2 ibu tab 800 mg 2 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2 indomethacin cap 25 mg 1 PA indomethacin cap 50 mg 1 PA meclofenamate sodium cap 100 mg 2 meclofenamate sodium cap 50 mg 2 meloxicam tab 15 mg 2 meloxicam tab 7.5 mg 2 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen sodium tab 275 mg 4 Imperial Health Plan of California 2018 處方藥一覽表 38

39 naproxen sodium tab 550 mg 4 naproxen sodium tab sr 24hr 375 mg (base equiv) 2 naproxen sodium tab sr 24hr 500 mg (base equiv) 4 naproxen susp 125 mg/5ml 4 naproxen tab 250 mg 2 naproxen tab 375 mg 2 naproxen tab 500 mg 2 naproxen tab ec 375 mg 4 naproxen tab ec 500 mg 4 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 TOLMETIN SODCAP400MG 2 tolmetin sodium tab 600 mg 2 ANTIMIGRAINE AGENTS Antimigraine Agents ergotamine w/ caffeine suppos mg 4 Ergot Alkaloids dihydroergotamine mesylate inj 1 mg/ml 3 DIHYDROERGOTSPR4MG/ML 5 ergotamine w/ caffeine tab mg 4 Prophylactic divalproex sodium tab delayed release 125 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 5 mg 2 topiramate sprinkle cap 15 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 topiramate tab 25 mg 2 topiramate tab 50 mg 2 Serotonin (5-HT) 1b/1d Receptor Agonists QL 8 PER 30 QL 480 PER 30 QL 240 PER 30 QL 1920 PER 30 QL 960 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 39

40 almotriptan malate tab 12.5 mg 2 QL 12 PER 30 almotriptan malate tab 6.25 mg 2 QL 12 PER 30 frovatriptan succinate tab 2.5 mg (base equivalent) 2 QL 12 PER 30 naratriptan hcl tab 1 mg (base equiv) 2 QL 9 PER 30 naratriptan hcl tab 2.5 mg (base equiv) 2 QL 9 PER 30 sumatriptan nasal spray 20 mg/act 2 sumatriptan nasal spray 5 mg/act 2 sumatriptan succinate inj 6 mg/0.5ml 4 QL 6 PER 30 sumatriptan succinate tab 100 mg 2 QL 9 PER 30 sumatriptan succinate tab 25 mg 2 QL 9 PER 30 sumatriptan succinate tab 50 mg 2 QL 9 PER 30 ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE TAB125MG 4 MESTINON SYP60MG/5ML 4 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab cr 180 mg 2 ANTIMYCOBACTERIALS Antimycobacterials aminosalicylic acid cr granules packet 4 gm 2 RIFAMATE CAP 4 Antimycobacterials, Other dapsone tab 100 mg 2 dapsone tab 25 mg 2 rifabutin cap 150 mg 4 Antituberculars CAPASTAT SULINJ1GM 4 B/D PA ethambutol hcl tab 100 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 40

41 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 4 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PRIFTIN TAB150MG 4 pyrazinamide tab 500 mg 2 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 4 B/D PA RIFATER TAB 5 SIRTURO TAB100MG 5 QL 68 PER 28 ; PA TRECATOR TAB250MG 4 ANTINEOPLASTICS Alkylating Agents BUSULFAN INJ6MG/ML 5 B/D PA CYCLOPHOSPH CAP25MG 4 B/D PA CYCLOPHOSPH CAP50MG 4 B/D PA GLEOSTINE CAP100MG 4 GLEOSTINE CAP10MG 4 GLEOSTINE CAP40MG 4 GLEOSTINE CAP5MG 4 HEXALEN CAP50MG 5 ifosfamide for inj 1 gm 4 B/D PA LEUKERAN TAB2MG 3 MATULANE CAP50MG 5 LA melphalan hcl for inj 50 mg (base equiv) 4 B/D PA MUSTARGEN INJ10MG 5 B/D PA TREANDA INJ25MG 5 B/D PA TREANDA INJ100MG 5 B/D PA VALCHLOR GEL0.016% 5 YONDELIS INJ1MG 5 LA; B/D PA Antiandrogens bicalutamide tab 50 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 41

42 ERLEADA TAB60MG 5 flutamide cap 125 mg 2 nilutamide tab 150 mg 2 LA; XTANDI CAP40MG 5 YONSA TAB125MG 5 LA; ZYTIGA TAB250MG 5 ZYTIGA TAB500MG 5 LA; Antiangiogenic Agents POMALYST CAP1MG 5 POMALYST CAP2MG 5 POMALYST CAP3MG 5 POMALYST CAP4MG 5 REVLIMID CAP10MG 5 REVLIMID CAP15MG 5 REVLIMID CAP2.5MG 5 REVLIMID CAP20MG 5 REVLIMID CAP25MG 5 REVLIMID CAP5MG 5 THALOMID CAP100MG 5 THALOMID CAP150MG 5 THALOMID CAP200MG 5 THALOMID CAP50MG 5 LA; LA; LA; LA; LA; LA; LA; LA; LA; LA; QL 150 PER 30 Imperial Health Plan of California 2018 處方藥一覽表 42

43 藥物名稱層級規定 / 限制 Antiestrogens/Modifiers EMCYT CAP140MG 5 FARESTON TAB60MG 5 SOLTAMOX SOL10MG/5ML 5 tamoxifen citrate tab 10 mg (base equivalent) 2 tamoxifen citrate tab 20 mg (base equivalent) 2 Antimetabolites DROXIA CAP200MG 4 DROXIA CAP300MG 4 DROXIA CAP400MG 4 hydroxyurea cap 500 mg 2 PURIXAN SUS20MG/ML 5 LA TABLOID TAB40MG 5 Antineoplastics ABRAXANE INJ100MG 5 B/D PA ALIMTA INJ100MG 5 B/D PA ALIMTA INJ500MG 5 B/D PA ARRANON INJ5MG/ML 5 B/D PA AVASTIN INJ 5 LA; B/D PA AVASTIN INJ400/16ML 5 LA; B/D PA bleomycin sulfate for inj 30 unit 4 B/D PA BORTEZOMIB INJ3.5MG 5 B/D PA carboplatin iv soln 150 mg/15ml 4 B/D PA cisplatin inj 100 mg/100ml (1 mg/ml) 4 B/D PA clofarabine iv soln 1 mg/ml 5 dacarbazine for inj 200 mg 4 B/D PA DARZALEX SOL100MG/5M 5 LA; B/D PA dactinomycininj0.5mg 5 B/D PA daunorubicin hcl inj 5 mg/ml (base equiv) 4 B/D PA DOCETAXEL INJ80MG/4ML 5 B/D PA DOCETAXEL INJ80MG/8ML 5 B/D PA doxorubicin hcl inj 2 mg/ml 4 B/D PA doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 2 B/D PA epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2 B/D PA ERBITUX INJ100MG 5 B/D PA FASLODEX INJ250MG 5 B/D PA Imperial Health Plan of California 2018 處方藥一覽表 43

44 HALAVEN INJ1MG/2ML 5 B/D PA HERCEPTIN INJ150MG 5 LA; B/D PA HERCEPTIN INJ440MG 5 LA; B/D PA hydroxyprogesterone caproate im in oil 1.25 gm/5ml 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 4 B/D PA IMFINZI INJ120/2.4 5 B/D PA IMFINZI INJ500/10 5 B/D PA irinotecan hcl inj 100 mg/5ml (20 mg/ml) 4 B/D PA KADCYLA INJ100MG 5 LA KADCYLA INJ160MG 5 LA KEYTRUDA INJ100MG/4M 5 B/D PA KEYTRUDA SOL50MG 5 B/D PA KISQALI 200 PAKFEMARA 5 QL 49 PER 28 KISQALI 400 PAKFEMARA 5 QL 70 PER 28 KISQALI 600 PAKFEMARA 5 QL 91 PER 28 levoleucovorinj50mg 5 B/D PA mitomycin for iv soln 20 mg 4 mitomycin for iv soln 40 mg 4 mitomycin for iv soln 5 mg 4 oxaliplatin inj100mg 4 B/D PA oxaliplatin iv soln 100 mg/20ml 4 B/D PA paclitaxel iv conc 300 mg/50ml (6 mg/ml) 4 B/D PA PERJETA INJ420/14ML 5 LA; B/D PA PROLEUKIN INJ22MU 5 B/D PA SYNRIBO INJ3.5MG 5 B/D PA thiotepa for inj 15 mg 5 B/D PA TRISENOX SOL10MG/10M 5 B/D PA TRISENOX SOL12MG/6ML 5 B/D PA VECTIBIX INJ100MG 5 B/D PA QL 112 PER 28 VERZENIO TAB100MG 5 VERZENIO TAB150MG 5 VERZENIO TAB200MG 5 QL 56 PER 28 QL 56 PER 28 Imperial Health Plan of California 2018 處方藥一覽表 44

45 QL 224 PER 28 VERZENIO TAB50MG 5 vinblastine sulfate inj 1 mg/ml 4 B/D PA vincristine sulfate iv soln 1 mg/ml 4 B/D PA vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv) 4 B/D PA VYXEOS INJ44-100MG 5 B/D PA ZALTRAP INJ100/4ML 5 B/D PA ZANOSAR INJ1GM 5 B/D PA Antineoplastics, Other cladribine iv soln 10 mg/10ml (1 mg/ml) 5 B/D PA cytarabine inj 20 mg/ml 4 B/D PA cytarabine inj pf 100 mg/ml 4 B/D PA decitabine for inj 50 mg 5 B/D PA ERWINAZE INJ10000UNT 5 B/D PA fludarabine phosphate for inj 50 mg 4 B/D PA fluorouracil inj 2.5 gm/50ml (50 mg/ml) 4 B/D PA fluorouracil inj 500 mg/10ml (50 mg/ml) 2 B/D PA gemcitabine hcl for inj 1 gm 5 B/D PA ISTODAX OVR INJ10MG 5 B/D PA KYPROLIS SOL30MG 5 LA; B/D PA KYPROLIS SOL60MG 5 LA; B/D PA leucovorin calcium for inj 100 mg 4 B/D PA leucovorin calcium for inj 350 mg 4 B/D PA leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 2 leucovorin calcium tab 25 mg 2 leucovorin calcium tab 5 mg 2 QL 110 PER 28 LONSURF TAB LONSURF TAB QL 80 PER 28 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 4 B/D PA QL 3 PER 28 NINLARO CAP2.3MG 5 NINLARO CAP3MG 5 QL 3 PER 28 QL 3 PER 28 NINLARO CAP4MG 5 Imperial Health Plan of California 2018 處方藥一覽表 45

46 RUBRACA TAB200MG 5 LA; QL 180 PER 30 RUBRACA TAB250MG 5 LA; RUBRACA TAB300MG 5 LA; VELCADE INJ3.5MG 5 B/D PA ZOLINZA CAP100MG 5 Aromatase Inhibitors, 3rd Generation anastrozole tab 1 mg 2 exemestane tab 25 mg 2 letrozole tab 2.5 mg 2 Enzyme Inhibitors ETOPOPHOS INJ100MG 5 B/D PA etoposide inj 1 gm/50ml (20 mg/ml) 4 B/D PA etoposide inj 500 mg/25ml (20 mg/ml) 3 B/D PA topotecan hcl for inj 4 mg 5 B/D PA Molecular Target Inhibitors AFINITOR TAB10MG 5 AFINITOR TAB2.5MG 5 AFINITOR TAB5MG 5 AFINITOR TAB7.5MG 5 AFINITOR DISTAB2MG 5 QL 150 PER 30 AFINITOR DISTAB3MG 5 QL 90 PER 30 AFINITOR DISTAB5MG 5 ALECENSA CAP150MG 5 LA; QL 240 PER 30 ALIQOPA INJ60MG 5 B/D PA ALUNBRIG PAK 5 Imperial Health Plan of California 2018 處方藥一覽表 46

47 ALUNBRIG TAB30MG 5 QL 180 PER 30 ALUNBRIG TAB180MG 5 ALUNBRIG TAB90MG 5 BELEODAQ INJ500MG 5 B/D PA BOSULIF TAB100MG 5 BOSULIF TAB400MG 5 BOSULIF TAB500MG 5 CABOMETYX TAB20MG 5 CABOMETYX TAB40MG 5 CABOMETYX TAB60MG 5 CALQUENCE CAP100MG 5 LA; LA; LA; CAPRELSA TAB100MG 5 LA; CAPRELSA TAB300MG 5 LA; COMETRIQ KIT100MG 5 LA; QL 56 PER 28 COMETRIQ KIT140MG 5 LA; QL 112 PER 28 COMETRIQ KIT60MG 5 LA; QL 84 PER 28 COTELLIC TAB20MG 5 LA; QL 63 PER 28 CYRAMZA INJ100/10ML 5 LA; B/D PA CYRAMZA INJ500/50ML 5 LA; B/D PA LA; ERIVEDGE CAP150MG 5 LA; FARYDAK CAP10MG 5 LA; FARYDAK CAP15MG 5 Imperial Health Plan of California 2018 處方藥一覽表 47

48 FARYDAK CAP20MG 5 LA; LA; GILOTRIF TAB20MG 5 GILOTRIF TAB30MG 5 LA; GILOTRIF TAB40MG 5 LA; LA; IBRANCE CAP100MG 5 IBRANCE CAP125MG 5 LA; IBRANCE CAP75MG 5 LA; ICLUSIG TAB15MG 5 LA; QL 90 PER 30 ICLUSIG TAB45MG 5 LA; IDHIFA TAB100MG 5 IDHIFA TAB50MG 5 imatinib mesylate tab 100 mg (base equivalent) 5 imatinib mesylate tab 400 mg (base equivalent) 5 IMBRUVICA CAP140MG 5 IMBRUVICA CAP70MG 5 IMBRUVICA TAB140MG 5 IMBRUVICA TAB280MG 5 IMBRUVICA TAB420MG 5 IMBRUVICA TAB560MG 5 INLYTA TAB1MG 5 INLYTA TAB5MG 5 IRESSA TAB250MG 5 LA; LA; QL 240 PER 30 LA; LA; LA; LA; LA; QL 240 PER 30 LA; LA; Imperial Health Plan of California 2018 處方藥一覽表 48

49 JAKAFI TAB10MG 5 LA; JAKAFI TAB15MG 5 LA; JAKAFI TAB20MG 5 LA; JAKAFI TAB25MG 5 LA; JAKAFI TAB5MG 5 LA; JEVTANA INJ60/1.5ML 5 B/D PA KISQALI TAB200DOSE 5 QL 21 PER 28 KISQALI TAB400DOSE 5 QL 63 PER 28 KISQALI TAB600DOSE 5 QL 63 PER 28 LENVIMA CAP10 MG 5 LA; QL 90 PER 30 LENVIMA CAP14 MG 5 LA; LENVIMA CAP18 MG 5 LA LENVIMA CAP20 MG 5 LA; LENVIMA CAP24 MG 5 LA; QL 90 PER 30 LENVIMA CAP8 MG 5 LA LA; QL 480 PER 30 LYNPARZA CAP50MG 5 LYNPARZA TAB100MG 5 LA; QL 180 PER 30 LYNPARZA TAB150MG 5 MEKINIST TAB0.5MG 5 MEKINIST TAB2MG 5 NERLYNX TAB40MG 5 NEXAVAR TAB200MG 5 LA; QL 180 PER 30 LA; Imperial Health Plan of California 2018 處方藥一覽表 49

50 ODOMZO CAP200MG 5 RYDAPT CAP25MG 5 QL 224 PER 28 SPRYCEL TAB100MG 5 SPRYCEL TAB140MG 5 SPRYCEL TAB20MG 5 SPRYCEL TAB50MG 5 SPRYCEL TAB70MG 5 SPRYCEL TAB80MG 5 LA; QL 84 PER 28 STIVARGA TAB40MG 5 QL 90 PER 30 SUTENT CAP12.5MG 5 SUTENT CAP25MG 5 SUTENT CAP37.5MG 5 SUTENT CAP50MG 5 QL 180 PER 30 TAFINLAR CAP50MG 5 TAFINLAR CAP75MG 5 TAGRISSO TAB40MG 5 LA; TAGRISSO TAB80MG 5 LA; LA; TARCEVA TAB100MG 5 TARCEVA TAB150MG 5 LA; TARCEVA TAB25MG 5 LA; QL 90 PER 30 QL 480 PER 30 TASIGNA CAP50MG 5 Imperial Health Plan of California 2018 處方藥一覽表 50

51 TASIGNA CAP150MG 5 TASIGNA CAP200MG 5 TYKERB TAB250MG 5 LA; QL 180 PER 30 LA; QL 112 PER 28 VENCLEXTA TAB100MG 5 VENCLEXTA TAB10MG 4 LA; QL 1120 PER 28 VENCLEXTA TAB50MG 4 LA; QL 224 PER 28 VENCLEXTA TABSTART PK 5 LA; QL 42 PER 28 VOTRIENT TAB200MG 5 LA; XALKORI CAP200MG 5 XALKORI CAP250MG 5 LA; ZEJULA CAP100MG 5 QL 90 PER 30 LA; QL 240 PER 30 ZELBORAF TAB240MG 5 LA; QL 90 PER 30 ZYDELIG TAB100MG 5 ZYDELIG TAB150MG 5 LA; ZYKADIA CAP150MG 5 LA; QL 150 PER 30 Monoclonal Antibody/Antibody-Drug Conjugate BAVENCIO INJ20MG/ML 5 LA; B/D PA EMPLICITI INJ300MG 5 B/D PA EMPLICITI INJ400MG 5 B/D PA LARTRUVO INJ10MG/ML 5 LA; B/D PA LARTRUVO INJ190MG/19ML 5 LA; B/D PA MYLOTARG INJ4.5MG 5 B/D PA QL 80 PER 28 OPDIVO INJ40MG/4ML 4 ; B/D PA OPDIVO INJ100MG/10ML 4 B/D PA RITUXAN INJ100MG 5 LA; B/D PA Imperial Health Plan of California 2018 處方藥一覽表 51

52 RITUXAN INJ500MG 5 LA; B/D PA TECENTRIQ INJ1200/20 5 LA; B/D PA YERVOY INJ50MG 5 Retinoids bexarotene cap 75 mg 5 PANRETIN GEL0.1% 5 TARGRETIN GEL1% 5 tretinoin cap 10 mg 5 tretinoin microsphere gel 0.04% 4 LA; QL 250 PER 21 ; B/D PA QL 300 PER 30 Treatment Adjuncts allopurinol tab 100 mg 2 ELITEK INJ1.5MG 5 B/D PA ELITEK INJ7.5MG 5 B/D PA mesna inj 100 mg/ml 4 B/D PA MESNEX TAB400MG 5 ANTIPARASITICS Antihelminthics ALBENZA TAB200MG 5 BILTRICIDE TAB600MG 4 ivermectin tab 3 mg 2 Antiprotozoals ALINIA SUS100/5ML 4 QL 180 PER 3 ALINIA TAB500MG 5 QL 40 PER 30 atovaquone susp 750 mg/5ml 5 PA atovaquone-proguanil hcl tab mg 2 atovaquone-proguanil hcl tab mg 4 chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 COARTEM TAB20-120MG 4 DARAPRIM TAB25MG 5 hydroxychloroquine sulfate tab 200 mg 2 mefloquine hcl tab 250 mg 2 Imperial Health Plan of California 2018 處方藥一覽表 52

53 NEBUPENT INH300MG 4 PA PENTAM 300 INJ300MG 4 PA primaquine phosphate tab 26.3 mg (15 mg base) 4 quinine sulfate cap 324 mg 2 PA Pediculicides/Scabicides lindane shampoo 1% 4 malathion lotion 0.5% 4 permethrin cream 5% 2 ANTIPARKINSON AGENTS Anticholinergics benztropine mesylate inj 1 mg/ml 4 B/D PA benztropine mesylate tab 0.5 mg 2 PA benztropine mesylate tab 1 mg 2 PA benztropine mesylate tab 2 mg 2 PA diphenhydramine hcl inj 50 mg/ml 4 B/D PA trihexyphenidyl hcl elixir 0.4 mg/ml 2 PA trihexyphenidyl hcl tab 2 mg 2 PA trihexyphenidyl hcl tab 5 mg 2 PA Antiparkinson Agents, Other amantadine hcl syrup 50 mg/5ml 4 entacapone tab 200 mg 2 tolcapone tab 100 mg 5 QL 270 PER 30 Dopamine Agonists APOKYN INJ10MG/ML 5 LA; PA NEUPRO DIS1MG/24HR 4 ; ST NEUPRO DIS2MG/24HR 4 ; ST NEUPRO DIS3MG/24HR 4 ; ST NEUPRO DIS4MG/24HR 4 NEUPRO DIS6MG/24HR 4 NEUPRO DIS8MG/24HR 4 ; ST Imperial Health Plan of California 2018 處方藥一覽表 53