P 9 H 東華 2019 F H A A HI N N AIN INF A I N A H IN HI AN H A F F I N F H H H H0571_2019_11 _FINA

Transcription

1 P 9 H 東華 019 F H A A HI N N AIN INF A I N A H IN HI AN H A F F I N 7 8 F H H H H0571_019_11 _FINA _1_C

2 會員請注意 : 此藥物表已經修改, 請查閱您服食的藥物是否仍受承保 在此藥物一覽表 ( 藥物表 ) 中, 我們 或 我們的 代表華人保健計劃 (CCHP) 計劃 本計劃 或 我們的計劃 代表東華耆英 (HMO) 計劃 此藥物表為 018 年 08 月 日起生效 欲索取最新的藥物表, 請與我們聯絡 我們的聯 絡資料連同最近更新藥物表的日期會列在本冊的封面及封底 保險受益人通常須前往聯網藥房, 以獲享配購處方藥物的保障 保障 藥物表 聯網藥房 月費及 / 或自付費 / 共同保險額, 或於 019 年 1 月起有更新 甚麼是東華耆英 (HMO) 計劃藥物表? 東華耆英 (HMO) 計劃與一組醫療保健提供者商議之下, 選擇了一批最能確保優質治療方案的處方藥物, 並在此列出這份藥物表 只要您配購的藥物是基於治療所需 在東華耆英 (HMO) 計劃屬下的聯網藥房購買, 以及附合其他條款, 則受承保 欲了解如何配取處方藥物, 請參閱保障說明書 藥物一覽表 ( 藥物表 ) 會有更改嗎? 一般來說, 如果您在年初開始服食的藥物仍包括在 019 年的藥物表內, 我們不會在 019 年內終止或減除您該項藥物的保障, 除非有一種更新更廉價的非商標藥物包括在新的藥物表內, 或與該藥物的效用或安全使用方面質疑的報導, 或該藥物在市場上被移除回收 ( 有關影響目前服用該藥物的會員, 請參閱下面列出的詳情 ) 若藥物表有其它方面的更改, 如刪除某些藥物, 不會對正在服食藥物的會員造成影響 受影響的會員, 於受保障的這一年內, 藥物仍會受到保障, 且自付費不變 以下列出影響會員服用該藥物的轉變 : 新非商標藥物, 如果我們同時以相同或更少限制及相同或較低分擔費用等級的新非商標藥替代藥物表中的商標藥 ; 我們可能會立即在我們的藥物表中刪除商標藥 此外, 在添加新非商標藥時, 我們可能會決定將商標藥物保留在我們的藥物表中, 但會立即將其移至不同的分擔費用等級或添加新的限制 如果您正在服用該商標藥物, 我們可能未提前通知您有關的更改, 但仍會在更改後通知您 如我們作出更改, 您或處方醫生可要求本計劃對藥物進行例外處理及要求繼續承保該商標藥物 了解如何提出例外處理, 請參閱本冊 如何要求東華耆英 (HMO) 計劃對藥物作出例外處理? 部分 I

3 藥物在市場上被移除回收 如果藥物表內有藥物經聯邦藥物及食品管理局認為不安全 或藥廠從市場上收回的藥物, 我們會立刻將該藥物從藥物表內刪除, 並通知服食該藥 物的會員 其他更改 我們的更改可能影響到會員正在服用的藥物 例如 : 我們可能增加一種並不是新的非商標藥以取代在藥物表上的商標藥, 或會更改商標藥的分擔費用等級或添加新的限制, 亦有可能亦有可能根據新的臨床醫療指南進行更改或增加事前批准條例, 數量限制或階段治療限制, 亦可能將藥物分擔費用等級提高 我們在更改前最少 0 日內通知會員或在會員提出加配藥物要求時我們會提供三十天的藥量 此藥物表為 018 年 08 月 日起更新 欲索取最新的藥物表, 請與我們聯絡 我們的聯絡資 料連同最近更新藥物表的日期會列在本冊的封面及封底 如果藥物表在年中有任何更改, 我們會寄發糾正通知, 您亦可瀏覽 查閱變更 如何使用此藥物表? 以下列出兩種方法查閲藥物表內的藥物 : 按疾病狀況 藥物表從第 頁開始, 並以疾病情況來分類 例如, 用來治療心臟病的藥物歸屬於 心血管藥物 - 其它 一欄 如果您知道您的藥物用來作何種用途的話, 請查閱分類目錄從第 7 頁開始, 然後按該目錄的分類找出您要配購的藥物 按藥物名稱的英文字母排列 如果您不確定藥物屬於那一項分類, 您可以查閱藥物表第 I-1 頁開始的藥物名稱的英文字母索引 英文字母索引列出藥物表所有的藥物, 包括商標及非商標藥物 請查閱索引, 找出您要配購的藥物 在藥物名稱的同一欄中, 找出有關該藥物保障資料的頁數, 然後到該頁內查閱藥物的資料 甚麼是非商標藥物? 東華耆英 (HMO) 計劃承保商標藥物及非商標藥物 非商標藥物與商標藥物通常是採用同樣的成份製成 非商標藥物是經過聯邦藥物及食品管理局 (FDA) 認可而價格比商標藥物較廉宜 保障的藥物有其它的限制嗎? 某些保障藥物可能有附加的限制或規定, 這些限制或規定可能包括以下幾點 : II

4 需取得事先批准 : 東華耆英 (HMO) 計劃要求某些藥物需事先取得批准方能購買 這就是說, 您 ( 或您的醫生 ) 必須取得東華耆英 (HMO) 計劃的批准, 方能配購這些處方藥物 否則, 東華耆英 (HMO) 計劃是不會承保該藥物的保障 數量限制 : 東華耆英 (HMO) 計劃對某些藥物的保障設有數量的限制 如東華耆英 (HMO) 計劃提供 JARDIANCE, 每張處方只可配 0 tablets 配購一個月或三個月的藥量可能有其他限制 階段治療 : 在某些情況下, 東華耆英 (HMO) 計劃可能要求您在治療疾病時, 先嘗試建議的藥物, 然後再考慮是否承保另一類的藥物 例如 A 類藥物與 B 類藥物皆可以治療您的疾病, 東華耆英 (HMO) 計劃可能讓您先使用 A 類藥物, 若沒有成效才保障 B 類藥物的費用 您可從第 7 頁開始, 找到您欲配購的處方藥物是否有附加規定或限制 查詢更多有關藥物的限制及附加規定, 請瀏覽我們的網址 我們的網址上載了關於事前批准及階段治療的條款限制 您亦可以聯絡我們索取一分影印本 我們的聯絡資料連同最近更新藥物表的日期會列在本冊的封面及封底 您可以要求東華耆英 (HMO) 計劃對這些附加規定或限制作出例外處理, 或提供治療同一種症狀的其它承保藥物名稱 了解如何提出例外處理, 請參閱本冊 如何要求東華耆英 (HMO) 計劃對藥物作出例外處理? 部分, 第 頁 什麼是非處方藥物 (OTC)? 配購非處方藥物無須醫生處方, 通常不受聯邦健保處方藥物計劃的保障 東華耆英 (HMO) 計劃會保障某些非處方藥物 FREESTYLE LITE METER FREESTYLE FREEDOM LITE METER FREESTYLE LITE TEST STRIPS FREESTYLE INSULINX METER FREESTYLE INSULINX TEST STRIPS FREESTYLE CONTROL SOLUTION PRECISION XTRA METER PRECISION XTRA TEST STRIPS MEDISENSE CONTROL SOLUTION LANCETS LANCET DEVICES LANCET KIT KETOTIFEN FUMARATE OPHTHALMIC SOLUTION 0.05% ARTIFICIAL TEARS 東華耆英 (HMO) 計劃免費提供以上非處方藥物 這些藥物的費用將不計算入您的 D 部份藥物費用總額 ( 即非處方藥物費用不計算入承保間斷期藥物費用額 ) III

5 如果我的藥物不包括在藥物表內該怎麼辦? 如果您的藥物並不包括在藥物表 ( 藥物一覽表 ) 內, 您應該首先與會員服務中心聯絡, 求證該藥物是否受保障 如果您的藥物不受保障, 您有以下兩種選擇 : 您可以向會員服務中心索取一份受東華耆英 (HMO) 計劃保障的同類型藥物表 然後出示給您的醫生, 要求醫生處方受保障的藥物 您也可以向東華耆英 (HMO) 計劃要求對您所需的藥物作出例外保障處理 請參閱以下, 了解如何提出例外處理 如何要求東華耆英 (HMO) 計劃對藥物作出例外處理? 您可以要求東華耆英 (HMO) 計劃對藥物保障作出例外處理 以下是幾種可以提出例外處理的例子 您可以要求本計劃承保沒有列在藥物表之內的藥物 若計劃批准您的要求, 您的藥物將會有一個特定的分攤費用, 而您將不能再申請降低該藥物的分攤費 除了特殊藥物外, 您可以要求本計劃以較低的分攤費等級承保您的藥物, 以減低您需要支付的藥物費用 您也可以要求我們取消對您所需藥物的限制或規定 例如東華耆英 (HMO) 計劃對某些藥物有數量的限制, 您可以要求我們取消此限制或增加承保的數量 一般來說, 如果其它在藥物表上的藥物及較低分擔費用藥物對您的病情無效或引起不良的副作用, 東華耆英 (HMO) 計劃才會批准您的要求作例外情況處理 您可以聯絡我們要求對您的申請作一個初級的審定附加條件限制例外處理 當在申請對藥物表或附加條件限制等例外處理時, 您必須附加一份醫生或處方藥劑師的證明作為支持申請的理據 一般來說, 我們會在收到有關醫生的證明文件後 7 小時內對您的申請作出答覆 如果您或您的醫生認為在等候的 7 小時內會危害到您的健康情況, 您可以要求加快例外處理 如果您的加快申請獲得批准, 我們會在收到有關醫生或處方藥劑師的證明文件後的 小時內作出決定 在與醫生商量改藥或申請例外處理之前, 我該怎麼辦? 無論是新會員或現任會員, 您正在服食的藥物可能不包括在藥物表內, 又或藥物在藥物表內但有限制 例如, 您需預先取得我們的批准方能配購藥物 您應與醫生商量您是否可轉用另一種保障之內的藥物, 或提出例外處理的申請以使您的藥物受到保障 在某情況下, 您與醫生商量 IV

6 的期間內, 我們可以在您成為會員的首 90 天之內承保您所需的藥物 如果您的藥物不在藥物表內或取不到藥物的情況下, 您必須在聯網藥房配購藥物, 我們會為每一種藥物提供 0 天的臨時保障 ( 如果您的藥物處方是少於 0 天, 我們會允許續配最多 0 天藥量 ) 但在 0 天之後, 即使您是加入不到 90 天的新會員, 我們也不再保障有關所需的藥物 如果您住在長期療養院內, 您需要的藥物不在藥物表內, 又或有困難取到藥物, 但您又超過了 90 天的新會員期, 在申請藥物例外處理的過程中, 我們會提供 1 天的緊急藥物補給量 欲了解有關詳情 欲了解更多有關東華耆英 (HMO) 計劃處方藥物保障, 請參閱保障說明書及計劃的其它說明資 料 如對東華耆英 (HMO) 計劃有任何疑問, 請與我們聯絡 我們的聯絡資料連同最近更新藥物 表的日期會列在本冊的封面及封底 如您對聯邦保健藥物保障有任何疑問, 可於每週 7 天, 每天 小時, 致電聯邦保健 MEDICARE ( ), 聽力殘障人士請致電 TTY , 或瀏覽 : 東華耆英 (HMO) 計劃處方藥物表 下頁的藥物目錄表提供了東華耆英 (HMO) 計劃承保的部份處方藥物資料 如您對查閱藥物有任何疑問, 請查閱索引目錄第 I-1 頁 藥物表內第一欄是藥物的名稱, 商標藥物以大寫字母列出, 如 (VYVANSE), 而非商標藥物則以斜體小寫字母列出, 如 (alendronate) 藥物表內第二欄列出藥物級別 欲了解更多有關處方藥物分擔費用, 請參閱保障說明或致電 與會員服務中心聯絡 聽力殘障人士請致電 TTY 在特殊要求該欄, 說明了東華耆英 (HMO) 計劃對您所需的藥物是否有特別的規定及限制 有 LD 標誌的藥物表示該藥物受聯邦藥物及食品管理局 (FDA) 的限制, 並只能在 指定藥房購買 詳情請查閱醫生名錄, 醫療服務及藥房手冊或請每週七天, 上午 8 時至晚上 8 時致電 與會員服務中心聯絡 聽力殘障人士請致電 TTY 有 NM 標誌的藥物表示該非郵寄服務藥物在零售及郵寄藥房都只供應 0 天的藥量 V

7 有 PA 標誌的藥物表示該藥物需要預先取得批准 這就是說, 在配購藥物前, 您 ( 或您的醫生 ) 必須取得東華耆英 (HMO) 計劃的批准, 方能配購這些處方藥物 否則, 東華耆英 (HMO) 計劃是不會承保該藥物的保障 有 PA BvD 標誌的藥物表示, 該藥物同時在聯邦保健 D 部分或 B 部分藥物承保 您 ( 或您的醫生 ) 需要東華耆英 (HMO) 計劃事前批准來確定該藥物被哪一個藥物保障部分承保, 你才能配藥 若沒有事前批准, 東華耆英 (HMO) 計劃可能不承保該藥物 有 PA NSO 標誌的藥物表示, 如會員從未配購該藥物, 您 ( 或您的醫生 ) 需要取得東華耆英 (HMO) 計劃事前批准才能配藥 若沒有事前批准, 東華耆英 (HMO) 計劃可能不承保該藥物 有 QL 標誌的藥物表示該藥物有數量的限制 東華耆英 (HMO) 計劃設有具體的限制包括 : 每日的數量限制, 每月的數量限制或每年的數量限制 有 ST 標誌的藥物表示該藥物在某些情況下, 東華耆英 (HMO) 計劃可能要求您在治療疾病時, 先嘗試建議的藥物, 然後再考慮是否承保另一類的藥物 例如 A 類藥物與 B 類藥物皆可以治療您的疾病, 東華耆英 (HMO) 計劃可能讓您先使用 A 類藥物, 若沒有成效才保障 B 類藥物的費用 VI

8 目錄 Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants... 8 Antidementia Agents... Antidepressants... Antidiabetic Agents... 5 Antifungals... 8 Antigout Agents... 0 Antihistamines... 0 Anti-Infectives (Skin And Mucous Membrane)... 1 Antimigraine Agents... 1 Antimycobacterials... Antinausea Agents... Antiparasite Agents... Antiparkinsonian Agents... Antipsychotic Agents... 6 Antivirals (Systemic)... 9 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives

9 Dental And Oral Agents Dermatological Agents Devices... 8 Enzyme Replacement/Modifiers... 8 Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents... 9 Heavy Metal Antagonists... 9 Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents... 10

10 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butorphanol tartrate injection solution 1 /ml, /ml butorphanol tartrate nasal spray,nonaerosol 10 /ml codeine sulfate oral tablet 15, 0, 60 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100- MG, MG, 0-1. MG, 50- MG, 60-. MG, 80-. MG endocet oral tablet 10-5, 5-5, fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution /15 ml QL (980 per 0 days) QL (90 per 0 days) (Tylenol-Codeine #) QL (90 per 0 days) (Tylenol-Codeine #) QL (90 per 0 days) (Buprenex) (Butrans) QL ( per 8 days) QL (10 per 0 days) QL (0 per 0 days) PA BvD QL (60 per 0 days) QL (60 per 0 days) (Actiq) PA; QL (10 per 0 days) (Duragesic) QL (10 per 0 days) PA; QL (10 per 0 days) (Hycet) QL (500 per 0 days)

11 hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per 0 days) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (90 per 0 days) 00 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (60 per 0 days) 5 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per 0 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (80 per 0 days), 5-00 hydrocodone-ibuprofen oral tablet QL (80 per 0 days) hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection syringe /ml (Dilaudid) hydromorphone oral liquid 1 /ml (Dilaudid) QL (00 per 0 days) hydromorphone oral tablet (Dilaudid) QL (50 per 0 days) hydromorphone oral tablet (Dilaudid) QL (0 per 0 days) hydromorphone oral tablet 8 (Dilaudid) QL (10 per 0 days) hydromorphone oral tablet extended (Exalgo ER) QL (0 per 0 days) release hr 1, 16,, 8 HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 days) ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG ibuprofen-oxycodone oral tablet 00-5 QL (0 per 0 days) KADIAN ORAL QL (60 per 0 days) CAPSULE,EXTEND.RELEASE PELLETS 00 MG, 0 MG LAZANDA NASAL SPRAY,NON- PA; QL (0 per 0 days) AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY levorphanol tartrate oral tablet QL (0 per 0 days) lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 days) lorcet hd oral tablet 10-5 QL (60 per 0 days) lorcet plus oral tablet QL (60 per 0 days)

12 meperidine (pf) injection solution 100 (Demerol (PF)) PA /ml, 50 /ml meperidine (pf) injection solution 5 PA /ml meperidine oral solution 50 /5 ml meperidine oral tablet 100 (Demerol) QL (60 per 0 days) meperidine oral tablet 50 QL (70 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (1800 per 0 days) methadone oral solution 5 /5 ml QL (600 per 0 days) methadone oral tablet 10, 5 (Dolophine) QL (60 per 0 days) morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine injection syringe /ml PA BvD morphine intravenous cartridge /ml PA BvD morphine oral capsule, er multiphase QL (60 per 0 days) hr 10, 0, 5, 60, 75, 90 morphine oral capsule,extend.release (Kadian) QL (60 per 0 days) pellets 10, 100, 0, 0, 50, 60, 80 morphine oral solution 10 /5 ml QL (1800 per 0 days) morphine oral solution 0 /5 ml ( QL (900 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG, 0 QL (180 per 0 days) MG morphine oral tablet extended release 100 (MS Contin) QL (10 per 0 days), 15, 00, 0, 60 NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 75 QL (180 per 0 days) MG NUCYNTA ORAL TABLET 50 MG QL (60 per 0 days) oxycodone oral capsule 5 QL (60 per 0 days) oxycodone oral concentrate 0 /ml QL (70 per 0 days) oxycodone oral solution 5 /5 ml QL (500 per 0 days) oxycodone oral tablet 10, 0 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (60 per 0 days) oxycodone-acetaminophen oral solution 5-5 /5 ml QL (1800 per 0 days) 5

13 oxycodone-acetaminophen oral tablet 10- (Endocet) QL (60 per 0 days) 5,.5-5, 5-5, oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 days) ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10, 5 (Opana) QL (60 per 0 days) oxymorphone oral tablet extended release QL (60 per 0 days) 1 hr 10, 15, 0, 0, 0, 5, 7.5 pentazocine-naloxone oral tablet QL (60 per 0 days) PRIMLEV ORAL TABLET MG, QL (90 per 0 days) 5-00 MG, MG tramadol oral tablet 50 (Ultram) QL (0 per 0 days) tramadol oral tablet extended release QL (60 per 0 days) hr 100, 00, 00 tramadol oral tablet, er multiphase hr QL (60 per 0 days) 100, 00, 00 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (60 per 0 days) 5 vicodin es oral tablet QL (90 per 0 days) vicodin hp oral tablet QL (90 per 0 days) vicodin oral tablet 5-00 QL (90 per 0 days) Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 days) 00, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % diclofenac sodium topical gel 1 % (Voltaren) QL (1000 per 0 days) diclofenac sodium topical gel % (Solaraze) PA NSO diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg (Arthrotec 50) 6

14 diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 FLECTOR TRANSDERMAL PATCH 1 PA; QL (60 per 0 days) HOUR 1. % flurbiprofen oral tablet 100, 50 1 ibu oral tablet 00, 600, ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, 800 (IBU) 1 INDOCIN ORAL SUSPENSION 5 MG/5 ML indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 ketorolac injection cartridge 15 /ml ketorolac injection solution 15 /ml, 0 /ml (1 ml) ketorolac injection syringe 15 /ml ketorolac intramuscular cartridge 60 / ml ketorolac oral tablet 10 QL (0 per 5 days) meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen sodium oral tablet 75 1 naproxen sodium oral tablet 550 (Anaprox DS) 1 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet sulindac oral tablet 00 Anesthetics 7

15 Local Anesthetics lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (0.5 %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 0 days) patch,medicated 5 % lidocaine topical ointment 5 % QL (50 per 0 days) lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual film 8- buprenorphine-naloxone sublingual tablet -0.5, 8- bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () (Suboxone) QL (90 per 0 days) (Zyban) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 1 QL (90 per 0 days) 8

16 NARCAN NASAL SPRAY,NON- AEROSOL MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 1- MG SUBOXONE SUBLINGUAL FILM -0.5 MG, -1 MG, 8- MG ZYBAN ORAL TABLET EXTENDED RELEASE 1 HR 150 MG Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.5, 0.5, 1, (Xanax) 1 alprazolam oral tablet extended release (Xanax XR) hr 0.5, 1,, alprazolam oral tablet,disintegrating 0.5, 0.5, 1, buspirone oral tablet 10, 15, 5 1 chlordiazepoxide hcl oral capsule 10, 1 5, 5 clonazepam oral tablet 0.5, 1, (Klonopin) 1 clonazepam oral tablet,disintegrating 0.15, 0.5, 0.5, 1, clorazepate dipotassium oral tablet 15, 1.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) 1 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml (1 /ml) diazepam oral tablet 10,, 5 (Valium) 1 estazolam oral tablet 1, 1 9 QL ( per days) QL (60 per 0 days) QL (90 per 0 days) ST

17 flurazepam oral capsule 15, 0 lorazepam injection solution /ml, (Ativan) /ml lorazepam injection syringe /ml, /ml lorazepam oral concentrate /ml (Lorazepam Intensol) lorazepam oral tablet 0.5, 1, (Ativan) 1 meprobamate oral tablet 00, 00 ONFI ORAL SUSPENSION.5 MG/ML PA NSO ONFI ORAL TABLET 10 MG, 0 MG PA NSO oxazepam oral capsule 10, 15, 0 temazepam oral capsule 15,.5, (Restoril) 0, 7.5 triazolam oral tablet 0.15 triazolam oral tablet 0.5 (Halcion) Antibacterials Aminoglycosides amikacin injection solution 500 / ml gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 60 /50 ml, 80 /100 ml, 80 /50 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) solution for nebulization 00 /5 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 10

18 clindamycin hcl oral capsule 150, 00 (Cleocin HCl) 1, 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 / ml colistin (colistimethate na) injection recon soln 150 (Coly-Mycin M Parenteral) DALVANCE INTRAVENOUS SOLUTION 500 MG daptomycin intravenous recon soln 500 (Cubicin) lincomycin injection solution 00 /ml (Lincocin) linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous piggyback 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral capsule 75 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) 1 MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) polymyxin b sulfate injection recon soln 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 00 MG ; QL (6 per 15 days) 11

19 SIVEXTRO ORAL TABLET 00 MG ; QL (6 per 15 days) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml vancomycin intravenous recon soln 10 gram, 5 gram vancomycin oral capsule 15 (Vancocin) QL (56 per 10 days) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG QL (9 per days) XIFAXAN ORAL TABLET 550 MG ; QL (60 per 0 days) Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN.5 GRAM cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefepime injection recon soln 1 gram, (Maxipime) gram cefixime oral suspension for reconstitution (Suprax) 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln gram (Claforan) cefotetan injection recon soln 1 gram, (Cefotan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram 1

20 cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), ( pack) azithromycin oral tablet 50, 500, 600 (Zithromax) 1 1

21 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NM; NDS; QL (0 per 5 days) E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG ery-tab oral tablet,delayed release (dr/ec) 500 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 500 PCE ORAL TABLET, PARTICLES/CRYSTALS MG, 500 MG ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN GRAM aztreonam injection recon soln 1 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon soln 500 (Primaxin IV) 1

22 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 (Merrem) Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin sodium injection recon soln 1 gram, 10 gram ampicillin sodium injection recon soln 15 ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) 15

23 BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram, 10 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram penicillin g 600,000 unit/1 ml inner 600,000 unit/ml penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, piperacillin-tazobactam intravenous recon (Zosyn) soln.75 gram,.5 gram, 0.5 gram ZOSYN.5 GRAM VIAL P/F,LTX- FR,INNER,SUV.5 GRAM ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.5 GRAM/50 ML,.75 GRAM/50 ML Quinolones AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 00 MG/50 ML ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr 1,000, 500 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin hcl oral tablet

24 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 levofloxacin oral tablet 500, 750 (Levaquin) 1 moxifloxacin 00 /50 ml bag 00 /50 ml moxifloxacin in nacl (iso-osm) intravenous (Avelox in NaCl (isoosmotic)) piggyback 00 /50 ml moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet 150, 75 (Acticlate) doxycycline hyclate oral tablet 50 (Targadox) doxycycline monohydrate oral capsule 100 (Mondoxyne NL), 50 17

25 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 100, 50 (Minocin) 1 minocycline oral capsule 75 1 minocycline oral tablet 100, 50, 75 okebo oral capsule 100 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) VIBRAMYCIN ORAL SYRUP 50 MG/5 ML Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION MG adriamycin intravenous solution 0 /10 PA BvD ml adrucil intravenous solution.5 gram/50 PA BvD ml AFINITOR DISPERZ ORAL TABLET 5 PA NSO; NM; NDS FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 5 PA NSO; NM; NDS; QL MG, 5 MG, 7.5 MG (0 per 0 days) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ALIMTA INTRAVENOUS RECON SOLN 500 MG ALIQOPA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 60 MG ALUNBRIG ORAL TABLET 180 MG, 5 PA NSO; NM; NDS 0 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE 5 PA NSO; NM; NDS PACK 90 MG (7)- 180 MG () anastrozole oral tablet 1 (Arimidex) 1 ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML AVASTIN INTRAVENOUS SOLUTION 5 MG/ML

26 azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 500 MG BESPONSA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NM; NDS bicalutamide oral tablet 50 (Casodex) BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 0 unit PA BvD BORTEZOMIB INTRAVENOUS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG, 00 5 PA NSO; NM; NDS MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) busulfan intravenous solution 60 /10 ml (Busulfex) 1 BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CABOMETYX ORAL TABLET 0 MG, 5 PA NSO; NM; NDS 0 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 00 MG carboplatin intravenous solution 10 /ml cisplatin intravenous solution 1 /ml cladribine intravenous solution 10 /10 ml PA BvD clofarabine intravenous solution 0 /0 ml (Clolar) COMETRIQ ORAL CAPSULE PA NSO; NM; NDS MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; NDS CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG PA BvD 19

27 藥物名稱 藥物等級 規定 / 限制 CYRAMZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 10 MG/ML cytarabine (pf) injection solution 100 /5 PA BvD ml (0 /ml), gram/0 ml (100 /ml) cytarabine injection solution 0 /ml PA BvD dacarbazine intravenous recon soln 100, 00 DACOGEN INTRAVENOUS RECON SOLN 50 MG dactinomycin intravenous recon soln 0.5 (Cosmegen) DARZALEX INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml decitabine intravenous recon soln 50 (Dacogen) docetaxel intravenous solution 160 /8 ml (0 /ml) docetaxel intravenous solution 0 / ml (10 /ml), 80 /8 ml (10 /ml) docetaxel intravenous solution 0 /ml (Taxotere) (1 ml), 80 / ml (0 /ml) DOXIL INTRAVENOUS SUSPENSION MG/ML doxorubicin intravenous recon soln 10, (Adriamycin) PA BvD 50 doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG 0

28 EMPLICITI INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 00 MG, 00 MG epirubicin intravenous recon soln 50 epirubicin intravenous solution 00 /100 ml (Ellence) ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 00 MG/100 ML ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS ERWINAZE INJECTION RECON SOLN 5 PA NSO; NM; NDS 10,000 UNIT ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG 5 PA NSO; NM; NDS; QL (6 per 1 days) FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML FIRMAGON KIT W DILUENT PA NSO SYRINGE SUBCUTANEOUS RECON SOLN 10 MG, 80 MG fludarabine intravenous recon soln 50 fludarabine intravenous solution 50 / ml fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 FOLOTYN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML (1 ML), 0 MG/ ML (0 MG/ML) gemcitabine intravenous recon soln 1 (Gemzar) gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/6. ml (8 /ml), 100 /ml, gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) 1

29 GILOTRIF ORAL TABLET 0 MG, 0 5 PA NSO; NM; NDS; QL MG, 0 MG (0 per 0 days) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/ ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 5 PA NSO; NM; NDS; QL 15 MG, 75 MG (1 per 8 days) ICLUSIG ORAL TABLET 15 MG, 5 5 PA NSO; NM; NDS MG idarubicin intravenous solution 1 /ml (Idamycin PFS) IDHIFA ORAL TABLET 100 MG, 50 5 PA NSO; NM; NDS; QL MG (0 per 0 days) ifosfamide intravenous recon soln 1 gram, (Ifex) gram ifosfamide intravenous solution 1 gram/0 ml, gram/60 ml imatinib oral tablet 100, 00 (Gleevec) 5 PA NSO; NM; NDS IMBRUVICA ORAL CAPSULE 10 5 PA NSO; NM; NDS; QL MG, 70 MG (10 per 0 days) IMBRUVICA ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) IMBRUVICA ORAL TABLET 80 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) IMBRUVICA ORAL TABLET 0 MG, 5 PA NSO; NM; NDS; QL 560 MG (0 per 0 days) IMFINZI INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 50 MG/ML INLYTA ORAL TABLET 1 MG, 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; NDS irinotecan intravenous solution 100 /5 (Camptosar) ml, 0 / ml irinotecan intravenous solution 500 /5 ml ISTODAX INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 10 MG/ ML JAKAFI ORAL TABLET 10 MG, 15 MG, 5 PA NSO; NM; NDS; QL 0 MG, 5 MG, 5 MG (60 per 0 days)

30 JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), 8 MG/DAY ( MG X ) letrozole oral tablet.5 (Femara) 1 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (9 per 8 days) 5 PA NSO; NM; NDS; QL (70 per 8 days) 5 PA NSO; NM; NDS; QL (91 per 8 days) 5 PA NSO; NM; NDS; QL (1 per 8 days) 5 PA NSO; NM; NDS; QL ( per 8 days) 5 PA NSO; NM; NDS; QL (6 per 8 days) 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (90 per 0 days) 5 PA NSO; NM; NDS

31 LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS LYNPARZA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 150 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 PA NSO MEKINIST ORAL TABLET 0.5 MG, 5 PA NSO; NM; NDS MG MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) melphalan hcl intravenous recon soln 50 (Alkeran) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitomycin intravenous recon soln 0, (Mutamycin) 0, 5 mitoxantrone intravenous concentrate /ml MUSTARGEN INJECTION RECON SOLN 10 MG mutamycin intravenous recon soln 0, 0, 5 MYLOTARG INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, MG 5 PA NSO; NM; NDS

32 NIPENT INTRAVENOUS RECON SOLN 10 MG ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS OPDIVO INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 100 MG/10 ML, 0 MG/ ML, 0 MG/ ML oxaliplatin intravenous recon soln 100, 50 oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 0 MG/1 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, 5 PA NSO; NM; NDS MG, MG, MG PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML romidepsin intravenous recon soln 10 (Istodax) 5 PA NSO; NM; NDS / ml RUBRACA ORAL TABLET 00 MG, 5 PA NSO; NM; NDS 50 MG, 00 MG RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS SOLTAMOX ORAL SOLUTION 10 PA NSO MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 PA NSO; NM MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) SUTENT ORAL CAPSULE 1.5 MG, 5 5 PA NSO; NM; NDS MG, 7.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TABLOID ORAL TABLET 0 MG 5

33 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) TAGRISSO ORAL TABLET 0 MG, 80 5 PA NSO; NM; NDS MG tamoxifen oral tablet 10, 0 1 TARCEVA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 150 MG, 5 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 5 PA NSO; NM; NDS 00 MG, 50 MG TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) 5 PA NSO; NM; NDS thiotepa injection recon soln 15 (Tepadina) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; NM; NDS toposar intravenous solution 0 /ml topotecan intravenous recon soln (Hycamtin) topotecan intravenous solution / ml (1 /ml) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 5 MG TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML,.5 MG/ ML,.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TRISENOX INTRAVENOUS SOLUTION MG/ML TYKERB ORAL TABLET 50 MG 5 PA NSO; NM; NDS VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML), 00 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG, 50 MG PA NSO 6

34 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; NDS VENCLEXTA STARTING PACK ORAL 5 PA NSO; NM; NDS TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) vinblastine intravenous solution 1 /ml PA BvD vincasar pfs intravenous solution / PA BvD ml vincristine intravenous solution 1 /ml, / ml (Vincasar PFS) PA BvD vinorelbine intravenous solution 10 /ml, (Navelbine) 50 /5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS VYXEOS INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN -100 MG XALKORI ORAL CAPSULE 00 MG, 5 PA NSO; NM; NDS 50 MG XATMEP ORAL SOLUTION.5 MG/ML XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) YERVOY INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 1 MG YONSA ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ZALTRAP INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 100 MG/ ML (5 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NM; NDS ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS ZYDELIG ORAL TABLET 100 MG, PA NSO; NM; NDS MG ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NM; NDS Anticholinergic Agents 7

35 Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 00 PA NSO MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG BRIVIACT INTRAVENOUS PA NSO SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 PA NSO MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG PA NSO; QL (60 per 0 days) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 00 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DEPACON INTRAVENOUS SOLUTION 500 MG/5 ML (100 MG/ML) DEPAKENE ORAL CAPSULE 50 MG DEPAKENE ORAL SOLUTION 50 MG/5 ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HR 50 MG, 500 MG DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 15 MG, 50 MG, 500 MG DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 15 MG 8

36 DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 0 MG DILANTIN-15 ORAL SUSPENSION 15 MG/5 ML divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 15 divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) 1 (dr/ec) 15, 50, 500 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 00, 600 (Felbatol) fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 PA NSO MG/ML FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG PA NSO gabapentin oral capsule 100, 00, (Neurontin) 1 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) KEPPRA ORAL SOLUTION 100 MG/ML KEPPRA ORAL TABLET 1,000 MG, 50 MG, 500 MG, 750 MG KEPPRA XR ORAL TABLET EXTENDED RELEASE HR 500 MG, 750 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 5 MG (5) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 MG (8) -100 MG (1) LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 5 MG () -100 MG (7) 9

37 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 5 MG (1) -50 MG (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(1)-100MG (1)-00 MG (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 5MG (1)-50 MG (1)-100MG (7) lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet extended release hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 lamotrigine oral tablets,dose pack 5 (5) lamotrigine oral tablets,dose pack 5 () -100 (7) lamotrigine oral tablets,dose pack 5 (8) -100 (1) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml (Lamictal) 1 (Lamictal XR) (Lamictal) (Lamictal ODT) (Lamictal Starter (Blue) Kit) (Lamictal Starter (Orange) Kit) (Lamictal Starter (Green) Kit) (Keppra) levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release (Keppra XR) hr 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML oxcarbazepine oral suspension 00 /5 ml (60 /ml) (Trileptal) 0

38 oxcarbazepine oral tablet 150, 00, (Trileptal) 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml ( /ml) phenobarbital oral tablet 100, 15, 16., 0,., 60, 6.8, 97. PHENYTEK ORAL CAPSULE 00 MG, 00 MG phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) phenytoin sodium extended oral capsule (Phenytek) 1 00, 00 phenytoin sodium intravenous solution 50 /ml primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 5 PA NSO; NM; NDS 500 MG SABRIL ORAL TABLET 500 MG 5 PA NSO; NM; NDS SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 50 MG, 500 MG, 750 MG PA NSO tiagabine oral tablet 1, 16,, (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er hr (Qudexy XR) PA NSO 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 5 (Topamax) 1, 50 valproate sodium intravenous solution 500 (Depacon) /5 ml (100 /ml) valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) 1

39 vigabatrin oral powder in packet 500 (Sabril) PA NSO VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG QL (60 per 0 days) zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 (Aricept) 1 QL (60 per 0 days) donepezil oral tablet (Aricept) QL (0 per 0 days) donepezil oral tablet,disintegrating 10, ST; QL (0 per 0 days) 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) hr 16,, 8 galantamine oral solution /ml galantamine oral tablet 1,, 8 (Razadyne) memantine oral capsule,sprinkle,er hr (Namenda XR) 1, 1, 8, 7 memantine oral solution /ml memantine oral tablet 10, 5 (Namenda) rivastigmine tartrate oral capsule 1.5,,.5, 6 rivastigmine transdermal patch hour 1. / hour,.6 / hr, 9.5 / hr (Exelon) ST Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet 1.5-5, 5-10 amoxapine oral tablet 100, 150, 5, 50 APLENZIN ORAL TABLET EXTENDED RELEASE HR 17 MG, 8 MG, 5 MG bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 1 ST

40 bupropion hcl oral tablet extended release (Wellbutrin XL) hr 150, 00 citalopram oral solution 10 /5 ml 1 citalopram oral tablet 10, 0, 0 (Celexa) 1 clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 DESVENLAFAXINE FUMARATE ST ORAL TABLET EXTENDED RELEASE HR 100 MG, 50 MG DESVENLAFAXINE ORAL TABLET ST EXTENDED RELEASE HR 100 MG, 50 MG doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 days) release(dr/ec) 0, 0, 60 duloxetine oral capsule,delayed ST; QL (0 per 0 days) release(dr/ec) 0 EMSAM TRANSDERMAL PATCH ST HOUR 1 MG/ HR, 6 MG/ HR, 9 MG/ HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0 (Lexapro) 1, 5 FETZIMA ORAL CAPSULE,EXT REL ST; QL (0 per 0 days) HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL ST; QL (0 per 0 days) CAPSULE,EXTENDED RELEASE HR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine oral capsule 10, 0, 0 (Prozac) 1 fluoxetine oral solution 0 /5 ml ( /ml) fluoxetine oral tablet 10, 0 (Sarafem) 1 fluvoxamine oral capsule,extended release hr 100, 150 ST

41 fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, (Tofranil) 1 50 imipramine pamoate oral capsule 100, 15, 150, 75 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG ST mirtazapine oral tablet 15, 0 (Remeron) 1 mirtazapine oral tablet 5 1 mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 0, 5 nefazodone oral tablet 100, 150, 00 nefazodone oral tablet 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 1 50, 75 nortriptyline oral solution 10 /5 ml olanzapine-fluoxetine oral capsule 1-5 (Symbyax), 1-50, -5, 6-5, 6-50 paroxetine hcl oral tablet 10, 0, (Paxil) 1 0, 0 paroxetine hcl oral tablet extended release (Paxil CR) hr 1.5, 5, 7.5 PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet - 10, -5, -10, -5, -50 PEXEVA ORAL TABLET 10 MG, 0 MG, 0 MG, 0 MG ST phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) 1 sertraline oral tablet 100, 5, 50 (Zoloft) 1 tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 150, 50 1 trazodone oral tablet 00

42 trimipramine oral capsule 100, 5, 50 TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release hr 150, 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 venlafaxine oral tablet extended release hr 150, 5, 7.5, 75 VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE HR 15-1,000 MG, 0-1,000 MG (Surmontil) (Effexor XR) (Precose) 5 ST; QL (0 per 0 days) ST; QL (0 per 0 days) ST; QL (0 per 0 days) AVANDIA ORAL TABLET MG, MG CYCLOSET ORAL TABLET 0.8 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG GLYSET ORAL TABLET 100 MG, 5 MG, 50 MG INVOKAMET ORAL TABLET 150- QL (60 per 0 days) 1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - QL (60 per 0 days) ER, BIPHASIC HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, QL (0 per 0 days) 00 MG JANUMET ORAL TABLET 50-1,000 QL (60 per 0 days) MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE HR 100-1,000 MG, 50-1,000 MG, MG QL (60 per 0 days)

43 JANUVIA ORAL TABLET 100 MG, 5 QL (0 per 0 days) MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 QL (0 per 0 days) MG KOMBIGLYZE XR ORAL TABLET, ER QL (0 per 0 days) MULTIPHASE HR.5-1,000 MG, 5-1,000 MG, MG KORLYM ORAL TABLET 00 MG metformin oral tablet 1,000, 500, (Glucophage) metformin oral tablet extended release (Glucophage XR) 1 hr 500, 750 miglitol oral tablet 100, 5, 50 (Glyset) nateglinide oral tablet 10, 60 (Starlix) ONGLYZA ORAL TABLET.5 MG, 5 MG QL (0 per 0 days) pioglitazone oral tablet 15, 0, 5 (Actos) 1 pioglitazone-glimepiride oral tablet 0- (DUETACT), 0- pioglitazone-metformin oral tablet (Actoplus MET), repaglinide oral tablet 0.5 repaglinide oral tablet 1, (Prandin) repaglinide-metformin oral tablet 1-500, -500 RIOMET ORAL SOLUTION 500 MG/5 ML SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 1.5-1,000 QL (60 per 0 days) MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - QL (0 per 0 days) ER, BIPHASIC HR 10-1,000 MG, 5-1,000 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML 6

44 VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) Insulins LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX U-00 SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) TOUJEO SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas chlorpropamide oral tablet 100, 50 glimepiride oral tablet 1,, (Amaryl) 1 7

45 glipizide oral tablet 10, 5 (Glucotrol) 1 glipizide oral tablet extended release hr (Glucotrol XL) 10,.5, 5 glipizide-metformin oral tablet.5-50,.5-500, glyburide micronized oral tablet 1.5, (Glynase), 6 glyburide oral tablet 1.5,.5, 5 glyburide-metformin oral tablet glyburide-metformin oral tablet (Glucovance) 1, tolazamide oral tablet 50, 500 tolbutamide oral tablet 500 Antifungals Antifungals ABELCET INTRAVENOUS PA BvD SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS PA BvD SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % 8