_FIDA 2T Formulary_November_CH

Transcription

1 處方藥一覽表 完整版 2018 第一保健誠康護理 FIDA 計劃 ( 老人醫療保險 - 醫療補助計劃 ) 紐約市 拿索郡及威徹斯特郡 請閱讀 : 本文件含有關於我們在本計劃承保藥物的資訊 本處方藥一覽表資料更新於 2018 年 10 月 23 日 如需最新的資訊或其他問題, 請聯絡第一保健誠康護理 FIDA 計劃的參保者服務部, 電話號碼 , 聽力語言殘障用戶請撥打 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 或者登錄網站 healthfirst.org/mmp H5441_QIP18_01(ch) Approved HPMS Approved Formulary File Submission ID , Version 14, as of 10/23/18

2 第一保健誠康護理 (AbsoluteCare)FIDA 計劃,( 老人醫保險 - 醫療補助計劃 ) 2018 年 承保藥物目錄 ( 處方藥一覽表 ) 這是第一保健誠康護理 FIDA 計劃的參保者可以獲取藥物的目錄 第一保健誠康護理全面整合雙重利惠 (FIDA) 計劃 ( 老人醫療保險 - 醫療補助計劃 ) 是一項與聯邦老人醫療保險 (Medicare) 和紐約州衛生署 (New York State Department of Health), 醫療補助 (Medicaid) 計劃均簽有合約, 以便經由全面整合雙重利惠 (Fully Integrated Duals Advantage, 簡稱,FIDA) 示範項目向參保者提供兩項計劃之福利的管理式醫療保健計劃 承保藥物目錄及藥房與服務提供者網絡在年度之內均可能不時更動 如果變動影響到您, 我們會在變動之前通知您 福利每年 1 月 1 日均可能更動 您隨時可以到 網站查看第一保健誠康護理 FIDA 計劃的承保藥物的最新目錄或者打電話給第一保健誠康護理 FIDA 計劃參保者服務部查詢, 電話號碼 , 或者聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天每天上午 8 時至晚上 8 時 可能有限製或限定 詳細資訊請給第一保健誠康護理 FIDA 計劃參保者服務部打電話, 或者參閱第一保健誠康護理 FIDA 計劃的參保者手冊 ( 參與者手冊 ) 就是說您必須遵守某些規則才能讓第一保健誠康護理 FIDA 計劃將為您的服務支付費用 任何承保藥物都無需支付定額手續費 如果您使用繁體中文, 您可以免費獲得 f 語言援助服務 請致電 , 聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 以上均為免費電話 v If you speak English, language assistance services, free of charge, are available to you. Call , TTY/TDD 711, 7 days a week, from 8am to 8pm. The call is free. v Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al , TTY/TDD 711, los 7 días de la semana de 8:00 a.m. a 8:00 p.m. La llamada es gratuita. 您可免費索取以其他形式提供的本文件, 諸如大字印本, 盲文或錄音等 請致電 或 聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 以上均為免費 電話 如果您收到材料不是您最常使用的語言製作, 您可以在任何時候聯絡第一保健誠康護理 FIDA 計劃告訴我們您希望我們使用哪種語言來製作計劃的材料 今後的所有郵件我們都會使用該語言 如想要求更換語言, 或者希望以其他形式為您提供材料, 請致電 及聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 以上均為免費電話 紐約州已設立名稱為 獨立消費者維權網 (Independent Consumer Advocacy Network, 簡稱 ICAN) 的參考者稽查項目, 針對第一保健誠康護理 FIDA 計劃所提供的任何服務, 為參與者提供免費保密協議 如需聯絡獨立消費者維權網 (ICAN) 請致電免費電話 , 或透過 icannys.org 網站與其聯絡 ( 聽力語言殘障用戶專線 711, 然後按提示撥打 ) H5441_QIP18_01(ch) Approved ? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 i

3 常見問題解答 (FAQ) 尋求您對本承保藥物目錄可能有問題的答案 您可以查閱所有的問題解答來瞭解更多資訊, 或者搜尋對某一具體問題的解答 1. 哪些處方藥物列入承保藥物目錄? ( 我們將 承保藥物目錄 簡稱為 藥物目錄 (Drug List)) 第 1 頁開始的承保藥物目錄上的藥物是第一保健誠康護理,FIDA 計劃承保的藥物 這些藥物我們網絡內的藥房均有供應 如果我們與一家藥房簽約讓他們與我們合作為您提供服務, 該藥房便屬於我們的網絡 我們將這些藥房稱作 網絡藥房 ( 網路藥房 ) 第一保健誠康護理,FIDA 計劃會承保 藥物目錄 上的所有藥物, 如果 : 您的醫生或其他處方醫生說您需要這些藥物以求好轉或保持健康, 對於您的病況為醫療上所必需, 及 您是在第一保健誠康護理,FIDA 計劃的網絡藥房配取該處方藥物 某些藥物第一保健誠康護理,FIDA 計劃規定須採取額外的步驟才能取得 ( 請參見下文問題, #5) 某些情況下, 您可能必須先做點什麼, 然後才能獲取某種藥物, 比如先試其他藥物等 您亦可在我們的網站 查看我們所承保的藥物的新目錄, 或者給參保者服務部 打電話號碼是 , 或者聽力語言殘障服務專線的 TTY/TDD 711, 服務時間每週七天, 每天 上午 8 時至晚上 8 時 2. 藥物目錄 / 會更動嗎? 會更動 年度期間第一保健 FIDA 計劃可能會增刪 藥物目錄 上的藥物 一般來說, 藥物目錄 只有在 下列情況下才會更動 : 新的藥物上市, 與 藥物目錄 上現有的藥物功效相當, 或者 我們瞭解到一種藥物不安全, 我們也可能會變更 我們有關藥物的規則 例如, 我們可能會, 決定一種藥物需要或不需要事前授權 事前授權 (prior authorization) 是從第一保健誠康護理 FIDA 計劃或者您跨專科團隊 (IDT) 取得核準才能獲取某種藥物 ) 增加或減少您能夠獲取某種藥物的數量 ( 稱作 數量限制 (quantity limits)) 增加或更改一種藥物的循序用藥限制 ( 循序用藥 (Step therapy) 意思是您必須先試用一種藥物, 然後我們才會承保其他藥物 )( 有關這些藥物的詳細資訊, 請參見第,iv-v 頁 )? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 ii

4 如果您所服用的藥物被從 藥物目錄 上刪除, 我們會告訴您 如果我們更改承保一種藥物的規定, 我們也會告訴您 下文的問題 3,4 與 7 有關 藥物目錄 變更後會發生什麼的詳細資訊 您隨時可以到 網站查看第一保健誠康護理 FIDA 計劃承保藥物 的最新目錄 您也可以給參保者服務部打電話查詢目前的承保藥物目錄, 電話號碼是 , 或者聽力語言殘障服務專線的 TTY/TDD 711, 服務時間每週七天每天 上午 8 時至晚上 8 時, 3. 如果一種便宜的藥物上市, 與 藥物目錄 上現有的藥物功效相當, 情況會怎樣? 如果一種便宜的藥物上市, 與 藥物目錄 上現有的藥物功效相當 : 您下次處方配藥時您的藥劑師可能 / 給您該便宜藥物 如果您和您的服務提供者確定該便宜藥物對您和不適當, 您的服務提供者可告訴藥劑師繼續配給您目前所服用的藥物 第一保健誠康護理 FIDA 計劃也許會決定將該昂貴藥物從藥物目錄上刪除 如果您所服用的藥物被我們從 藥物目錄 上刪除, 原因是一種便宜的藥物上市, 與 藥物目錄 上現有的藥功效相當, 我們會在將從 藥物目錄 上刪除或在您要求增配之前至少 60 天讓您知道 然後在 藥物目錄 的, 動作出之前您可以獲取 60 天的用量 如果您近期配過, 我們會在您的 福利解說 (Explanation of Benefits) 中通知您 如果您沒有, 但是您在最近 180 天服用過, 我們會給您寄一封信通知您該項更動 無論哪種情況, 您都會在更動發生之前至少 60 天得到通知 4. 如果我們發現一種藥物不安全會怎樣? 如果美國食品與藥品管局總署 (Food and Drug Administration, 簡稱 FDA) 說您所服用的一種藥物不安全, 我們會立即將其從 藥物目錄 上刪除 我們還會給您寄一封信並給您打電話告訴您該不安全的藥物已經被從 藥物目錄 上刪除 除了通知您之外, 我們還會給您的醫生寄一封信, 讓醫生跟您一起尋找另外一種能夠治療您狀況的藥物 如果您有任何問題, 可直接與您的醫生聯絡, 或者給第一保健誠康護理 FIDA 計劃打電話, 號碼是 , 或者聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天, 每天上午 8 時至 晚上 8 時 5. 藥物承保是否有什麼限制? 或者說某些藥物是否要採取什麼措施才能得到? 是的, 某些藥物有承保規定或者對於您能夠得到的數量有限制 某些情下, 您或您的醫生或其他開具處方者必須先做點什麼, 然後才能獲取某種藥物例如 : 事前核准 ( 事前授權 ): 某些藥物, 您和您的醫生或其他處方醫生必須獲取第一保健誠康護理,FIDA 計畫或者您的跨專科團隊 (IDT) 的核准才能去配取處方藥物 如果您不獲取核準, 第一保健誠康護理 FIDA 計劃可能不會承保? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 iii

5 數量限制 : 有的時候第一保健誠康護理 FIDA 計劃會限制一種藥物您可以得到的數量 循序用藥 : 有的時候第一保健誠康護理 FIDA 計劃會規定您必須循序用藥 這意味著您必須 按照一定的順序使用藥物來治療您的病症 您可能必須先試用一種藥物, 然後我們才會承保另外一種藥物 如果您的醫生認為第一種藥物對您沒有作用, 然後我們才會承保第二種 如需瞭解您服用的藥物是否有任何額外的規定或限制, 請查看 1 頁開始的圖表 您亦可到我們的網站, 獲取更多資訊 我們在上貼出了文件, 對我們的事前授權與循序用藥限制作出了說明 您亦可要求我們給您寄來一份 您可以要求對這些限制作出 例外處理 (exception) 有關例外處理的更多資訊請參見問題 11 如果您住在安養設或者其他長期護理設施, 需要一種 藥物目錄 上沒有的藥物, 或者如果 您不能輕易得到您所需要的藥物, 我們能夠提供幫助 無論您是否第一保健誠康護理 FIDA 計劃新註冊的參保者, 我們都會給您所需要的藥物 31 天 ( 除非您的處方開具較少的天數 ) 的緊急供應 這將讓您有時間與您的醫生或其他處方醫生討論 醫生能夠幫助您決定 藥物目錄 上是否有類似藥物可以替代或者還是提出例外處理要求 有關例外處理的更多資訊請 參見問題 您如何知道自己想要的藥物是否有限制或者是否要採取什麼措施才能得到? 第 1 頁開始的 藥物目錄 上有一欄標題 必要的措施, 對使用的限定或限制 (Necessary actions, restrictions, or limits on use) 7. 如果我們更改我們如何承保某些藥物的規定會怎樣? 例如, 如果我們一種藥物增加事前授權 ( 核準 ), 數量限制與會或循序用藥等限制 如果我們對一種藥物增加事前核準數量限制與 / 或循序用藥等限制, 我們會告訴您 我們會在增加, 限製或在您下一次要求增配之前至少 60 天告訴您 然後, 在 藥物目錄 的更動作出之前您可以獲取 60 天的用量 這讓您有時間與您的醫生或其他處方醫討論怎麼辦 8. 您如何才能在 藥物目錄 上找到某種藥物 尋找一種藥物有兩個途徑 : 您可以按一個字母順序搜索 ( 如果您知道藥物名稱的拼法 ), 或者 您可以按一醫療狀況檢索 如要按照字母順序搜尋, 請到 86 頁的字母順序目錄 然後到目錄中檢索您的藥物的名稱 如要照醫療狀況檢索, 找到第 1 頁開始標有 按照適合醫院列出的藥物目錄 的部份 這一部份的藥物 按照其以治療狀況分類列出 例如, 如果您有心臟狀況, 您應該到,β 受體阻滯劑,(Beta-Blockers) 類別 去搜尋 這是您會找到治療該心臟狀況藥物的地方? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 iv

6 9. 如果您想要服用的藥物不在 藥物目錄 上怎麼辦? 如果您在 藥物目錄 找不到您的藥物, 請給參保者服務部打電話詢問有關情況, 電話號碼是 , 或者聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天每天上午 8 時至晚上 8 時 如果您瞭解到第一保健誠康護理,FIDA 計劃不會承保, 您可以採取這些措施之一 : 要求參保者服務部提供一份與您所想要服用的藥物類似的藥物目錄 然後將該目錄拿給您的醫生或其他處方醫生 他們可以從與您所想要服用的藥物類似似的藥物目錄中選取一種開給您 或者 您可以要求本計劃或您的跨專科團隊 (IDT) 作出 例外處理, 承保您的藥物. 有關例外處理的更多資訊請參見問題 如果您是第一保健誠康護理 FIDA 計劃新註冊的參保者, 而您在 藥物目錄 上找不到您的藥物, 或者獲取您的藥物有困難怎麼辦? 我們能夠提供幫助 在您成為第一保健誠康護理 FIDA 計劃的參保者最初的 90 天期間, 我們必需根據需要為您的藥物承保最多 90 天臨時供應 這將讓您有時間與您的醫生或其他處方醫生討論 醫生能夠幫助您決定 藥物目錄 上是否有類似藥物可以替代或者還是提出例外處理要求 如屬下列情況, 我們會為您的藥物承保最多 90 天的臨時供應 您所服用的藥物沒有列在我們的 藥物目錄 上, 或者健保計劃的規定不容許您獲取處方醫生開具的藥量, 或者需要第一保健誠康護理,FIDA 計劃或者您的跨專科團隊 (IDT) 的事前核準, 或者您所服用的藥物屬於循序用藥限制的一個環節 如果您在安養設施或其他長期護理設施, 您可以增配您的處方藥物最多 93 天 在您參加本計劃的最初 93 天期間您可以多次增配 這讓您的處方醫生有時間將您的藥物, 換為 藥物目錄 上的藥物, 或者要求作出例外處理 非長期護理層級的護理更動 對於住在非長期護理設施的人士, 可以自動提供過渡期 否則藥房將會遞交護理層級過渡 要求 住在非長期護理設施的人士獲准 多 30 天過渡期用量的 D 部份藥物 ; 如果配藥數量少於處方 數量, 則獲准多次增配, 多累計達到 90 天的用量 根據計劃的福利設計, 這些計劃規定的數量限制可能提高, 但是必須限制於處方開具的藥量? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 v

7 長期護理層級的護理的更動, 對於住在長期護理設施的人士, 藥房要求容許新住進來的人能有過渡期, 並取消增配太早, 即予拒絕的規定 護理層級過渡期用量容許至少達到 93 天的用量, 但除了聯邦老人醫療保險 與醫療補助服務中心 (CMS) 特別規定之外, 原廠藥口服液限制只能配 31 天的用量 所有經歷護理層級更動的參保者, 如果劑量的更動導致 提前增配 或者增配太早而遭拒絕, 藥房可致電配藥求助台獲得取消規定的許可 根據計劃的福利設計, 這些計劃規定的數量限制可能提高, 但是必須限制於處方開具的藥量 11. 您是否可以要求我們作出例外處理, 承保您的藥物 可以 您可以要求第一保健誠康護理 FIDA 計劃或您跨專科團隊 (IDT) 作出 例外處理 承保 藥物目錄 上 沒有的藥物 您也可以要求第一保健誠康護理 FIDA 計劃或您噸跨專科團隊 (IDT), 改對您的藥物的規定 例如, 第一保健誠康護理 FIDA 計劃可能會限制我們對一種藥物的承保數量 如果您的藥物 有數量限制, 您可以要求我們或您跨專科團隊 (IDT), 更改該限制, 承保更多數量 其他情況舉例 : 您可以要求我們或您的跨專科團隊 (IDT) 取消循序用藥限制或事前核準規定 12. 作出例外處理需要多長時間? 首先, 第一保健誠康護理 FIDA 計劃或您跨專科團隊 (IDT) 必須收到您的處方醫支持您要求作出, 例外處理的證言 在我們收到該證言之後, 您會在 72 小時之內收到有關您的例外處理要求的裁決 如果您或您的處方醫生認為等待 72 小時才能得到裁定可能危害您的健康, 您可以要求加快作出例外處理 這是一條快速裁決 如果您的處方醫支持您的要求, 您會在我們收到您的處方醫生的支持, 證言之後 24 小時之內收到裁決 13. 您如何要求作出例外處理? 如要提出例外處理要求, 請給您的醫療護理管員打電話 您的醫療護理管員會與您和您的服務提供者一起幫助您提出例外處理要求 14. 什麼叫副廠藥 (generic drugs)? 副廠藥與原廠藥是用同樣的成份製成 它們一般比原廠藥便宜, 只是通常名氣不大 副廠藥都得到美國食品與藥物管理總署 (US Food and Drug Administration) 的核准 第一保健誠康護理,FIDA 計劃既承保原廠藥, 也承保副廠藥? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 vi

8 15. 什麼叫 OTC 藥物? OTC 全選是 over-the-counter, 意思是 不用處方在櫃檯自行選購 某些非處方 OTC 自選藥物, 如果您的服務提供者將其作為處方藥物開出, 第一保健誠康護理 FIDA 計劃可予承保 您可以查閱第一保健誠康護理,FIDA 計劃的 藥物目錄, 瞭解哪些 OTC 自選藥物獲得承保 16. 第一保健誠康護理 FIDA 計劃是否承保 OTC 非藥物類物品? 某些非處方 OTC 非藥物產品, 如果您的服務提供者開具處方, 第一保健誠康護理 FIDA 計劃可予承保 OTC 非藥物產品舉例如纖維補充品 紗布與酒精棉棒等 您可以查閱第一保健誠康護理 FIDA 計劃的 藥物目錄, 瞭解哪些 OTC 非藥物類物品獲得承保 17. 您的定額手續費是多少? 藥物目錄 上的藥物不會向您收取定額手續費 18. 甚麼叫 (drug tiers)? 是我們 藥物目錄 上藥物的分組 本計劃 藥物目錄 上的每一種藥物都屬於三個層次 之一 任何層次的藥物您都無需支付任何費用 第一層次包括 ( 老人醫療保險 ) 副廠藥 第二層次包括 ( 老人醫療保險 ) 原廠藥 第三層次包括非老人醫療保險 ( 醫療補助 ) 藥物? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 vii

9 承保藥物目錄 (List of Covered Drugs) 下列 承保藥物目錄 為您提供有關第一保健誠康護理 FIDA 計劃所承保藥物的資訊 如果您在目錄中找 不到您的藥物, 請翻到第 86 頁開始的索引 圖表的第一欄列出的是藥物名稱 原廠藥名稱全部大寫 ( 例如,CIPRO), 副廠藥名稱則以小寫斜體列出, ( 例如,ciprofloxacin hcl) 必要的措施對使用的限定或限制 (necessary actions, restrictions, or limits) 一欄告訴您第一保健誠康護理 FIDA 計劃對於承保您的藥物是否有甚麼規定 請注意 : 藥物名稱旁邊的 * 星號表明不是 D 部份藥物 (Part D drug) 這些藥物的上訴有不同的規則 上訴是在您認為決定有錯的情況下要求我們對承保決定進行審查並作出更改的正式途徑 例如, 第一保健誠康護理 FIDA 計劃或您的跨專科團隊 (IDT) 可能會決定您所要求的藥物, 聯邦老人醫療保險或醫療補助不予承保或不再予以承保 如果您的醫生或其他處方醫生不同意, 該項決定, 您可以上訴 如需索取有關如何上訴的說明, 請給參保者服務部打電話, 號碼是 , 聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週 7 天, 上午 8 時至晚上 8 時, 您亦可致電獨立消費者維權網 (Independent Consumer Advocacy Network, 簡稱 ICAN), 電話號碼是 ( 聽力語言殘障用戶請撥打聽力語言殘障服務專線 TTY 711, 然後根據提示撥打電話 ) 您亦可閱讀參保者手冊瞭解如何對一項裁決提出上訴 此處說明 必要的措施對使用的限定或限制 (Necessary actions, restrictions, or limits) 一欄所使用的代碼的意義 * = 這是醫療補助承保的藥物, 上訴須不同的規則 NM =No mail-order ( 非郵購 ) 不能經由郵購配藥 B/D = 所列藥物為 B 部份或 D 部份藥物 LA = 限制供應 (Limited availability): 必須有處方才能配發, 或者必須由藥劑師, 照藥物毒性分類法及章程進行監管或介入的情況下方可出售 PA = Prior authorization (approval 事前授權 ( 核准 )): 您必須獲取本計劃或您的跨專科團隊 (IDT) 核准才能獲取 QL = Quantity limit ( 數量限制 ): 我們對承保多少有限制 ST = Step therapy ( 循序用藥 ): 您必須先試用另外一種藥物, 然後您才能得到? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 viii

10 反歧視通知 第一保健遵守適用的聯邦民權法律規定 第一保健不因種族 膚色 民族血統 年齡 殘障或性別而排斥或差別待遇任何人 第一保健提供下列服務 : 免費的協助與服務, 讓殘障人士能有效地與我們溝通, 例如 : 符合資質的手語翻譯員 其他形式的書面資訊 ( 大字印本 音頻 可獲取的電子形式與其他形式 ) 為主要語言不是英語的人士提供免費的語言服務, 例如 : 符合資質的口譯員 以其他語言書寫的資訊 如果您需要這些服務, 請給第一保健來電, 電話號碼是 如需聽力語言殘障 TTY/TDD 服務, 請致電 如果您認為第一保健並未為您提供這些服務或因種族 膚色 民族血統 年齡 殘障或性別而對您有差別待遇, 您可以下列方式向我們的民權協調團隊提出申訴 : 郵寄 : FIDA Participant Services, P.O. Box 5165, New York, NY, 電話 : ( 如需聽力語言殘障 TTY/TDD 服務, 請致電 ) 傳真 : 親自前來 : 100 Church Street, New York, NY 電子郵件 : 透過電子郵件遞交問題或申訴以聯絡第一保健, 網址是 您也可以透過下列方式向美國衛生部 (U.S. Department of Health and Human Services) 的民權辦公室 (Office for Civil Rights) 提出民權投訴 : 上網 : 民權辦公室投訴網站 (Office for Civil Rights Complaint Portal), 網址是 郵寄 :U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC 投訴表格可在 獲得 電話 : ( 聽力語言殘障服務專線 TTY/TDD ) 2017 HF Management Services, LLC

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12 根據醫療狀況列出的藥物目錄 (List of Drugs by Medical Condition) 本部份藥物以所用於治療的病況類別分類 例如, 如果您有心臟病, 您應該到背塔阻滯劑類別中尋找 您在這裏可以找到治療心臟病的藥物? 如果您有什麼問題, 請每週七天每天上午 8 時至晚上 8 時給第一保健誠康護理 FIDA 計劃打電話, 電話號碼是 , 聽力語言殘障服務專線 TTY/TDD 711 撥打此電話免費 如要了解詳細資訊, 請瀏覽 xi

13 NY_CY18_2T_MMP eff 11/01/2018 藥物名稱 ANALGESICS - 治療疼痛與炎症的藥物 GOUT - 治療痛風的藥物 allopurinol tab 1 $0 colchicine w/ probenecid 1 $0 COLCRYS 2 $0 QL (120 tabs / 30 days) MITIGARE 2 $0 QL (60 caps / 30 days) probenecid 1 $0 ULORIC 2 $0 ST MISCELLANEOUS 雜類 acephen 3 $0 NM; * acetaminophen CHEW; LIQD; SUPP; TABS; TBCR 3 $0 NM; * acetaminophen extra stren TABS 3 $0 NM; * arthritis pain relief TBCR 3 $0 NM; * arthritis pain reliever 3 $0 NM; * aspir-81 3 $0 NM; * aspir-low 3 $0 NM; * aspirin CHEW; SUPP; TABS; TBEC 3 $0 NM; * aspirin adult low strengt 3 $0 NM; * aspirin ec low dose 3 $0 NM; * aspirin low dose 3 $0 NM; * aspirin low strength 3 $0 NM; * childrens acetaminophen 3 $0 NM; * childrens aspirin 3 $0 NM; * childrens aspirin low str 3 $0 NM; * childrens pain reliever 3 $0 NM; * childrens silapap 3 $0 NM; * ecpirin 3 $0 NM; * extra strength pain relie 3 $0 NM; * feverall adults 3 $0 NM; * feverall childrens 3 $0 NM; * FEVERALL INFANTS 3 $0 NM; * feverall junior strength 3 $0 NM; * gnp adult aspirin low str 3 $0 NM; * gnp arthritis pain relief 3 $0 NM; * gnp aspirin 3 $0 NM; * gnp childrens pain relief 3 $0 NM; * gnp pain & fever children 3 $0 NM; * 1

14 gnp pain relief TABS 3 $0 NM; * gnp pain relief extra str TABS 3 $0 NM; * goodsense arthritis pain 3 $0 NM; * goodsense aspirin 3 $0 NM; * goodsense pain & fever ch 3 $0 NM; * goodsense pain & fever in 3 $0 NM; * goodsense pain relief 3 $0 NM; * goodsense pain relief ext 3 $0 NM; * hm arthritis pain relief 3 $0 NM; * hm aspirin 3 $0 NM; * hm aspirin ec 3 $0 NM; * hm aspirin ec low dose 3 $0 NM; * hm pain & fever childrens 3 $0 NM; * hm pain & fever infants 3 $0 NM; * hm pain relief extra stre 3 $0 NM; * hm pain reliever 3 $0 NM; * 8 hour pain relief 3 $0 NM; * infants pain relief 3 $0 NM; * mapap 3 $0 NM; * mapap arthritis pain 3 $0 NM; * mapap childrens SUSP; TBDP 3 $0 NM; * mapap extra strength 3 $0 NM; * pain & fever 3 $0 NM; * pain & fever childrens CHEW 80mg3 $0 NM; * pain & fever childrens SOLN 3 $0 NM; * pain & fever extra streng 3 $0 NM; * pain & fever infants 3 $0 NM; * pain relief 3 $0 NM; * pain relief childrens 3 $0 NM; * pain relief extra strengt 3 $0 NM; * pain reliever extra stren 3 $0 NM; * pharbetol 3 $0 NM; * pharbetol extra strength 3 $0 NM; * q-pap 3 $0 NM; * q-pap childrens 3 $0 NM; * q-pap extra strength 3 $0 NM; * qc arthritis pain relief 3 $0 NM; * qc aspirin 3 $0 NM; * qc chewable aspirin low d 3 $0 NM; * qc non-aspirin extra stre 3 $0 NM; * sb aspirin 3 $0 NM; * 2

15 sb aspirin adult low stre 3 $0 NM; * sb low dose asa ec 3 $0 NM; * sb non-aspirin TABS 3 $0 NM; * sb non-aspirin extra stre 3 $0 NM; * sb pain reliever extra st 3 $0 NM; * sm 8 hour pain relief 3 $0 NM; * sm arthritis pain relief 3 $0 NM; * sm aspirin 3 $0 NM; * sm aspirin adult low stre 3 $0 NM; * sm aspirin low dose 3 $0 NM; * sm childrens aspirin 3 $0 NM; * sm pain & fever childrens 3 $0 NM; * sm pain reliever extra st 3 $0 NM; * tactinal 3 $0 NM; * tactinal extra strength 3 $0 NM; * tri-buffered aspirin 3 $0 NM; * NSAIDS - 治療疼痛與炎症的藥物 celecoxib CAPS 50mg 1 $0 QL (240 caps / 30 days) celecoxib CAPS 100mg 1 $0 QL (120 caps / 30 days) celecoxib CAPS 200mg 1 $0 QL (60 caps / 30 days) celecoxib CAPS 400mg 1 $0 QL (30 caps / 30 days) childrens ibuprofen 100mg/5ml 3 $0 NM; * childs ibuprofen 3 $0 NM; * diclofenac potassium 1 $0 QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC 1 $0 diflunisal 1 $0 etodolac 1 $0 etodolac er 1 $0 flurbiprofen TABS 1 $0 gnp childrens ibuprofen 3 $0 NM; * gnp ibuprofen 3 $0 NM; * goodsense ibuprofen 3 $0 NM; * goodsense ibuprofen child 3 $0 NM; * hm ibuprofen CAPS; TABS 3 $0 NM; * hm ibuprofen childrens 3 $0 NM; * hm ibuprofen ib 3 $0 NM; * ibu tabs 600mg 1 $0 ibu tabs 800mg 1 $0 ibu $0 NM; * ibuprofen SUSP 100mg/5ml 1 $0 ibuprofen SUSP 100mg/5ml 3 $0 NM; * 3

16 ibuprofen TABS 200mg 3 $0 NM; * ibuprofen TABS 400mg, 600mg, 1 $0 800mg ibuprofen childrens 3 $0 NM; * ketoprofen CAPS 50mg, 75mg 1 $0 meloxicam TABS 1 $0 nabumetone TABS 1 $0 naproxen SUSP; TABS 1 $0 naproxen dr 1 $0 naproxen sodium TABS 275mg, 1 $0 550mg piroxicam CAPS 1 $0 provil 3 $0 NM; * qc childrens ibuprofen 3 $0 NM; * qc ibuprofen 3 $0 NM; * sb childrens ibuprofen 3 $0 NM; * sb ibuprofen 3 $0 NM; * sm childrens ibuprofen 3 $0 NM; * sm ibuprofen 3 $0 NM; * sm ibuprofen ib TABS 3 $0 NM; * sulindac TABS 1 $0 OPIOID ANALGESICS - 治療疼痛的藥物 acetaminophen w/ codeine SOLN 1 $0 QL (5000 ml / 30 days) acetaminophen w/ codeine TABS 1 $0 QL (400 tabs / 30 days) butorphanol tartrate SOLN 2 $0 1mg/ml, 2mg/ml BUTRANS 5mcg/hr 2 $0 QL (16 patches / 28 days) BUTRANS 7.5mcg/hr, 10mcg/hr 2 $0 QL (8 patches / 28 days) BUTRANS 15mcg/hr, 20mcg/hr 2 $0 QL (4 patches / 28 days) nalbuphine hcl SOLN 2 $0 tramadol hcl TABS 1 $0 QL (240 tabs / 30 days) tramadol-acetaminophen 1 $0 QL (240 tabs / 30 days) OPIOID ANALGESICS, CII - 治療疼痛的藥物 endocet 1 $0 QL (360 tabs / 30 days) fentanyl citrate LPOP 2 $0 QL (120 lozenges / 30 days), PA fentanyl patch 12 mcg/hr 1 $0 QL (10 patches / 30 days) 4

17 fentanyl patch 25 mcg/hr 1 $0 QL (10 patches / 30 days) fentanyl patch 50 mcg/hr 1 $0 QL (10 patches / 30 days), PA fentanyl patch 75 mcg/hr 1 $0 QL (10 patches / 30 days), PA fentanyl patch 100 mcg/hr 1 $0 QL (10 patches / 30 days), PA FENTORA 2 $0 QL (120 tabs / 30 days), PA hydroco/apap tab 5-325mg 1 $0 QL (360 tabs / 30 days) hydroco/apap tab $0 QL (360 tabs / 30 days) hydroco/apap tab mg 1 $0 QL (360 tabs / 30 days) hydrocodone-acetaminophen mg/15ml 1 $0 QL (5400 ml / 30 days) hydrocodone-ibuprofen tab $0 QL (150 tabs / 30 days) mg hydromorphone hcl LIQD 1 $0 hydromorphone hcl SOLN 2 $0 B/D 10mg/ml, 50mg/5ml, 500mg/50ml hydromorphone hcl TABS 1 $0 QL (270 tabs / 30 days) HYSINGLA ER 20mg, 30mg, 2 $0 QL (60 tabs / 30 days) 40mg, 60mg HYSINGLA ER 80mg, 100mg, 2 $0 QL (30 tabs / 30 days) 120mg lorcet hd tab mg 1 $0 QL (360 tabs / 30 days) lorcet plus tab $0 QL (360 tabs / 30 days) methadone hcl SOLN 5mg/5ml, 1 $0 QL (450 ml / 30 days) 10mg/5ml methadone hcl 5mg 1 $0 QL (180 tabs / 30 days) methadone hcl 10mg 1 $0 QL (180 tabs / 30 days) methadone hcl intensol 1 $0 QL (120 ml / 30 days) morphine ext-rel tab 15mg, 30mg, 1 $0 QL (90 tabs / 30 days) 60mg, 100mg morphine ext-rel tab 200mg 1 $0 QL (60 tabs / 30 days) morphine sul inj 1mg/ml 2 $0 B/D MORPHINE SUL INJ 4MG/ML 2 $0 B/D morphine sul inj 10mg/ml 2 $0 B/D MORPHINE SULFATE SOLN 2 $0 B/D 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml 5

18 morphine sulfate SOLN 4mg/ml, 2 $0 B/D 8mg/ml, 10mg/ml morphine sulfate TABS 1 $0 QL (180 tabs / 30 days) morphine sulfate oral sol 1 $0 NUCYNTA ER 50mg, 100mg 2 $0 QL (120 tabs / 30 days) NUCYNTA ER 150mg, 200mg, 2 $0 QL (60 tabs / 30 days) 250mg oxycodone hcl CAPS 1 $0 QL (180 caps / 30 days) oxycodone hcl CONC; SOLN 1 $0 oxycodone hcl TABS 1 $0 QL (180 tabs / 30 days) oxycodone w/ acetaminophen 1 $0 QL (360 tabs / 30 days) mg oxycodone w/ acetaminophen 1 $0 QL (360 tabs / 30 days) 5-325mg oxycodone w/ acetaminophen 1 $0 QL (360 tabs / 30 days) mg oxycodone w/ acetaminophen 1 $0 QL (360 tabs / 30 days) mg OXYCONTIN 2 $0 QL (120 tabs / 30 days) ANESTHETICS - 痲醉藥物 LOCAL ANESTHETICS 局部痲醉藥物 lidocaine inj 0.5% 1 $0 B/D lidocaine inj 0.5% preservative free 1 $0 B/D (pf) lidocaine inj 1% 1 $0 B/D lidocaine inj 1% preservative free (pf) 1 $0 B/D lidocaine inj 1.5% preservative free 1 $0 B/D (pf) lidocaine inj 2% 1 $0 B/D ANTI-INFECTIVES - 治療感染的藥物 ANTI-BACTERIALS - 各種抗菌素 amikacin sulfate SOLN 1 $0 gentamicin in saline 1 $0 gentamicin sulfate SOLN 1 $0 neomycin sulfate TABS 1 $0 paromomycin sulfate CAPS 1 $0 streptomycin sulfate SOLR 1 $0 SULFADIAZINE TABS 2 $0 tobramycin NEBU 2 $0 NM, PA tobramycin inj 1.2 gm/30ml 1 $0 6

19 tobramycin inj 1.2gm 2 $0 tobramycin inj 10mg/ml 1 $0 tobramycin inj 40mg/ml 1 $0 tobramycin inj 80mg/2ml 1 $0 ANTI-INFECTIVES - 各種抗感染藥物 ALBENZA 2 $0 ALINIA 2 $0 atovaquone SUSP 2 $0 AZACTAM IN ISO-OSMOTIC DE 2 $0 AZACTAM/DEX INJ 2 $0 aztreonam 1 $0 BILTRICIDE 2 $0 CAYSTON 2 $0 NM, LA, PA clindamycin cap 75mg 1 $0 clindamycin cap 300mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin phosphate in d5w 1 $0 CLINDAMYCIN PHOSPHATE IN NACL2 $0 clindamycin phosphate inj 1 $0 clindamycin soln 75mg/5ml 1 $0 colistimethate sodium SOLR 1 $0 dapsone TABS 1 $0 daptomycin 500mg 2 $0 EMVERM 2 $0 ertapenem sodium 1 $0 imipenem-cilastatin 1 $0 INVANZ 2 $0 ivermectin TABS 1 $0 linezolid 2 $0 linezolid in sodium chloride 2 $0 meropenem 1 $0 methenamine hippurate 1 $0 metronidazole TABS 1 $0 metronidazole in nacl 1 $0 NEBUPENT 2 $0 B/D nitrofurantoin macrocrystal 50mg, 100mg 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year 7

20 nitrofurantoin monohyd macro 2 $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM $0 praziquantel TABS 1 $0 SIVEXTRO 2 $0 sulfamethoxazole-trimethop ds 1 $0 sulfamethoxazole-trimethoprim 1 $0 sulfamethoxazole-trimethoprim inj 1 $0 SYNERCID 2 $0 tigecycline 50mg 2 $0 TIGECYCLINE 50mg 2 $0 trimethoprim TABS 1 $0 vancomycin hcl CAPS 2 $0 vancomycin hcl SOLR 1gm, 5gm, 1 $0 10gm, 500mg, 750mg VANCOMYCIN IN NACL 2 $0 ANTIFUNGALS - 治療真菌感染的藥物 ABELCET 2 $0 B/D AMBISOME 2 $0 B/D amphotericin b SOLR 1 $0 B/D CANCIDAS 2 $0 caspofungin acetate 50mg, 70mg 2 $0 CASPOFUNGIN ACETATE 50mg, 2 $0 70mg fluconazole SUSR; TABS 1 $0 fluconazole in dextrose 1 $0 FLUCONAZOLE INJ NACL $0 fluconazole inj nacl $0 fluconazole inj nacl $0 flucytosine CAPS 2 $0 griseofulvin microsize 1 $0 griseofulvin ultramicrosize 1 $0 itraconazole CAPS 1 $0 PA ketoconazole TABS 1 $0 PA MYCAMINE 2 $0 NOXAFIL SUSP 2 $0 QL (630 ml / 30 days) NOXAFIL TBEC 2 $0 QL (93 tabs / 30 days) nystatin TABS 1 $0 terbinafine hcl TABS 1 $0 QL (90 tabs / 365 days) 8

21 voriconazole SOLR 1 $0 voriconazole SUSR; TABS 2 $0 ANTIMALARIALS - 治療瘧疾的藥物 atovaquone-proguanil hcl 1 $0 chloroquine phosphate TABS 1 $0 COARTEM 2 $0 mefloquine hcl 1 $0 PRIMAQUINE PHOSPHATE 2 $0 quinine sulfate CAPS 1 $0 PA ANTIRETROVIRAL AGENTS - 抗 HIV/ 愛滋病毒感染藥物 abacavir sulfate 1 $0 APTIVUS 2 $0 atazanavir sulfate 2 $0 CRIXIVAN 2 $0 didanosine 1 $0 EDURANT 2 $0 efavirenz CAPS 50mg 1 $0 efavirenz CAPS 200mg 2 $0 efavirenz TABS 2 $0 EMTRIVA 2 $0 fosamprenavir tab 700 mg 2 $0 FUZEON 2 $0 NM INTELENCE 2 $0 INVIRASE 2 $0 ISENTRESS 2 $0 ISENTRESS HD 2 $0 lamivudine 1 $0 LEXIVA 2 $0 nevirapine susp 50 mg/5ml 1 $0 nevirapine tab 100mg 1 $0 nevirapine tab 200mg 1 $0 nevirapine tab 400mg er 1 $0 NORVIR 2 $0 PREZISTA SUSP 2 $0 QL (400 ml / 30 days) PREZISTA TABS 75mg 2 $0 QL (480 tabs / 30 days) PREZISTA TABS 150mg 2 $0 QL (240 tabs / 30 days) PREZISTA TABS 600mg 2 $0 QL (60 tabs / 30 days) PREZISTA TABS 800mg 2 $0 QL (30 tabs / 30 days) RESCRIPTOR 2 $0 RETROVIR IV INFUSION 2 $0 9

22 REYATAZ PACK 2 $0 ritonavir 1 $0 SELZENTRY 2 $0 stavudine 1 $0 SUSTIVA TABS 2 $0 tenofovir disoproxil fumarate 2 $0 TIVICAY 2 $0 TROGARZO 2 $0 NM, LA TYBOST 2 $0 VIDEX EC 125mg 2 $0 VIDEX PEDIATRIC 2 $0 VIRACEPT 2 $0 VIRAMUNE SUSP 2 $0 VIREAD 2 $0 ZERIT SOLR 2 $0 zidovudine cap 100mg 1 $0 zidovudine syp 50mg/5ml 1 $0 zidovudine tab 300mg 1 $0 ANTIRETROVIRAL COMBINATION AGENTS - 抗 HIV/ 愛滋病毒感染藥物 abacavir sulfate-lamivudine 2 $0 abacavir 2 $0 sulfate-lamivudine-zidovudine ATRIPLA 2 $0 BIKTARVY 2 $0 CIMDUO 2 $0 COMPLERA 2 $0 DESCOVY 2 $0 EVOTAZ 2 $0 GENVOYA 2 $0 JULUCA 2 $0 KALETRA TAB MG 2 $0 KALETRA TAB MG 2 $0 lamivudine-zidovudine 1 $0 lopinavir-ritonavir 2 $0 ODEFSEY 2 $0 PREZCOBIX 2 $0 STRIBILD 2 $0 SYMFI 2 $0 SYMFI LO 2 $0 SYMTUZA 2 $0 TRIUMEQ 2 $0 10

23 TRUVADA TAB $0 QL (60 tabs / 30 days) TRUVADA TAB $0 QL (30 tabs / 30 days) TRUVADA TAB $0 QL (30 tabs / 30 days) TRUVADA TAB $0 QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS - 治療肺結核病的藥物 CAPASTAT SULFATE 2 $0 cycloserine CAPS 2 $0 ethambutol hcl TABS 1 $0 isoniazid TABS 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syp 50mg/5ml 1 $0 PASER D/R 2 $0 PRIFTIN 2 $0 pyrazinamide TABS 1 $0 rifabutin 1 $0 rifampin CAPS; SOLR 1 $0 RIFATER 2 $0 SIRTURO 2 $0 LA, PA TRECATOR 2 $0 ANTIVIRALS - 治療病毒感染的藥物 acyclovir CAPS; SUSP; TABS 1 $0 acyclovir sodium 1 $0 B/D adefovir dipivoxil 2 $0 BARACLUDE SOLN 2 $0 DAKLINZA 2 $0 NM, PA entecavir 2 $0 EPCLUSA 2 $0 NM, PA EPIVIR HBV SOLN 2 $0 famciclovir TABS 1 $0 ganciclovir inj 500mg 1 $0 B/D GANCICLOVIR INJ 500MG/10ML 1 $0 B/D HARVONI 2 $0 NM, PA lamivudine (hbv) 1 $0 MAVYRET 2 $0 NM, PA moderiba tab 200mg 1 $0 NM oseltamivir phosphate CAPS 30mg 1 $0 QL (168 caps / year) oseltamivir phosphate CAPS 1 $0 QL (84 caps / year) 45mg, 75mg oseltamivir phosphate SUSR 1 $0 QL (1080 ml / year) PEGASYS 2 $0 NM, PA PEGASYS PROCLICK 2 $0 NM, PA 11

24 REBETOL SOLN 2 $0 NM RELENZA DISKHALER 2 $0 QL (6 inhalers / year) ribasphere CAPS 1 $0 NM ribasphere TABS 200mg 1 $0 NM ribasphere TABS 400mg, 600mg 2 $0 NM ribavirin 200mg 1 $0 NM rimantadine hydrochloride 1 $0 SOVALDI 2 $0 NM, PA valacyclovir hcl TABS 1 $0 valganciclovir hcl 2 $0 VEMLIDY 2 $0 VOSEVI 2 $0 NM, PA ZEPATIER 2 $0 NM, PA CEPHALOSPORINS 治療感染的藥物 cefaclor 1 $0 CEFACLOR MONOHYDRATE ER 2 $0 cefadroxil 1 $0 CEFAZOLIN IN DEXTROSE 2 $0 2GM/100ML-4% cefazolin inj 1 $0 cefazolin sodium SOLR 1gm, 20gm1 $0 CEFAZOLIN SODIUM 1 GM/50ML 2 $0 cefdinir 1 $0 cefepime hcl 1 $0 cefixime 1 $0 cefotaxime sodium 1 $0 cefoxitin sodium 1 $0 cefpodoxime proxetil 1 $0 cefprozil 1 $0 ceftazidime SOLR 1 $0 CEFTAZIDIME/DEXTROSE 2 $0 ceftriaxone sodium SOLR 1gm, 1 $0 2gm, 10gm, 250mg, 500mg cefuroxime axetil 1 $0 cefuroxime sodium 1 $0 cephalexin CAPS 250mg, 500mg 1 $0 cephalexin SUSR 1 $0 SUPRAX CAPS 2 $0 SUPRAX CHEW 2 $0 SUPRAX SUSR 500mg/5ml 2 $0 tazicef SOLR 1 $0 12

25 TEFLARO 2 $0 ERYTHROMYCINS/MACROLIDES - 治療病毒感染的藥物 azithromycin PACK; SOLR; SUSR; 1 $0 TABS clarithromycin TABS 1 $0 clarithromycin er 1 $0 clarithromycin for susp 1 $0 DIFICID 2 $0 e.e.s $0 ery-tab 1 $0 ERYTHROCIN LACTOBIONATE 2 $0 erythrocin stearate 1 $0 erythromycin base 1 $0 erythromycin cap 250mg ec 1 $0 erythromycin ethylsuccinate TABS 1 $0 FLUOROQUINOLONES - 治療病毒感染的藥物 ciprofloxacin SUSR 1 $0 ciprofloxacin hcl tab 1 $0 ciprofloxacin in d5w 1 $0 levofloxacin TABS 1 $0 levofloxacin in d5w 1 $0 levofloxacin inj 25mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 moxifloxacin hcl TABS 1 $0 PENICILLINS - 治療病毒感染的藥物 amoxicillin 1 $0 amoxicillin & pot clavulanate 1 $0 ampicillin & sulbactam sodium 1 $0 ampicillin cap 250mg 1 $0 ampicillin cap 500mg 1 $0 ampicillin inj 1 $0 ampicillin sodium 1 $0 ampicillin susp 1 $0 BICILLIN L-A 2 $0 dicloxacillin sodium 1 $0 nafcillin sodium 1gm, 2gm 1 $0 nafcillin sodium 10gm 2 $0 oxacillin sodium 1gm, 2gm 1 $0 oxacillin sodium 10gm 2 $0 13

26 PENICILLIN G POT IN DEXTROSE 2 $0 2MU PENICILLIN G POT IN DEXTROSE 2 $0 3MU PENICILLIN G PROCAINE 2 $0 penicillin g sodium 1 $0 penicillin v potassium 1 $0 penicilln gk inj 5mu 1 $0 penicilln gk inj 20mu 1 $0 pfizerpen-g inj 5mu 1 $0 pfizerpen-g inj 20mu 1 $0 piper/tazoba inj gm 1 $0 piper/tazoba inj gm 1 $0 piper/tazoba inj 4-0.5gm 1 $0 PIPER/TAZOBA INJ GM 2 $0 piper/tazoba inj gm 1 $0 TETRACYCLINES - 治療病毒感染的藥物 doxy $0 doxycycline (monohydrate) CAPS 1 $0 50mg, 100mg doxycycline (monohydrate) TABS 1 $0 doxycycline hyclate CAPS 1 $0 doxycycline hyclate SOLR 1 $0 doxycycline hyclate TABS 20mg, 1 $0 100mg minocycline hcl CAPS 1 $0 morgidox cap 1x50mg 1 $0 ANTINEOPLASTIC AGENTS - 治療癌症的藥物 ALKYLATING AGENTS 烷化劑 BENDEKA 2 $0 B/D, NM busulfan 2 $0 B/D cyclophosphamide CAPS 25mg, 1 $0 B/D 50mg CYCLOPHOSPHAMIDE CAPS 2 $0 B/D 25mg, 50mg cyclophosphamide SOLR 2 $0 B/D dacarbazine 1 $0 B/D EMCYT 2 $0 GLEOSTINE 2 $0 HEXALEN 2 $0 IFEX INJ 3GM 2 $0 B/D 14

27 ifosfamide inj 1gm 1 $0 B/D ifosfamide inj 1gm/20ml 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide inj 3gm/60ml 1 $0 B/D LEUKERAN 2 $0 melphalan hcl 2 $0 B/D MUSTARGEN 2 $0 B/D ANTHRACYCLINES 蒽環類藥物 adriamycin 1 $0 B/D doxorubicin hcl 1 $0 B/D doxorubicin hcl liposomal inj 2 $0 B/D 2mg/ml doxorubicin hcl soln 2mg/ml 1 $0 B/D epirubicin hcl 1 $0 B/D ANTIBIOTICS 抗生素 bleomycin sulfate 1 $0 B/D mitomycin SOLR 2 $0 B/D ANTIMETABOLITES 抗代謝藥物 adrucil 1 $0 B/D ALIMTA 2 $0 B/D azacitidine 2 $0 B/D, NM cladribine 2 $0 B/D cytarabine 20mg/ml 1 $0 B/D fludarabine phosphate 1 $0 B/D fluorouracil SOLN 1 $0 B/D gemcitabine inj soln 1 $0 B/D gemcitabine inj solr 2 $0 B/D mercaptopurine TABS 1 $0 methotrexate sodium inj 1 $0 B/D NIPENT 2 $0 B/D PURIXAN 2 $0 NM TABLOID 2 $0 ANTIMITOTIC, TAXOIDS 紫杉烷類抗癌藥物 ABRAXANE 2 $0 B/D docetaxel CONC 20mg/ml, 2 $0 B/D 80mg/4ml DOCETAXEL CONC 80mg/4ml, 2 $0 B/D 160mg/8ml, 200mg/10ml docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml 2 $0 B/D 15

28 DOCETAXEL SOLN 20mg/2ml, 2 $0 B/D 80mg/8ml, 160mg/16ml paclitaxel 1 $0 B/D TAXOTERE 80mg/4ml 2 $0 B/D ANTIMITOTIC, VINCA ALKALOIDS 長春鹼類抗腫瘤藥物 vinblastine sulfate 1 $0 B/D vincasar pfs 1 $0 B/D vincristine sulfate 1 $0 B/D vinorelbine tartrate 1 $0 B/D BIOLOGIC RESPONSE MODIFIERS 生物反應調節劑 AVASTIN 2 $0 NM, LA, PA BELEODAQ 2 $0 NM, PA BORTEZOMIB 2 $0 NM, PA ERIVEDGE 2 $0 NM, LA, PA FARYDAK 2 $0 NM, LA, PA HERCEPTIN 2 $0 NM, PA IBRANCE 2 $0 NM, LA, PA IDHIFA 2 $0 NM, LA, PA KADCYLA 2 $0 B/D, NM KEYTRUDA 2 $0 NM, PA KISQALI 2 $0 NM, PA KISQALI FEMARA 200 DOSE 2 $0 NM, PA KISQALI FEMARA 400 DOSE 2 $0 NM, PA KISQALI FEMARA 600 DOSE 2 $0 NM, PA LYNPARZA 2 $0 NM, LA, PA MYLOTARG 2 $0 NM, LA, PA NINLARO 2 $0 NM, PA ODOMZO 2 $0 NM, LA, PA RITUXAN 2 $0 NM, LA, PA RITUXAN HYCELA 2 $0 NM, LA, PA RUBRACA 2 $0 NM, LA, PA TECENTRIQ 2 $0 NM, LA, PA TIBSOVO 2 $0 NM, LA, PA VELCADE 2 $0 NM, PA VENCLEXTA 2 $0 NM, LA, PA VENCLEXTA STARTING PACK 2 $0 NM, LA, PA VERZENIO 2 $0 NM, LA, PA YERVOY 2 $0 NM, PA ZEJULA 2 $0 NM, LA, PA ZOLINZA 2 $0 NM, PA 16

29 HORMONAL ANTINEOPLASTIC AGENTS 激素類抗腫瘤藥物 anastrozole TABS 1 $0 bicalutamide 1 $0 DEPO-PROVERA INJ 400/ML 2 $0 B/D ERLEADA 2 $0 NM, LA, PA exemestane 1 $0 FARESTON 2 $0 FASLODEX 2 $0 B/D flutamide 1 $0 hydroxyprogesterone caproate 2 $0 B/D (antineoplastic) letrozole TABS 1 $0 leuprolide inj 1mg/0.2 1 $0 NM, PA LUPRON DEPOT (1-MONTH) 2 $0 NM, PA 3.75mg LUPRON DEPOT INJ 11.25MG 2 $0 NM, PA (3-MONTH) LYSODREN 2 $0 megestrol ac sus 40mg/ml 2 $0 PA; PA if 65 years and older megestrol ac tab 20mg 2 $0 PA; PA if 65 years and older megestrol ac tab 40mg 2 $0 PA; PA if 65 years and older megestrol sus 625mg/5ml 2 $0 PA nilutamide 2 $0 SOLTAMOX 2 $0 tamoxifen citrate TABS 1 $0 TRELSTAR DEP INJ 3.75MG 2 $0 NM, PA TRELSTAR LA INJ 11.25MG 2 $0 NM, PA XTANDI 2 $0 NM, LA, PA ZYTIGA 2 $0 NM, LA, PA IMMUNOMODULATORS 免疫調節劑 POMALYST CAP 1MG 2 $0 NM, LA, PA POMALYST CAP 2MG 2 $0 NM, LA, PA POMALYST CAP 3MG 2 $0 NM, LA, PA POMALYST CAP 4MG 2 $0 NM, LA, PA REVLIMID 2 $0 QL (28 caps / 28 days), NM, LA, PA THALOMID 50mg, 100mg 2 $0 QL (30 caps / 30 days), NM, PA 17

30 THALOMID 150mg, 200mg 2 $0 QL (60 caps / 30 days), NM, PA KINASE INHIBITORS 激酶抑制劑 AFINITOR 2 $0 QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg 2 $0 QL (150 tabs / 30 days), NM, PA AFINITOR DISPERZ 3mg 2 $0 QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg 2 $0 QL (60 tabs / 30 days), NM, PA ALECENSA 2 $0 NM, LA, PA ALUNBRIG 2 $0 NM, LA, PA BOSULIF 2 $0 NM, PA BRAFTOVI 2 $0 NM, LA, PA CABOMETYX 2 $0 QL (30 tabs / 30 days), NM, LA, PA CALQUENCE 2 $0 NM, LA, PA CAPRELSA 2 $0 NM, LA, PA COMETRIQ 2 $0 NM, LA, PA COTELLIC 2 $0 NM, LA, PA GILOTRIF TAB 20MG 2 $0 NM, LA, PA GILOTRIF TAB 30MG 2 $0 NM, LA, PA GILOTRIF TAB 40MG 2 $0 NM, LA, PA ICLUSIG 2 $0 NM, LA, PA imatinib mesylate 100mg 2 $0 QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg 2 $0 QL (60 tabs / 30 days), NM, PA IMBRUVICA 2 $0 NM, LA, PA INLYTA 1mg 2 $0 QL (180 tabs / 30 days), NM, LA, PA INLYTA 5mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA IRESSA 2 $0 NM, LA, PA JAKAFI 2 $0 QL (60 tabs / 30 days), NM, LA, PA LENVIMA 4 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 8 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 10 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 12MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 14 MG DAILY DOSE 2 $0 NM, LA, PA 18

31 LENVIMA 18 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 20 MG DAILY DOSE 2 $0 NM, LA, PA LENVIMA 24 MG DAILY DOSE 2 $0 NM, LA, PA MEKINIST 2 $0 NM, LA, PA MEKTOVI 2 $0 NM, LA, PA NERLYNX 2 $0 NM, LA, PA NEXAVAR 2 $0 NM, LA, PA RYDAPT 2 $0 NM, PA SPRYCEL 2 $0 NM, PA STIVARGA 2 $0 NM, LA, PA SUTENT 2 $0 NM, PA TAFINLAR 2 $0 NM, LA, PA TAGRISSO 2 $0 NM, LA, PA TARCEVA 25mg 2 $0 QL (90 tabs / 30 days), NM, LA, PA TARCEVA 100mg, 150mg 2 $0 QL (30 tabs / 30 days), NM, LA, PA TASIGNA 2 $0 NM, PA TYKERB 2 $0 NM, LA, PA VOTRIENT 2 $0 NM, LA, PA XALKORI 2 $0 NM, LA, PA ZELBORAF 2 $0 NM, LA, PA ZYDELIG 2 $0 NM, LA, PA ZYKADIA 2 $0 NM, LA, PA MISCELLANEOUS 雜類 bexarotene 2 $0 NM, PA DROXIA 2 $0 hydroxyurea CAPS 1 $0 LONSURF 2 $0 NM, PA MATULANE 2 $0 LA mitoxantrone hcl 1 $0 B/D, NM SYLATRON KIT 200MCG 2 $0 NM, PA SYLATRON KIT 300MCG 2 $0 NM, PA SYLATRON KIT 600MCG 2 $0 NM, PA SYNRIBO 2 $0 NM, PA tretinoin (chemotherapy) 2 $0 TRISENOX 2 $0 B/D PLATINUM-BASED AGENTS 鉑基抗腫瘤藥物 carboplatin 1 $0 B/D cisplatin 1 $0 B/D oxaliplatin inj 50mg 2 $0 B/D 19

32 oxaliplatin inj 50mg/10ml 1 $0 B/D oxaliplatin inj 100mg 2 $0 B/D oxaliplatin inj 100mg/20ml 1 $0 B/D PROTECTIVE AGENTS 保護劑 dexrazoxane 2 $0 B/D ELITEK 2 $0 B/D leucovorin calcium SOLR 1 $0 B/D leucovorin calcium TABS 1 $0 levoleucovorin calcium 2 $0 B/D, NM 175mg/17.5ml levoleucovorin calcium 1 $0 B/D, NM 250mg/25ml LEVOLEUCOVORIN CALCIUM 2 $0 B/D, NM 250mg/25ml levoleucovorin calcium 50mg 2 $0 B/D, NM LEVOLEUCOVORIN CALCIUM 2 $0 B/D, NM 175MG mesna 1 $0 B/D MESNEX TABS 2 $0 TOPOISOMERASE INHIBITORS 拓撲異構酶抑制劑 etoposide SOLN 1 $0 B/D irinotecan hcl 1 $0 B/D toposar 1 $0 B/D topotecan inj 4mg 2 $0 B/D TOPOTECAN INJ 4MG/4ML 2 $0 B/D CARDIOVASCULAR - 治療心臟與循環病況的藥物 ACE INHIBITOR COMBINATIONS - 血管緊張素轉換酶抑制劑組合 - 治療高血壓的藥物 amlodipine--benazepril hcl cap 1 $ mg amlodipine-benazepril hcl cap mg 1 $0 amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap $0 mg amlodipine-benazepril hcl cap 1 $ mg benazepril & hydrochlorothiazide 1 $0 20

33 captopril & hydrochlorothiazide 1 $0 enalapril maleate & 1 $0 hydrochlorothiazide fosinopril sodium & 1 $0 hydrochlorothiazide lisinopril & hydrochlorothiazide 1 $0 moexipril-hydrochlorothiazide 1 $0 quinapril-hydrochlorothiazide 1 $0 ACE INHIBITORS - 治療高血壓的藥物 benazepril hcl TABS 1 $0 captopril TABS 1 $0 enalapril maleate TABS 1 $0 fosinopril sodium 1 $0 lisinopril TABS 1 $0 moexipril hcl 1 $0 perindopril erbumine 1 $0 quinapril hcl 1 $0 ramipril 1 $0 trandolapril 1 $0 ALDOSTERONE RECEPTOR ANTAGONISTS - 治療高血壓的藥物 eplerenone 1 $0 spironolactone TABS 1 $0 ALPHA BLOCKERS - 治療高血壓的藥物 doxazosin mesylate TABS 1mg, 1 $0 QL (30 tabs / 30 days) 2mg, 4mg doxazosin mesylate TABS 8mg 1 $0 prazosin hcl 1 $0 terazosin hcl 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - 治療高血壓的藥物 amlodipine besylate-olmesartan 1 $0 medoxomil amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab 1 $ mg amlodipine besylate-valsartan tab mg 1 $0 21

34 amlodipine-valsartan-hydrochlorot 1 $0 hiazide mg amlodipine-valsartan-hydrochlorot 1 $0 hiazide mg amlodipine-valsartan-hydrochlorot 1 $0 hiazide mg amlodipine-valsartan-hydrochlorot 1 $0 hiazide mg amlodipine-valsartan-hydrochlorot 1 $0 hiazide mg candesartan 1 $0 cilexetil-hydrochlorothiazide ENTRESTO 2 $0 irbesartan-hydrochlorothiazide 1 $0 losartan-hydrochlorothiazide 1 $0 olmesartan 1 $0 medoxomil-amlodipine-hydrochloro thiazide olmesartan 1 $0 medoxomil-hydrochlorothiazide telmisartan-hydrochlorothiazide 1 $0 valsartan-hydrochlorothiazide 1 $0 ANGIOTENSIN II RECEPTOR ANTAGONISTS - 治療高血壓的藥物 candesartan cilexetil 1 $0 irbesartan 1 $0 losartan potassium 1 $0 olmesartan medoxomil TABS 1 $0 telmisartan 1 $0 valsartan 1 $0 ANTIARRHYTHMICS - 控制心律的藥物 amiodarone hcl 1 $0 disopyramide phosphate 2 $0 PA; PA if 65 years and older dofetilide 1 $0 NM flecainide acetate 1 $0 mexiletine hcl 1 $0 MULTAQ 2 $0 NORPACE CR 2 $0 PA; PA if 65 years and older pacerone 1 $0 propafenone hcl 1 $0 propafenone hcl 12hr 1 $0 22

35 quinidine gluconate TBCR 1 $0 quinidine sulfate TABS 1 $0 sorine 1 $0 sotalol hcl 1 $0 sotalol hcl (afib/afl) 1 $0 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - 治療高膽固醇的藥物 atorvastatin calcium TABS 1 $0 lovastatin 1 $0 pravastatin sodium 1 $0 rosuvastatin calcium 1 $0 QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 1 $0 20mg, 40mg simvastatin TABS 80mg 1 $0 QL (30 tabs / 30 days) ANTILIPEMICS, MISCELLANEOUS - 治療高膽固醇的藥物 cholestyramine 1 $0 cholestyramine light 1 $0 colesevelam hcl 1 $0 colestipol hcl gran 1 $0 colestipol hcl pack 1 $0 colestipol hcl tabs 1 $0 ezetimibe 1 $0 fenofibrate TABS 48mg, 54mg, 1 $0 145mg, 160mg fenofibrate micronized 67mg, 1 $0 134mg, 200mg gemfibrozil TABS 1 $0 JUXTAPID 2 $0 NM, LA, PA KYNAMRO 2 $0 NM, PA niacin er (antihyperlipidemic) 1 $0 QL (90 tabs / 30 days) 500mg niacin er (antihyperlipidemic) 1 $0 750mg, 1000mg niacor 1 $0 omega-3-acid ethyl esters 1 $0 PRALUENT 2 $0 NM, PA prevalite 1 $0 VASCEPA 2 $0 WELCHOL 2 $0 BETA-BLOCKER/DIURETIC COMBINATIONS - 治療高血壓與心臟病況的藥物 atenolol & chlorthalidone 1 $0 bisoprolol & hydrochlorothiazide 1 $0 23

36 metoprolol & hctz tab 50-25mg 1 $0 metoprolol & hctz tab mg 1 $0 metoprolol & hctz tab mg 1 $0 propranolol & hydrochlorothiazide 1 $0 BETA-BLOCKERS - 治療高血壓與心臟病況的藥物 acebutolol hcl CAPS 1 $0 atenolol TABS 1 $0 bisoprolol fumarate 1 $0 BYSTOLIC 2.5mg, 5mg, 10mg 2 $0 QL (30 tabs / 30 days) BYSTOLIC 20mg 2 $0 QL (60 tabs / 30 days) carvedilol 1 $0 labetalol hcl TABS 1 $0 metoprolol succinate 1 $0 metoprolol tartrate SOCT 1 $0 metoprolol tartrate SOLN 1 $0 metoprolol tartrate TABS 25mg, 1 $0 50mg, 100mg nadolol TABS 1 $0 pindolol 1 $0 propranolol cap er 1 $0 propranolol hcl SOLN; TABS 1 $0 propranolol oral sol 1 $0 timolol maleate TABS 1 $0 CALCIUM CHANNEL BLOCKERS - 治療高血壓與心臟病況的藥物 afeditab cr 1 $0 amlodipine besylate TABS 1 $0 cartia xt cap 120/24hr 1 $0 cartia xt cap 180/24hr 1 $0 cartia xt cap 240/24hr 1 $0 cartia xt cap 300/24hr 1 $0 dilt-xr cap 1 $0 diltiazem cap 120mg cd 1 $0 diltiazem cap 180mg cd 1 $0 diltiazem cap 240mg cd 1 $0 diltiazem cap 300mg cd 1 $0 diltiazem cap 360mg cd 1 $0 diltiazem cap er/12hr 1 $0 diltiazem hcl TABS 1 $0 diltiazem hcl cap sr 24hr 1 $0 diltiazem hcl coated beads cap sr 24hr 1 $0 24

37 diltiazem hcl extended release 1 $0 beads cap sr diltiazem inj 1 $0 felodipine 1 $0 isradipine 1 $0 nicardipine hcl CAPS 1 $0 nifedical xl 1 $0 nifedipine TB24 1 $0 nifedipine er 1 $0 nimodipine CAPS 2 $0 NYMALIZE 2 $0 taztia xt 1 $0 verapamil cap er 1 $0 verapamil hcl SOLN; TABS 1 $0 verapamil hcl tab er 1 $0 DIGITALIS GLYCOSIDES - 治療心臟病況的藥物 digitek.25mg 1 $0 PA; PA if 65 years and older digitek.125mg 1 $0 QL (30 tabs / 30 days) digox 125mcg 1 $0 QL (30 tabs / 30 days) digox 250mcg 1 $0 PA; PA if 65 years and older digoxin TABS 125mcg 1 $0 QL (30 tabs / 30 days) digoxin TABS 250mcg 1 $0 PA; PA if 65 years and older digoxin inj 1 $0 digoxin sol 50mcg/ml 1 $0 PA; PA if 65 years and older DIRECT RENIN INHIBITORS/COMBINATIONS - 治療心臟病況的藥物 TEKTURNA 2 $0 TEKTURNA HCT 2 $0 DIURETICS - 治療心臟病況的藥物 acetazolamide CP12; TABS 1 $0 amiloride & hydrochlorothiazide 1 $0 amiloride hcl TABS 1 $0 bumetanide 1 $0 chlorothiazide tabs 1 $0 chlorthalidone 1 $0 furosemide SOLN; TABS 1 $0 furosemide inj 1 $0 hydrochlorothiazide CAPS; TABS 1 $0 25

38 indapamide 1 $0 methazolamide TABS 1 $0 methyclothiazide 1 $0 metolazone 1 $0 spironolactone & 1 $0 hydrochlorothiazide torsemide tabs 1 $0 triamterene & hydrochlorothiazide 1 $0 cap mg triamterene & hydrochlorothiazide 1 $0 tabs MISCELLANEOUS 治療心臟病況的其他藥物 clonidine hcl TABS 1 $0 clonidine hcl ptwk 1 $0 CORLANOR 2 $0 DEMSER 2 $0 hydralazine hcl SOLN; TABS 1 $0 midodrine hcl 1 $0 minoxidil TABS 1 $0 NORTHERA 2 $0 NM, LA, PA RANEXA 2 $0 NITRATES - 治療心臟病況的藥物 isosorb mononitrate tab 1 $0 isosorbide dinitrate 1 $0 isosorbide dinitrate er 1 $0 isosorbide mononitrate er 1 $0 minitran 1 $0 NITRO-BID 2 $0 NITRO-DUR DIS 0.3MG/HR 2 $0 NITRO-DUR DIS 0.8MG/HR 2 $0 nitroglycerin SUBL 1 $0 nitroglycerin td patch 1 $0 PULMONARY ARTERIAL HYPERTENSION - 治療肺動脈高壓的藥物 ADCIRCA 2 $0 QL (60 tabs / 30 days), NM, PA ADEMPAS 2 $0 QL (90 tabs / 30 days), NM, LA, PA LETAIRIS 2 $0 QL (30 tabs / 30 days), NM, LA, PA OPSUMIT 2 $0 QL (30 tabs / 30 days), NM, LA, PA 26

39 REMODULIN 2 $0 NM, LA, PA sildenafil citrate (pulmonary hypertension) TABS 1 $0 QL (90 tabs / 30 days), NM, PA tadalafil (pulmonary hypertension) 2 $0 QL (60 tabs / 30 days), NM, PA TRACLEER TABS 62.5mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA TRACLEER TABS 125mg 2 $0 QL (60 tabs / 30 days), NM, LA, PA VENTAVIS 2 $0 NM, PA CENTRAL NERVOUS SYSTEM - 治療神經系統失調的藥物 ANTIANXIETY - 治療焦慮症的藥物 alprazolam tab 0.5mg 1 $0 QL (240 tabs / 30 days) alprazolam tab 0.25mg 1 $0 QL (480 tabs / 30 days) alprazolam tab 1mg 1 $0 QL (120 tabs / 30 days) alprazolam tab 2mg 1 $0 QL (150 tabs / 30 days) buspirone hcl TABS 1 $0 fluvoxamine maleate TABS 25mg, 1 $0 QL (45 tabs / 30 days) 50mg fluvoxamine maleate TABS 100mg1 $0 lorazepam SOLN 1 $0 lorazepam TABS 1 $0 QL (150 tabs / 30 days) lorazepam intensol 1 $0 QL (150 ml / 30 days) ANTICONVULSANTS - 治療癲癇的藥物 APTIOM 200mg 2 $0 QL (180 tabs / 30 days) APTIOM 400mg 2 $0 QL (90 tabs / 30 days) APTIOM 600mg, 800mg 2 $0 QL (60 tabs / 30 days) BANZEL SUS 40MG/ML 2 $0 PA BANZEL TAB 200MG 2 $0 PA BANZEL TAB 400MG 2 $0 PA BRIVIACT 2 $0 PA carbamazepine CHEW; CP12; 1 $0 SUSP; TABS; TB12 CELONTIN 2 $0 clonazepam TABS 1mg 1 $0 QL (120 tabs / 30 days) clonazepam TABS 2mg 1 $0 QL (300 tabs / 30 days) clonazepam TABS.5mg 1 $0 QL (240 tabs / 30 days) clonazepam TBDP 1mg 1 $0 QL (120 tabs / 30 days) clonazepam TBDP 2mg 1 $0 QL (300 tabs / 30 days) clonazepam TBDP.5mg 1 $0 QL (240 tabs / 30 days) clonazepam TBDP.25mg 1 $0 QL (480 tabs / 30 days) 27

40 clonazepam TBDP.125mg 1 $0 QL (960 tabs / 30 days) clorazepate dipotassium 3.75mg, 1 $0 QL (120 tabs / 30 days), 7.5mg PA; PA if 65 years and older clorazepate dipotassium 15mg 1 $0 QL (180 tabs / 30 days), PA; PA if 65 years and older DIASTAT ACUDIAL 2 $0 DIASTAT PEDIATRIC 2 $0 diazepam SOLN 5mg/5ml 1 $0 QL (1200 ml / 30 days), PA; PA if 65 years and older diazepam SOLN 5mg/ml 1 $0 diazepam TABS 1 $0 QL (120 tabs / 30 days), PA; PA if 65 years and older diazepam gel 1 $0 diazepam intensol 1 $0 QL (240 ml / 30 days), PA; PA if 65 years and older DILANTIN 2 $0 DILANTIN-125 SUS 125/5ML 2 $0 divalproex sodium CSDR; TB24; 1 $0 TBEC epitol 1 $0 ethosuximide CAPS; SOLN 1 $0 felbamate SUSP 2 $0 felbamate TABS 1 $0 FYCOMPA SUSP 2 $0 QL (720 ml / 30 days), PA FYCOMPA TABS 2mg 2 $0 QL (180 tabs / 30 days), PA FYCOMPA TABS 4mg 2 $0 QL (90 tabs / 30 days), PA FYCOMPA TABS 6mg 2 $0 QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg2 $0 QL (30 tabs / 30 days), PA gabapentin CAPS 100mg 1 $0 QL (1080 caps / 30 days) gabapentin CAPS 300mg 1 $0 QL (360 caps / 30 days) gabapentin CAPS 400mg 1 $0 QL (270 caps / 30 days) 28

41 gabapentin SOLN 1 $0 QL (2160 ml / 30 days) gabapentin TABS 600mg 1 $0 QL (180 tabs / 30 days) gabapentin TABS 800mg 1 $0 QL (120 tabs / 30 days) GABITRIL 12mg, 16mg 2 $0 lamotrigine CHEW; TABS; TB24 1 $0 levetiracetam SOLN; TABS; TB24 1 $0 levetiracetam in sodium chloride 1 $0 levetiracetam oral soln 100 mg/ml 1 $0 LYRICA CAPS 25mg, 50mg, 75mg, 2 $0 QL (120 caps / 30 days) 100mg, 150mg LYRICA CAPS 200mg 2 $0 QL (90 caps / 30 days) LYRICA CAPS 225mg, 300mg 2 $0 QL (60 caps / 30 days) LYRICA SOLN 2 $0 QL (946 ml / 30 days) ONFI 2 $0 PA oxcarbazepine 1 $0 PEGANONE 2 $0 phenobarbital ELIX; TABS 2 $0 PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml 2 $0 PA; PA if 65 years and older phenobarbital sodium SOLN 130mg/ml 2 $0 PA; PA if 65 years and older PHENYTEK 2 $0 phenytoin CHEW; SUSP 1 $0 phenytoin sodium SOLN 1 $0 phenytoin sodium extended 1 $0 primidone TABS 1 $0 roweepra 1 $0 roweepra xr 1 $0 SABRIL TABS 2 $0 QL (180 tabs / 30 days), NM, LA, PA SPRITAM 2 $0 subvenite tab 1 $0 TEGRETOL 2 $0 TEGRETOL-XR 2 $0 tiagabine hcl 1 $0 topiramate CPSP; TABS 1 $0 valproate sodium SOLN 1 $0 valproic acid 1 $0 vigabatrin powd pack 500mg 2 $0 QL (180 packets / 30 days), NM, LA, PA 29

42 VIMPAT SOLN 10mg/ml 2 $0 QL (1200 ml / 30 days) VIMPAT SOLN 200mg/20ml 2 $0 VIMPAT TABS 50mg 2 $0 QL (180 tabs / 30 days) VIMPAT TABS 100mg, 150mg, 2 $0 QL (60 tabs / 30 days) 200mg zonisamide CAPS 1 $0 ANTIDEMENTIA - 治療失智與失憶症的藥物 donepezil hydrochloride TABS 1 $0 QL (60 tabs / 30 days) 5mg donepezil hydrochloride TABS 1 $0 10mg, 23mg donepezil hydrochloride TBDP 1 $0 QL (60 tabs / 30 days) 5mg donepezil hydrochloride TBDP 10mg 1 $0 galantamine hydrobromide SOLN 1 $0 galantamine hydrobromide TABS 1 $0 QL (180 tabs / 30 days) 4mg galantamine hydrobromide TABS 1 $0 QL (90 tabs / 30 days) 8mg galantamine hydrobromide TABS 1 $0 12mg galantamine hydrobromide er 1 $0 QL (30 caps / 30 days) 8mg, 16mg galantamine hydrobromide er 1 $0 24mg memantine hcl cp24 1 $0 PA; PA if < 30 yrs memantine hcl soln 1 $0 PA; PA if < 30 yrs memantine hcl tabs 1 $0 PA; PA if < 30 yrs NAMENDA XR 2 $0 PA; PA if < 30 yrs NAMENDA XR TITRATION PACK 2 $0 PA; PA if < 30 yrs NAMZARIC 2 $0 rivastigmine tartrate 1 $0 rivastigmine td patch 24hr 4.6 mg/24hr 1 $0 QL (30 patches / 30 days) rivastigmine td patch 24hr 9.5 mg/24hr 1 $0 QL (30 patches / 30 days) rivastigmine td patch 24hr 13.3 mg/24hr 1 $0 QL (30 patches / 30 days) ANTIDEPRESSANTS - 治療憂鬱症的藥物 amitriptyline hcl TABS 2 $0 PA; PA if 65 years and older 30

43 amoxapine tab 25mg 1 $0 amoxapine tab 50mg 1 $0 amoxapine tab 100mg 1 $0 amoxapine tab 150mg 1 $0 bupropion hcl TABS 1 $0 bupropion hcl TB12 1 $0 bupropion hcl TB24 150mg 1 $0 QL (90 tabs / 30 days) bupropion hcl TB24 300mg 1 $0 QL (30 tabs / 30 days) citalopram hydrobromide SOLN 1 $0 citalopram hydrobromide TABS 1 $0 QL (45 tabs / 30 days) 10mg, 20mg citalopram hydrobromide TABS 1 $0 QL (30 tabs / 30 days) 40mg clomipramine hcl CAPS 2 $0 PA; PA if 65 years and older desipramine hcl TABS 1 $0 desvenlafaxine succinate 1 $0 QL (30 tabs / 30 days) doxepin hcl CAPS; CONC 2 $0 PA; PA if 65 years and older duloxetine hcl CPEP 20mg 1 $0 QL (180 caps / 30 days) duloxetine hcl CPEP 30mg 1 $0 QL (120 caps / 30 days) duloxetine hcl CPEP 60mg 1 $0 QL (60 caps / 30 days) EMSAM 2 $0 QL (30 patches / 30 days), PA escitalopram oxalate SOLN 1 $0 QL (600 ml / 30 days) escitalopram oxalate TABS 5mg, 10mg 1 $0 QL (45 tabs / 30 days) escitalopram oxalate TABS 20mg 1 $0 QL (60 tabs / 30 days) FETZIMA 20mg 2 $0 QL (180 caps / 30 days) FETZIMA 40mg 2 $0 QL (90 caps / 30 days) FETZIMA 80mg, 120mg 2 $0 QL (30 caps / 30 days) FETZIMA TITRATION PACK 2 $0 fluoxetine cap 10mg 1 $0 QL (30 caps / 30 days) fluoxetine cap 20mg 1 $0 QL (120 caps / 30 days) fluoxetine cap 40mg 1 $0 fluoxetine hcl SOLN 1 $0 imipramine hcl TABS 2 $0 PA; PA if 65 years and older maprotiline hcl 1 $0 MARPLAN TAB 10MG 2 $0 QL (180 tabs / 30 days) mirtazapine TABS 7.5mg, 15mg 1 $0 QL (45 tabs / 30 days) mirtazapine TABS 30mg, 45mg 1 $0 31

44 mirtazapine TBDP 15mg 1 $0 QL (30 tabs / 30 days) mirtazapine TBDP 30mg, 45mg 1 $0 nefazodone hcl 1 $0 nortriptyline hcl CAPS; SOLN 1 $0 paroxetine hcl tabs 10mg, 20mg, 1 $0 QL (45 tabs / 30 days) 40mg paroxetine hcl tabs 30mg 1 $0 QL (60 tabs / 30 days) PAXIL SUSP 2 $0 QL (900 ml / 30 days) phenelzine sulfate TABS 1 $0 protriptyline hcl 1 $0 sertraline hcl CONC 1 $0 sertraline hcl TABS 25mg, 50mg 1 $0 QL (45 tabs / 30 days) sertraline hcl TABS 100mg 1 $0 tranylcypromine sulfate 1 $0 trazodone hcl TABS 50mg, 100mg, 1 $0 150mg trimipramine maleate CAPS 25mg 2 $0 QL (240 caps / 30 days), PA; PA if 65 years and older trimipramine maleate CAPS 50mg 2 $0 QL (120 caps / 30 days), PA; PA if 65 years and older trimipramine maleate CAPS 100mg 2 $0 QL (60 caps / 30 days), PA; PA if 65 years and older TRINTELLIX 5mg 2 $0 QL (120 tabs / 30 days) TRINTELLIX 10mg 2 $0 QL (60 tabs / 30 days) TRINTELLIX 20mg 2 $0 QL (30 tabs / 30 days) venlafaxine hcl CP mg, 1 $0 QL (30 caps / 30 days) 75mg venlafaxine hcl CP24 150mg 1 $0 QL (60 caps / 30 days) venlafaxine hcl TABS 1 $0 VIIBRYD STARTER PACK 2 $0 VIIBRYD TAB 2 $0 QL (30 tabs / 30 days) ANTIPARKINSONIAN AGENTS - 治療帕金森症的藥物 amantadine hcl CAPS 1 $0 QL (120 caps / 30 days) amantadine hcl SYRP; TABS 1 $0 APOKYN 2 $0 NM, LA, PA benztropine mesylate SOLN 1 $0 benztropine mesylate TABS 2 $0 PA; PA if 65 years and older 32

45 bromocriptine mesylate CAPS; 1 $0 TABS carbidopa-levodopa 1 $0 carbidopa/levodopa/entacapone 1 $0 entacapone 1 $0 NEUPRO 2 $0 pramipexole tab 0.5mg 1 $0 pramipexole tab 0.25mg 1 $0 pramipexole tab 0.75mg 1 $0 pramipexole tab 0.125mg 1 $0 pramipexole tab 1.5mg 1 $0 pramipexole tab 1mg 1 $0 rasagiline mesylate TABS 1 $0 ropinirole tab 0.5mg 1 $0 ropinirole tab 0.25mg 1 $0 ropinirole tab 1mg 1 $0 ropinirole tab 2mg 1 $0 ropinirole tab 3mg 1 $0 ropinirole tab 4mg 1 $0 ropinirole tab 5mg 1 $0 selegiline hcl CAPS; TABS 1 $0 trihexyphenidyl hcl 2 $0 PA; PA if 65 years and older ANTIPSYCHOTICS - 治療精神病的藥物 ABILIFY MAINTENA 2 $0 QL (1 injection / 28 days) aripiprazole odt 2 $0 QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml 2 $0 QL (900 ml / 30 days) aripiprazole tab 2mg, 5mg, 10mg, 1 $0 QL (30 tabs / 30 days) 15mg aripiprazole tab 20mg, 30mg 2 $0 QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml 2 $0 QL (1 injection / 28 days) ARISTADA 1064mg/3.9ml 2 $0 QL (1 injection / 56 days) ARISTADA INITIO 2 $0 chlorpromazine hcl TABS 1 $0 CHLORPROMAZINE INJ 2 $0 clozapine odt 12.5mg, 25mg 1 $0 PA clozapine odt 100mg 1 $0 QL (270 tabs / 30 days), PA 33

46 clozapine odt 150mg 1 $0 QL (180 tabs / 30 days), PA clozapine odt 200mg 2 $0 QL (135 tabs / 30 days), PA clozapine tab 25mg 1 $0 clozapine tab 50mg 1 $0 clozapine tab 100mg 1 $0 QL (270 tabs / 30 days) clozapine tab 200mg 1 $0 QL (135 tabs / 30 days) FANAPT 2 $0 QL (60 tabs / 30 days) FANAPT TITRATION PACK 2 $0 fluphenazine decanoate SOLN 1 $0 fluphenazine hcl 1 $0 GEODON SOLR 2 $0 QL (6 ml / 3 days) haloperidol TABS 1 $0 haloperidol conc 2mg/ml 1 $0 haloperidol decanoate SOLN 1 $0 haloperidol inj 5mg/ml 1 $0 haloperidol lactate inj 5 mg/ml 1 $0 INVEGA SUST INJ 39 MG/0.25 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML 2 $0 QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML 2 $0 QL (1 injection / 28 days) INVEGA TRINZA 2 $0 QL (1 injection / 90 days) LATUDA 20mg 2 $0 QL (240 tabs / 30 days) LATUDA 40mg, 120mg 2 $0 QL (30 tabs / 30 days) LATUDA 60mg, 80mg 2 $0 QL (60 tabs / 30 days) loxapine succinate 1 $0 NUPLAZID CAP 34MG 2 $0 QL (30 caps / 30 days), NM, LA, PA NUPLAZID TAB 10MG 2 $0 QL (30 tabs / 30 days), NM, LA, PA NUPLAZID TAB 17MG 2 $0 QL (60 tabs / 30 days), NM, LA, PA olanzapine SOLR 1 $0 QL (3 vials / 1 day) olanzapine TABS 2.5mg 1 $0 QL (240 tabs / 30 days) 34

47 olanzapine TABS 5mg 1 $0 QL (120 tabs / 30 days) olanzapine TABS 7.5mg 1 $0 QL (30 tabs / 30 days) olanzapine TABS 10mg, 15mg, 1 $0 QL (60 tabs / 30 days) 20mg olanzapine TBDP 5mg 1 $0 QL (30 tabs / 30 days) olanzapine TBDP 10mg, 15mg, 1 $0 QL (60 tabs / 30 days) 20mg paliperidone 1.5mg, 3mg, 9mg 2 $0 QL (30 tabs / 30 days) paliperidone 6mg 2 $0 QL (60 tabs / 30 days) perphenazine TABS 1 $0 pimozide 1 $0 quetiapine fumarate TABS 1 $0 QL (90 tabs / 30 days) quetiapine fumarate TB24 50mg 1 $0 QL (120 tabs / 30 days) quetiapine fumarate TB24 150mg, 1 $0 QL (30 tabs / 30 days) 200mg quetiapine fumarate TB24 300mg, 1 $0 QL (60 tabs / 30 days) 400mg REXULTI 1mg 2 $0 QL (90 tabs / 30 days) REXULTI 2mg 2 $0 QL (60 tabs / 30 days) REXULTI 3mg, 4mg 2 $0 QL (30 tabs / 30 days) REXULTI.5mg 2 $0 QL (180 tabs / 30 days) REXULTI.25mg 2 $0 QL (360 tabs / 30 days) RISPERDAL INJ 12.5MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 25MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 37.5MG 2 $0 QL (2 injections / 28 days) RISPERDAL INJ 50MG 2 $0 QL (2 injections / 28 days) risperidone SOLN 1 $0 QL (240 ml / 30 days) risperidone TABS 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 days) risperidone TABS 4mg 1 $0 QL (120 tabs / 30 days) risperidone TABS.25mg,.5mg 1 $0 QL (90 tabs / 30 days) risperidone TBDP 1mg, 2mg, 3mg 1 $0 QL (60 tabs / 30 days) risperidone TBDP 4mg 1 $0 QL (120 tabs / 30 days) risperidone TBDP.25mg,.5mg 1 $0 QL (90 tabs / 30 days) SAPHRIS 2.5mg 2 $0 QL (240 tabs / 30 days) SAPHRIS 5mg 2 $0 QL (120 tabs / 30 days) SAPHRIS 10mg 2 $0 QL (60 tabs / 30 days) thioridazine hcl TABS 2 $0 PA; PA if 65 years and older 35

48 thiothixene 1 $0 trifluoperazine hcl 1 $0 VERSACLOZ 2 $0 QL (600 ml / 30 days), PA VRAYLAR 1.5mg 2 $0 QL (120 caps / 30 days), PA VRAYLAR 3mg 2 $0 QL (60 caps / 30 days), PA VRAYLAR 4.5mg, 6mg 2 $0 QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK 2 $0 PA ziprasidone hcl 1 $0 QL (60 caps / 30 days) ZYPREXA RELPREVV 300mg 2 $0 QL (2 vials / 28 days), PA ZYPREXA RELPREVV 405mg 2 $0 QL (1 vial / 28 days), PA ZYPREXA RELPREVV INJ 210MG 2 $0 QL (2 vials / 28 days), PA ATTENTION DEFICIT HYPERACTIVITY DISORDER - 治療注意力缺乏性多動 症 (ADHD) 的藥物 amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 days) cap sr 24hr 5 mg amphetamine-dextroamphetamine 1 $0 QL (90 caps / 30 days) cap sr 24hr 10 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 days) cap sr 24hr 15 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 days) cap sr 24hr 20 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 days) cap sr 24hr 25 mg amphetamine-dextroamphetamine 1 $0 QL (30 caps / 30 days) cap sr 24hr 30 mg amphetamine-dextroamphetamine 1 $0 QL (360 tabs / 30 days) tab 5 mg amphetamine-dextroamphetamine 1 $0 QL (240 tabs / 30 days) tab 7.5 mg amphetamine-dextroamphetamine 1 $0 QL (180 tabs / 30 days) tab 10 mg amphetamine-dextroamphetamine 1 $0 QL (144 tabs / 30 days) tab 12.5 mg amphetamine-dextroamphetamine 1 $0 QL (120 tabs / 30 days) tab 15 mg 36

49 amphetamine-dextroamphetamine 1 $0 QL (90 tabs / 30 days) tab 20 mg amphetamine-dextroamphetamine 1 $0 QL (60 tabs / 30 days) tab 30 mg atomoxetine hcl 10mg, 18mg, 1 $0 QL (120 caps / 30 days) 25mg atomoxetine hcl 40mg 1 $0 QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 1 $0 QL (30 caps / 30 days) 100mg guanfacine er (adhd) 2 $0 PA; PA if 65 years and older metadate er tab 20mg 1 $0 QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg 1 $0 QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg 1 $0 QL (90 tabs / 30 days) methylphenidate hcl oral soln 1 $0 QL (1800 ml / 30 days) 5mg/5ml methylphenidate hcl oral soln 1 $0 QL (900 ml / 30 days) 10mg/5ml methylphenidate tab 10mg er 1 $0 QL (90 tabs / 30 days) methylphenidate tab 20mg er 1 $0 QL (90 tabs / 30 days) HYPNOTICS - 治療失眠的藥物 eszopiclone 2 $0 QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year HETLIOZ 2 $0 NM, LA, PA SILENOR 3mg 2 $0 QL (60 tabs / 30 days) SILENOR 6mg 2 $0 QL (30 tabs / 30 days) temazepam 7.5mg 1 $0 QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year temazepam 15mg 1 $0 QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year 37

50 zolpidem tartrate TABS 2 $0 QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year MIGRAINE - 治療劇烈頭痛的藥物 dihydroergotamine mesylate 1mg/ml 2 $0 dihydroergotamine mesylate nasal 2 $0 QL (8 ml / 30 days) eletriptan hydrobromide 1 $0 QL (12 tabs / 30 days) ergotamine w/ caffeine 1 $0 migergot 2 $0 naratriptan hcl 1 $0 QL (12 tabs / 30 days) rizatriptan benzoate 1 $0 QL (18 tabs / 30 days) rizatriptan benzoate odt 1 $0 QL (18 tabs / 30 days) sumatriptan SOLN 5mg/act 1 $0 QL (24 inhalers / 30 days) sumatriptan SOLN 20mg/act 1 $0 QL (12 inhalers / 30 days) sumatriptan inj 4mg/0.5ml 1 $0 QL (18 injections / 30 days) sumatriptan inj 6mg/0.5ml 1 $0 QL (12 injections / 30 days) sumatriptan succinate TABS 1 $0 QL (12 tabs / 30 days) zolmitriptan TABS 1 $0 QL (12 tabs / 30 days) zolmitriptan odt 1 $0 QL (12 tabs / 30 days) MISCELLANEOUS 其他藥物 AUSTEDO 6mg 2 $0 QL (60 tabs / 30 days), NM, LA, PA AUSTEDO 9mg, 12mg 2 $0 QL (120 tabs / 30 days), NM, LA, PA lithium carbonate CAPS; TABS 1 $0 lithium carbonate er 1 $0 LITHIUM SOLN 8MEQ/5ML 2 $0 LYRICA CR 82.5mg, 165mg 2 $0 QL (90 tabs / 30 days), PA LYRICA CR 330mg 2 $0 QL (60 tabs / 30 days), PA NUEDEXTA 2 $0 PA pyridostigmine tab 60mg 1 $0 riluzole 1 $0 38

51 tetrabenazine 12.5mg 2 $0 QL (240 tabs / 30 days), NM, PA tetrabenazine 25mg 2 $0 QL (120 tabs / 30 days), NM, PA MULTIPLE SCLEROSIS AGENTS - 治療多發性硬化病的藥物 AMPYRA 2 $0 NM, LA, PA BETASERON 2 $0 QL (14 syringes / 28 days), NM, PA dalfampridine 2 $0 NM, PA GILENYA CAP 0.5MG 2 $0 QL (28 caps / 28 days), NM, PA glatiramer acetate 20mg/ml 2 $0 QL (30 syringes / 30 days), NM, PA glatiramer acetate 40mg/ml 2 $0 QL (12 syringes / 28 days), NM, PA glatopa 20mg/ml 2 $0 QL (30 syringes / 30 days), NM, PA glatopa 40mg/ml 2 $0 QL (12 syringes / 28 days), NM, PA TYSABRI 2 $0 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS - 治療肌肉痙攣的藥物 baclofen TABS 10mg, 20mg 1 $0 carisoprodol TABS 350mg 2 $0 QL (120 tabs / 30 days), PA; PA if 65 years and older cyclobenzaprine hcl TABS 5mg, 10mg 2 $0 PA; PA if 65 years and older dantrolene sodium CAPS 1 $0 methocarbamol TABS 2 $0 PA; PA if 65 years and older tizanidine hcl TABS 1 $0 NARCOLEPSY/CATAPLEXY - 治療睡眠障礙的藥物 armodafinil 50mg 1 $0 QL (150 tabs / 30 days), PA armodafinil 150mg 1 $0 QL (60 tabs / 30 days), PA armodafinil 200mg, 250mg 1 $0 QL (30 tabs / 30 days), PA XYREM 2 $0 QL (540 ml / 30 days), NM, LA, PA PSYCHOTHERAPEUTIC- 各類心理治療用藥 acamprosate calcium 1 $0 39

52 buprenorphine hcl SUBL 1 $0 PA buprenorphine hcl-naloxone hcl sl 1 $0 QL (120 tabs / 30 days), PA bupropion hcl (smoking deterrent) 1 $0 CHANTIX 2 $0 PA CHANTIX CONTINUING MONTH 2 $0 PA CHANTIX STARTER PACK 2 $0 PA disulfiram TABS 1 $0 gnp nicotine mini lozenge 3 $0 NM; * gnp nicotine polacrilex 3 $0 NM; * gnp nicotine polacrilex m 3 $0 NM; * gnp nighttime sleep aid 3 $0 NM; * goodsense nicotine gum 3 $0 NM; * goodsense nicotine polacr 3 $0 NM; * hm nicotine transdermal s 3 $0 NM; * naloxone inj 0.4mg/ml 1 $0 naloxone inj 1mg/ml 1 $0 naltrexone hcl TABS 1 $0 NARCAN 2 $0 nicorelief 3 $0 NM; * nicotine 3 $0 NM; * nicotine polacrilex GUM; LOZG 3 $0 NM; * nicotine transdermal syst PT24 3 $0 NM; * NICOTROL INHALER 2 $0 NICOTROL NS 2 $0 night time sleep aid 3 $0 NM; * nighttime sleep aid 3 $0 NM; * sb sleep 3 $0 NM; * sleep tabs 3 $0 NM; * sm nicotine 3 $0 NM; * sm nicotine polacrilex 3 $0 NM; * sm nicotine transdermal s 3 $0 NM; * sm sleep aid night time 3 $0 NM; * SUBOXONE MIS 2-0.5MG 2 $0 QL (120 SL films / 30 days), PA SUBOXONE MIS 4-1MG 2 $0 QL (120 SL films / 30 days), PA SUBOXONE MIS 8-2MG 2 $0 QL (120 SL films / 30 days), PA SUBOXONE MIS 12-3MG 2 $0 QL (60 SL films / 30 days), PA 40

53 thrive 3 $0 NM; * VIVITROL 2 $0 NM ENDOCRINE AND METABOLIC - 治療糖尿病與調節荷爾蒙的藥物 ANDROGENS - 調節男性荷爾蒙的藥物 ANADROL-50 2 $0 PA ANDRODERM 2 $0 QL (30 patches / 30 days), PA ANDROGEL 1.62% 2 $0 QL (150 grams / 30 days), PA ANDROGEL PUMP 2 $0 QL (150 grams / 30 days), PA oxandrolone TABS 1 $0 PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm 1 $0 QL (300 gm / 30 days), PA testosterone cypionate SOLN 1 $0 PA testosterone enanthate SOLN 1 $0 PA ANTIDIABETICS, INJECTABLE - 治療糖尿病的注射藥物 ALCOHOL SWABS 2 $0 BASAGLAR KWIKPEN 2 $0 BD ULTRAFINE INSULIN SYRINGE 2 $0 BD ULTRAFINE/NANO PEN NEEDLES2 $0 BYDUREON BCISE 2 $0 QL (4 pens / 28 days) BYDUREON INJ 2 $0 QL (4 vials / 28 days) BYDUREON PEN 2 $0 QL (4 pens / 28 days) BYETTA 2 $0 QL (1 pen / 30 days) FIASP 2 $0 FIASP FLEXTOUCH 2 $0 GAUZE PADS 2" X 2" 2 $0 HUMULIN R INJ U $0 B/D HUMULIN R U-500 KWIKPEN 2 $0 INSULIN PEN NEEDLE 2 $0 INSULIN SAFETY NEEDLES 2 $0 INSULIN SYRINGE 2 $0 LEVEMIR 2 $0 LEVEMIR FLEXTOUCH 2 $0 NOVOLIN 70/30 2 $0 (brand RELION not covered) NOVOLIN N 2 $0 (brand RELION not covered) NOVOLIN R 2 $0 (brand RELION not covered) 41

54 NOVOLOG 2 $0 NOVOLOG 70/30 FLEXPEN 2 $0 NOVOLOG FLEXPEN 2 $0 NOVOLOG MIX 70/30 2 $0 NOVOLOG PENFILL 2 $0 OZEMPIC INJ 0.25 OR 0.5MG/DOSE2 $0 QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE 2 $0 QL (2 pens / 28 days) SOLIQUA 100/33 2 $0 QL (10 pens / 30 days) TRESIBA FLEXTOUCH 2 $0 TRULICITY 2 $0 QL (4 pens / 28 days) VICTOZA 2 $0 QL (3 pens / 30 days) XULTOPHY 100/3.6 2 $0 QL (5 pens / 30 days) ANTIDIABETICS, ORAL - 治療糖尿病的口服藥物 acarbose 1 $0 FARXIGA 5mg 2 $0 QL (60 tabs / 30 days) FARXIGA 10mg 2 $0 QL (30 tabs / 30 days) glimepiride 1mg 1 $0 QL (240 tabs / 30 days) glimepiride 2mg 1 $0 QL (120 tabs / 30 days) glimepiride 4mg 1 $0 QL (60 tabs / 30 days) glip/metform tab mg 1 $0 QL (240 tabs / 30 days) glip/metform tab mg 1 $0 QL (120 tabs / 30 days) glip/metform tab 5-500mg 1 $0 QL (120 tabs / 30 days) glipizide TABS 5mg 1 $0 QL (240 tabs / 30 days) glipizide TABS 10mg 1 $0 QL (120 tabs / 30 days) glipizide TB24 2.5mg 1 $0 QL (240 tabs / 30 days) glipizide TB24 5mg 1 $0 QL (120 tabs / 30 days) glipizide TB24 10mg 1 $0 QL (60 tabs / 30 days) glipizide xl 2.5mg 1 $0 QL (240 tabs / 30 days) glipizide xl 5mg 1 $0 QL (120 tabs / 30 days) glipizide xl 10mg 1 $0 QL (60 tabs / 30 days) glyburide TABS 1.25mg 2 $0 QL (480 tabs / 30 days), PA; PA if 65 years and older glyburide TABS 2.5mg 2 $0 QL (240 tabs / 30 days), PA; PA if 65 years and older glyburide TABS 5mg 2 $0 QL (120 tabs / 30 days), PA; PA if 65 years and older 42

55 glyburide micronized 1.5mg 2 $0 QL (240 tabs / 30 days), PA; PA if 65 years and older glyburide micronized 3mg 2 $0 QL (120 tabs / 30 days), PA; PA if 65 years and older glyburide micronized 6mg 2 $0 QL (60 tabs / 30 days), PA; PA if 65 years and older INVOKAMET TAB MG 2 $0 QL (120 tabs / 30 days) INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 days) INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 days) INVOKAMET TAB MG 2 $0 QL (60 tabs / 30 days) INVOKAMET XR TAB MG 2 $0 QL (120 tabs / 30 days) INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 days) INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 days) INVOKAMET XR TAB MG 2 $0 QL (60 tabs / 30 days) INVOKANA 100mg 2 $0 QL (90 tabs / 30 days) INVOKANA 300mg 2 $0 QL (30 tabs / 30 days) JANUMET 2 $0 QL (60 tabs / 30 days) JANUMET XR TAB MG 2 $0 QL (60 tabs / 30 days) JANUMET XR TAB $0 QL (60 tabs / 30 days) JANUMET XR TAB $0 QL (30 tabs / 30 days) JANUVIA 2 $0 QL (30 tabs / 30 days) JENTADUETO 2 $0 QL (60 tabs / 30 days) JENTADUETO TAB XR MG 2 $0 QL (60 tabs / 30 days) JENTADUETO TAB XR MG 2 $0 QL (30 tabs / 30 days) metformin er 500mg 1 $0 QL (120 tabs / 30 days); (generic of GLUCOPHAGE XR) metformin er 750mg 1 $0 QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR) metformin hcl TABS 500mg 1 $0 QL (150 tabs / 30 days) metformin hcl TABS 850mg 1 $0 QL (90 tabs / 30 days) metformin hcl TABS 1000mg 1 $0 QL (75 tabs / 30 days) nateglinide 1 $0 QL (90 tabs / 30 days) pioglitazone hcl 1 $0 QL (30 tabs / 30 days) repaglinide 2mg 1 $0 QL (240 tabs / 30 days) repaglinide.5mg, 1mg 1 $0 QL (120 tabs / 30 days) TRADJENTA 2 $0 QL (30 tabs / 30 days) XIGDUO XR TAB MG 2 $0 QL (60 tabs / 30 days) 43

56 XIGDUO XR TAB 5-500MG 2 $0 QL (60 tabs / 30 days) XIGDUO XR TAB MG 2 $0 QL (60 tabs / 30 days) XIGDUO XR TAB MG 2 $0 QL (30 tabs / 30 days) XIGDUO XR TAB MG 2 $0 QL (30 tabs / 30 days) BISPHOSPHONATES - 治療骨質流失的藥物 alendronate sodium TABS 5mg, 10mg, 40mg 1 $0 alendronate sodium TABS 35mg, 1 $0 QL (4 tabs / 28 days) 70mg PAMIDRONATE DISODIUM 2 $0 B/D 6mg/ml pamidronate disodium 1 $0 B/D 30mg/10ml, 90mg/10ml pamidronate inj 30mg 1 $0 B/D pamidronate inj 90mg 1 $0 B/D zoledronic acid 5mg/100ml 1 $0 B/D, NM zoledronic inj 4mg/5ml 1 $0 B/D, NM CALCIUM RECEPTOR AGONISTS 鈣受體促效劑 SENSIPAR 30mg, 90mg 2 $0 B/D, QL (120 tabs / 30 days), NM SENSIPAR 60mg 2 $0 B/D, QL (60 tabs / 30 days), NM CHELATING AGENTS 螯合劑 CHEMET 2 $0 DEPEN TITRATABS 2 $0 JADENU 2 $0 NM, LA, PA JADENU SPRINKLE 2 $0 NM, LA, PA kionex sus 15gm/60ml 1 $0 sodium polystyrene sulfonate 1 $0 sps susp 15gm/60ml 1 $0 SYPRINE 2 $0 trientine hcl 2 $0 CONTRACEPTIVES - 節制生育藥物 aftera 3 $0 NM; * altavera tab 1 $0 alyacen 1/35 1 $0 apri 1 $0 aranelle 1 $0 aubra 1 $0 aviane 1 $0 balziva 1 $0 44

57 bekyree 1 $0 blisovi fe 1.5/30 1 $0 blisovi fe 1/20 1 $0 briellyn 1 $0 camila 1 $0 caziant pak 1 $0 cryselle-28 1 $0 cyclafem 1/35 1 $0 cyclafem 7/7/7 1 $0 cyred tab 1 $0 dasetta 1/35 1 $0 dasetta 7/7/7 1 $0 deblitane 1 $0 delyla 1 $0 desogestrel & ethinyl estradiol 1 $0 desogestrel-ethinyl estradiol 1 $0 (biphasic) drospirenone-ethinyl estradiol 1 $0 econtra ez 3 $0 NM; * ELLA 2 $0 emoquette 1 $0 enpresse-28 1 $0 enskyce 1 $0 errin 1 $0 estarylla tab $0 ethynodiol diacet & eth estrad 1 $0 ethynodiol tab $0 fallback solo 3 $0 NM; * falmina 1 $0 femynor 1 $0 gianvi 1 $0 gildagia 1 $0 heather 1 $0 incassia 1 $0 introvale 1 $0 isibloom 1 $0 jolessa tab mg 1 $0 jolivette 1 $0 juleber 1 $0 junel 1.5/30 1 $0 junel 1/20 1 $0 45

58 junel fe 1.5/30 1 $0 junel fe 1/20 1 $0 kariva 1 $0 kelnor 1/35 1 $0 kelnor 1/50 1 $0 kimidess 1 $0 kurvelo 1 $0 larin 1.5/30 1 $0 larin 1/20 1 $0 larin fe 1.5/30 1 $0 larin fe 1/20 1 $0 larissia tab 1 $0 leena 1 $0 lessina 1 $0 levonest 1 $0 levonor/ethi tab 1 $0 levonorgestrel & eth estradiol 1 $0 levonorgestrel (emergency oc) 3 $0 NM; * levonorgestrel-ethinyl estradiol 1 $0 (91-day) levora 0.15/ $0 loryna 1 $0 low-ogestrel 1 $0 lutera 1 $0 lyza 1 $0 marlissa 1 $0 medroxyprogesterone acetate 1 $0 (contraceptive) microgestin 1.5/30 1 $0 microgestin 1/20 1 $0 microgestin fe 1.5/30 1 $0 microgestin fe 1/20 1 $0 mili 1 $0 mono-linyah tab $0 mononessa 1 $0 my way 3 $0 NM; * myzilra 1 $0 necon 0.5/ $0 necon 1/ $0 necon 7/7/7 1 $0 next choice one dose 3 $0 NM; * 46

59 nikki 1 $0 nora-be tab 1 $0 norethindrone (contraceptive) 1 $0 norethindrone acet & eth estra 1 $0 norgest/ethi tab 0.25/35 1 $0 norgestimate-ethinyl estradiol (triphasic) 1 $ / / mg-mcg norgestimate-ethinyl estradiol (triphasic) 1 $ / / mg-mcg norlyroc 1 $0 nortrel 0.5/35 (28) 1 $0 nortrel 1/35 1 $0 nortrel 7/7/7 1 $0 NUVARING 2 $0 ocella tab mg 1 $0 opcicon one-step 3 $0 NM; * option 2 3 $0 NM; * orsythia 1 $0 philith 1 $0 pimtrea 1 $0 pirmella 1/35 1 $0 portia-28 1 $0 previfem 1 $0 quasense 1 $0 react 3 $0 NM; * reclipsen 1 $0 setlakin tab 1 $0 sharobel 1 $0 sprintec 28 1 $0 sronyx 1 $0 syeda 1 $0 take action 3 $0 NM; * tarina fe 1/20 1 $0 tilia fe 1 $0 tri-legest fe 1 $0 tri-linyah 1 $0 tri-lo marzia 1 $0 tri-lo-estarylla 1 $0 tri-lo-sprintec 1 $0 47

60 tri-mili 1 $0 tri-previfem 1 $0 tri-sprintec 1 $0 tri-vylibra 1 $0 trinessa 1 $0 trinessa lo 1 $0 trivora-28 1 $0 tulana 1 $0 velivet 1 $0 vestura 1 $0 vienva 1 $0 viorele 1 $0 vyfemla 1 $0 vylibra 1 $0 xulane 1 $0 zarah 1 $0 zenchent 1 $0 zovia 1/35e 1 $0 zovia 1/50e 1 $0 ENDOMETRIOSIS 子宮內膜異位藥物 danazol CAPS 1 $0 SYNAREL 2 $0 ENZYME REPLACEMENTS - 治療轉胺脢缺陷的藥物 ADAGEN 2 $0 NM, LA, PA ALDURAZYME 2 $0 NM, LA, PA CARBAGLU 2 $0 NM, LA, PA CERDELGA 2 $0 NM, PA CEREZYME 2 $0 NM, LA, PA CYSTADANE 2 $0 NM, LA CYSTAGON 2 $0 NM, LA, PA FABRAZYME 2 $0 NM, LA, PA KUVAN 2 $0 NM, LA, PA levocarnitine (metabolic modifiers) 1 $0 B/D LUMIZYME 2 $0 NM, LA, PA miglustat 2 $0 NM, PA NAGLAZYME 2 $0 NM, LA, PA ORFADIN 2 $0 NM, LA, PA sodium phenylbutyrate 2 $0 NM, PA ZAVESCA 2 $0 NM, LA, PA 48

61 ESTROGENS - 調節女性荷爾蒙的藥物 DELESTROGEN 10mg/ml 2 $0 estradiol PTWK; TABS 2 $0 PA; PA if 65 years and older estradiol vaginal cream 1 $0 estradiol vaginal tab 1 $0 estradiol valerate OIL 1 $0 fyavolv tab 1-5mg 2 $0 PA; PA if 65 years and older jinteli 2 $0 PA; PA if 65 years and older norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg 2 $0 PA; PA if 65 years and older yuvafem vaginal tablet 10 mcg 1 $0 GLUCOCORTICOIDS - 治療炎性反應的藥物 cortisone acetate TABS 1 $0 DEXAMETHASONE CONC 2 $0 dexamethasone ELIX; SOLN; TABS 1 $0 dexamethasone sodium phosphate 1 $0 fludrocortisone acetate TABS 1 $0 hydrocortisone TABS 1 $0 methylpr ace inj 40mg/ml 1 $0 B/D methylpr ace inj 80mg/ml 1 $0 B/D methylpr ss inj 1gm 1 $0 B/D methylpr ss inj 40mg 1 $0 B/D methylpr ss inj 125mg 1 $0 B/D methylpred pak 4mg 1 $0 methylpred tab 4mg 1 $0 B/D methylpred tab 8mg 1 $0 B/D methylpred tab 16mg 1 $0 B/D methylpred tab 32mg 1 $0 B/D pred sod pho sol 5mg/5ml 1 $0 B/D prednisolone sodium phosphate 1 $0 B/D SOLN 15mg/5ml prednisolone sol 15mg/5ml 1 $0 B/D prednisolone sol 25mg/5ml 1 $0 B/D PREDNISONE CON 5MG/ML 2 $0 B/D prednisone pak 5mg 1 $0 prednisone pak 10mg 1 $0 prednisone sol 5mg/5ml 1 $0 B/D 49

62 prednisone tab 1mg 1 $0 B/D prednisone tab 2.5mg 1 $0 B/D prednisone tab 5mg 1 $0 B/D prednisone tab 10mg 1 $0 B/D prednisone tab 20mg 1 $0 B/D prednisone tab 50mg 1 $0 B/D SOLU-CORTEF 250mg 2 $0 GLUCOSE ELEVATING AGENTS - 治療低血糖的藥物 GLUCAGEN HYPOKIT 2 $0 GLUCAGON EMERGENCY KIT 2 $0 HM GLUCOSE 3 $0 NM; * PROGLYCEM SUS 50MG/ML 2 $0 SM GLUCOSE 3 $0 NM; * HUMAN GROWTH HORMONES - 調節垂體激素的藥物 NORDITROPIN FLEXPRO 2 $0 NM, PA MISCELLANEOUS 其他藥物 cabergoline 1 $0 calcitonin (salmon) 1 $0 B/D FORTEO 2 $0 NM, PA INCRELEX 2 $0 NM, LA, PA KORLYM 2 $0 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG 2 $0 NM, PA LUPRON DEP-PED INJ 11.25MG 2 $0 NM, PA (3-MONTH) LUPRON DEP-PED INJ 15MG 2 $0 NM, PA LUPRON DEP-PED INJ 30MG 2 $0 NM, PA (3-MONTH) MIACALCIN 2 $0 B/D NATPARA 2 $0 NM, PA octreotide acetate 50mcg/ml, 1 $0 NM, PA 100mcg/ml, 200mcg/ml octreotide acetate 500mcg/ml, 2 $0 NM, PA 1000mcg/ml PROLIA 2 $0 QL (1 injection / 180 days), NM raloxifene hcl 1 $0 SANDOSTATIN LAR DEPOT 2 $0 NM, PA SIGNIFOR 2 $0 NM, LA, PA SOMATULINE DEPOT 2 $0 NM, PA SOMAVERT 2 $0 NM, LA, PA 50

63 XGEVA 2 $0 NM, PA PHOSPHATE BINDER AGENTS - 調節鈣與磷水平的藥物 AURYXIA 2 $0 QL (360 tabs / 30 days), PA calcium acetate (phosphate binder) 1 $0 QL (360 caps / 30 days) CAPS calcium acetate (phosphate binder) 1 $0 QL (360 tabs / 30 days) TABS sevelamer carbonate PACK 2.4gm 1 $0 QL (180 packs / 30 days) sevelamer carbonate PACK.8gm 1 $0 QL (540 packs / 30 days) sevelamer carbonate TABS 1 $0 QL (540 tabs / 30 days) PROGESTINS - 調節女性荷爾蒙的藥 medroxyprogesterone acetate tab 1 $0 norethindrone acetate TABS 1 $0 THYROID AGENTS - 調節甲狀腺素水平的藥物 levo-t 1 $0 levothyroxine sodium TABS 1 $0 levoxyl 1 $0 liothyronine sodium TABS 1 $0 methimazole TABS 1 $0 propylthiouracil TABS 1 $0 SYNTHROID 2 $0 unithroid 1 $0 VASOPRESSINS - 調節垂體荷爾蒙的藥物 desmopressin acetate spray 1 $0 desmopressin acetate spray 1 $0 refrigerated desmopressin acetate tabs 1 $0 desmopressin inj 4mcg/ml 1 $0 STIMATE 2 $0 NM GASTROINTESTINAL - 治療胃腸功能紊亂的藥物 ANTACIDS 解酸藥物 acid gone 3 $0 NM; * almacone 3 $0 NM; * almacone double strength 3 $0 NM; * ALUMINUM HYDROXIDE 3 $0 NM; * antacid CHEW 500mg 3 $0 NM; * antacid SUSP 3 $0 NM; * 51

64 antacid anti-gas maximum 3 $0 NM; * antacid calcium extra st 3 $0 NM; * antacid calcium regular s 3 $0 NM; * antacid extra strength 3 $0 NM; * antacid fast acting 3 $0 NM; * antacid fast relief 3 $0 NM; * antacid maximum strength 3 $0 NM; * antacid plus anti-gas fas 3 $0 NM; * antacid plus anti-gas rel 3 $0 NM; * antacid regular strength 3 $0 NM; * cal-gest antacid 3 $0 NM; * calcium antacid 3 $0 NM; * calcium antacid extra str 3 $0 NM; * calcium antacid ultra 3 $0 NM; * calcium antacid ultra max 3 $0 NM; * calcium carbonate TABS 648mg 3 $0 NM; * calcium carbonate (antacid) TABS 3 $0 NM; * chewable antacid 3 $0 NM; * GAVISCON CHEW 3 $0 NM; * GAVISCON EXTRA STRENGTH R 3 $0 NM; * gnp antacid anti-gas 3 $0 NM; * gnp antacid extra strengt 3 $0 NM; * gnp masanti regular stren 3 $0 NM; * heartburn antacid extra s 3 $0 NM; * hm advanced antacid maxim 3 $0 NM; * hm antacid 3 $0 NM; * hm antacid anti-gas extra 3 $0 NM; * hm antacid/antigas 3 $0 NM; * hm calcium antacid 3 $0 NM; * hm calcium antacid extra 3 $0 NM; * hm calcium antacid smooth 3 $0 NM; * mag-al plus 3 $0 NM; * magnesium oxide TABS 400mg, 3 $0 NM; * 420mg MI-ACID CHEW 3 $0 NM; * mi-acid SUSP 3 $0 NM; * mi-acid maximum strength 3 $0 NM; * mintox 3 $0 NM; * mintox plus 3 $0 NM; * qc antacid 3 $0 NM; * qc antacid/anti-gas 3 $0 NM; * 52

65 rulox 3 $0 NM; * sb antacid 3 $0 NM; * sb antacid anti-gas doubl 3 $0 NM; * sb antacid extra strength 3 $0 NM; * sb antacid/antigas 3 $0 NM; * sm antacid advanced 3 $0 NM; * sm antacid anti-gas 3 $0 NM; * sm antacid maximum streng 3 $0 NM; * sm antacid/antigas 3 $0 NM; * sm calcium antacid 3 $0 NM; * sm calcium antacid extra 3 $0 NM; * sodium bicarbonate (antacid) 3 $0 NM; * tums freshers 3 $0 NM; * tums smoothies 3 $0 NM; * ANTI-DIARRHEAL 抗腹瀉藥物 anti-diarrheal TABS 3 $0 NM; * bismatrol 3 $0 NM; * bismuth subsalicylate CHEW 3 $0 NM; * gnp anti-diarrheal TABS 3 $0 NM; * hm anti-diarrheal 3 $0 NM; * loperamide hcl LIQD 3 $0 NM; * peptic relief 3 $0 NM; * pink bismuth 3 $0 NM; * qc anti-diarrheal 3 $0 NM; * sb anti-diarrhea 3 $0 NM; * sb bismuth SUSP 3 $0 NM; * sb peptic relief 3 $0 NM; * sm anti-diarrheal TABS 3 $0 NM; * sm stomach relief CHEW; SUSP 3 $0 NM; * stomach relief 262mg/15ml 3 $0 NM; * ANTIEMETICS - 止嘔止吐藥 aprepitant 1 $0 B/D aprepitant pak 80mg & 125mg 1 $0 B/D compro 1 $0 driminate 3 $0 NM; * dronabinol 1 $0 B/D, QL (60 caps / 30 days) EMEND SUSR 2 $0 B/D gnp motion sickness relie 50mg 3 $0 NM; * granisetron hcl SOLN 1 $0 granisetron hcl TABS 1 $0 B/D 53

66 meclizine hcl CHEW 3 $0 NM; * meclizine hcl TABS 12.5mg 3 $0 NM; * meclizine hcl TABS 12.5mg, 25mg 1 $0 metoclopramide hcl SOLN; TABS 1 $0 metoclopramide inj 1 $0 motion-time 3 $0 NM; * ondansetron hcl TABS 1 $0 B/D ondansetron hcl inj 1 $0 ondansetron hcl oral soln 1 $0 B/D ondansetron odt 1 $0 B/D prochlorperazine inj 1 $0 prochlorperazine maleate TABS 1 $0 prochlorperazine supp 1 $0 promethazine hcl SOLN; SYRP; TABS 2 $0 PA; PA if 65 years and older sb motion sickness 3 $0 NM; * scopolamine patch 2 $0 QL (10 patches / 30 days), PA; PA if 65 years and older sm motion sickness relief 3 $0 NM; * TRANSDERM-SCOP 2 $0 QL (10 patches / 30 days), PA; PA if 65 years and older travel sickness 3 $0 NM; * ANTISPASMODICS - 胃痙攣藥物 dicyclomine hcl CAPS 1 $0 dicyclomine hcl SOLN 10mg/5ml 1 $0 dicyclomine hcl TABS 1 $0 glycopyrrolate TABS 1 $0 glycopyrrolate inj 1 $0 H2-RECEPTOR ANTAGONISTS - 胃潰瘍與胃酸藥物 acid reducer TABS 3 $0 NM; * acid reducer maximum stre 3 $0 NM; * famotidine SUSR 1 $0 famotidine TABS 10mg 3 $0 NM; * famotidine TABS 20mg, 40mg 1 $0 famotidine inj 1 $0 gnp acid reducer maximum 3 $0 NM; * gnp heartburn relief 3 $0 NM; * heartburn relief 3 $0 NM; * heartburn relief 150 maxi 3 $0 NM; * 54

67 hm acid reducer 3 $0 NM; * hm famotidine 3 $0 NM; * qc acid controller maximu 3 $0 NM; * ranitidine hcl TABS 75mg, 150mg 3 $0 NM; * ranitidine hcl TABS 150mg, 300mg1 $0 ranitidine hcl inj 1 $0 ranitidine syrup 1 $0 sm acid reducer 3 $0 NM; * sm acid reducer maximum s 3 $0 NM; * INFLAMMATORY BOWEL DISEASE 腸道發炎藥物 APRISO 2 $0 balsalazide disodium 1 $0 budesonide ec 2 $0 CANASA 2 $0 colocort enema 100mg 1 $0 DELZICOL 2 $0 hydrocortisone (enema) 1 $0 mesalamine ENEM 1 $0 mesalamine TBEC 800mg 1 $0 mesalamine w/ cleanser 1 $0 sulfasalazine TABS 1 $0 sulfasalazine ec 1 $0 LAXATIVES 瀉藥 bisac-evac 3 $0 NM; * bisacodyl SUPP 3 $0 NM; * bisacodyl ec 3 $0 NM; * biscolax 3 $0 NM; * calcium polycarbophil 3 $0 NM; * clearlax 3 $0 NM; * constulose 1 $0 diocto 3 $0 NM; * doc-q-lax 3 $0 NM; * docqlace 3 $0 NM; * docu 3 $0 NM; * docusate sodium CAPS; LIQD 3 $0 NM; * docusil 3 $0 NM; * DOCUSOL MINI 3 $0 NM; * dok 3 $0 NM; * ducodyl 3 $0 NM; * ENEMEEZ MINI 3 $0 NM; * 55

68 ENEMEEZ PLUS 3 $0 NM; * enulose 1 $0 fiber laxative TABS 3 $0 NM; * fiber-caps 3 $0 NM; * fiber-lax 3 $0 NM; * FLEET BISACODYL 3 $0 NM; * fleet laxative 3 $0 NM; * gavilax 3 $0 NM; * gavilyte-c 1 $0 gavilyte-g 1 $0 gavilyte-n/flavor pack 1 $0 generlac 1 $0 glycerin infants & childr 1gm 3 $0 NM; * glycolax 3 $0 NM; * gnp bisa-lax 3 $0 NM; * gnp clearlax 3 $0 NM; * gnp fiber-caps 3 $0 NM; * gnp laxative 3 $0 NM; * gnp milk of magnesia 3 $0 NM; * gnp senna plus 3 $0 NM; * gnp senna-lax 3 $0 NM; * gnp stool softener 3 $0 NM; * gnp stool softener/stimul 3 $0 NM; * GOLYTELY 2 $0 goodsense senna laxative 3 $0 NM; * healthylax 3 $0 NM; * hm clearlax 3 $0 NM; * hm enema ready-to-use 3 $0 NM; * hm enema saline laxative 3 $0 NM; * hm fiber POWD 58.6% 3 $0 NM; * hm fiber TABS 3 $0 NM; * hm laxative 3 $0 NM; * hm milk of magnesia 3 $0 NM; * hm senna 3 $0 NM; * hm stool softener 3 $0 NM; * kao-tin 3 $0 NM; * konsyl POWD 30.9% 3 $0 NM; * KONSYL POWD 60.3%, 71.67% 3 $0 NM; * KONSYL DAILY FIBER PACK 100% 3 $0 NM; * konsyl fiber 3 $0 NM; * KONSYL-D 3 $0 NM; * 56

69 lactulose SOLN 1 $0 lactulose (encephalopathy) 1 $0 laxative 3 $0 NM; * laxative feminine 3 $0 NM; * magnesium citrate SOLN 3 $0 NM; * milk of magnesia 3 $0 NM; * mineral oil OIL 3 $0 NM; * MOVIPREP 2 $0 natural fiber therapy 3 $0 NM; * NULYTELY/FLAVOR PACKS 2 $0 peg 3350-kcl-sod bicarb-sod 1 $0 chloride-sod sulfate peg 3350-potassium chloride-sod 1 $0 bicarbonate-sod chloride peg 3350/electrolytes 1 $0 polyethylene glycol 3350 PACK 1 $0 polyethylene glycol 3350 PACK 3 $0 NM; * polyethylene glycol 3350 POWD 1 $0 polyethylene glycol 3350 POWD 3 $0 NM; * psyllium 3 $0 NM; * qc enema 3 $0 NM; * qc milk of magnesia 3 $0 NM; * reguloid POWD 3 $0 NM; * sb bisacodyl laxative ec 3 $0 NM; * sb docusate sodium 3 $0 NM; * sb gentle laxative womens 3 $0 NM; * sb milk of magnesia 3 $0 NM; * senexon 3 $0 NM; * senexon-s 3 $0 NM; * senna lax 3 $0 NM; * senna laxative 3 $0 NM; * senna plus 3 $0 NM; * senna-lax 3 $0 NM; * senna-time 3 $0 NM; * senna-time s 3 $0 NM; * sennalax-s 3 $0 NM; * senno 3 $0 NM; * sennosides 3 $0 NM; * sennosides-docusate sodium 3 $0 NM; * silace 3 $0 NM; * sm clearlax 3 $0 NM; * 57

70 sm fiber POWD 28.3%, 48.57% 3 $0 NM; * sm fiber TABS 3 $0 NM; * sm fiber laxative 3 $0 NM; * sm gentle laxative 3 $0 NM; * sm milk of magnesia 3 $0 NM; * sm mineral oil OIL 3 $0 NM; * sm natural laxative plus 3 $0 NM; * sm senna laxative 3 $0 NM; * sm senna laxative maximum 3 $0 NM; * sm senna-s 3 $0 NM; * sm stool softener 3 $0 NM; * sodium phosphates 3 $0 NM; * soluble fiber 3 $0 NM; * stimulant laxative 3 $0 NM; * stool softener 3 $0 NM; * stool softener extra stre 3 $0 NM; * SUPREP BOWEL PREP KIT 2 $0 trilyte 1 $0 womans laxative 3 $0 NM; * MISCELLANEOUS 其他藥物 alosetron hcl 2 $0 PA AMITIZA CAP 8MCG 2 $0 QL (180 caps / 30 days) AMITIZA CAP 24MCG 2 $0 QL (60 caps / 30 days) cromolyn sodium (mastocytosis) 2 $0 diphenoxylate w/ atropine 1 $0 GATTEX 2 $0 NM, LA, PA LINZESS 72mcg, 290mcg 2 $0 QL (30 caps / 30 days) LINZESS 145mcg 2 $0 QL (60 caps / 30 days) loperamide hcl CAPS 1 $0 misoprostol TABS 1 $0 MOVANTIK 12.5mg 2 $0 QL (60 tabs / 30 days) MOVANTIK 25mg 2 $0 QL (30 tabs / 30 days) RELISTOR SOLN 2 $0 PA sm gas relief extra stren 3 $0 NM; * sucralfate TABS 1 $0 ursodiol CAPS; TABS 1 $0 XIFAXAN 550mg 2 $0 PA PANCREATIC ENZYMES 胰腺酶 CREON 2 $0 ZENPEP 2 $0 58

71 PROTON PUMP INHIBITORS - 胃潰瘍與胃酸藥物 DEXILANT 2 $0 QL (30 caps / 30 days) esomeprazole magnesium 1 $0 QL (30 caps / 30 days) esomeprazole sodium inj 1 $0 gnp lansoprazole 3 $0 NM; * GNP OMEPRAZOLE 3 $0 NM; * heartburn treatment 24 ho 15mg 3 $0 NM; * hm lansoprazole 3 $0 NM; * HM OMEPRAZOLE 3 $0 NM; * lansoprazole CPDR 15mg 3 $0 NM; * lansoprazole CPDR 15mg, 30mg 1 $0 QL (30 caps / 30 days) OMEPRAZOLE TBEC 3 $0 NM; * omeprazole cap 10mg 1 $0 QL (30 caps / 30 days) omeprazole cap 20mg 1 $0 QL (60 caps / 30 days) omeprazole cap 40mg 1 $0 QL (30 caps / 30 days) pantoprazole sodium tbec 1 $0 QL (30 tabs / 30 days) rabeprazole sodium 1 $0 QL (30 tabs / 30 days) SM OMEPRAZOLE 3 $0 NM; * GENITOURINARY - 治療性器官與尿道狀況的藥物 BENIGN PROSTATIC HYPERPLASIA - 治療前列腺肥大的藥物 alfuzosin hcl 1 $0 QL (30 tabs / 30 days) dutasteride CAPS 1 $0 QL (30 caps / 30 days) dutasteride-tamsulosin hcl 1 $0 QL (30 caps / 30 days) finasteride TABS 5mg 1 $0 tamsulosin hcl 1 $0 MISCELLANEOUS 其他藥物 bethanechol chloride TABS 1 $0 potassium citrate (alkalinizer) er tabs 1 $0 URINARY ANTISPASMODICS - 治療尿失禁藥物 MYRBETRIQ 25mg 2 $0 QL (60 tabs / 30 days) MYRBETRIQ 50mg 2 $0 QL (30 tabs / 30 days) oxybutynin chloride SYRP 1 $0 oxybutynin chloride TABS 1 $0 oxybutynin chloride TB24 5mg 1 $0 QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 1 $0 QL (60 tabs / 30 days) 15mg tolterodine tartrate cap er 1 $0 QL (30 caps / 30 days) tolterodine tartrate tabs 1 $0 TOVIAZ 2 $0 QL (30 tabs / 30 days) 59

72 trospium chloride TABS 1 $0 QL (60 tabs / 30 days) VESICARE 2 $0 QL (30 tabs / 30 days) VAGINAL ANTI-INFECTIVES 陰道抗炎藥物 clindamycin phosphate vaginal 1 $0 clotrimazole vaginal 3 $0 NM; * gnp miconazole 7 3 $0 NM; * metronidazole vaginal 1 $0 miconazole 7 3 $0 NM; * miconazole nitrate vaginal CREA 3 $0 NM; * miconazole nitrate vaginal SUPP 3 $0 NM; * 100mg sm miconazole 7 3 $0 NM; * terconazole vaginal 1 $0 vandazole 1 $0 HEMATOLOGIC - 治療血液病的藥物 ANTICOAGULANTS - 血液稀釋劑 COUMADIN 2 $0 ELIQUIS 2 $0 ELIQUIS STARTER PACK 2 $0 enoxaparin sodium 1 $0 fondaparinux sodium 2.5mg/0.5ml 1 $0 fondaparinux sodium 5mg/0.4ml, 2 $0 7.5mg/0.6ml, 10mg/0.8ml heparin sod (porcine) in d5w 2 $0 heparin sod inj 1000/ml 1 $0 B/D heparin sod inj 5000/ml 1 $0 B/D heparin sod inj 10000/ml 1 $0 B/D heparin sod inj 20000/ml 1 $0 B/D heparin sodium/d5w 2 $0 HEPARIN SODIUM/NACL 0.45% 2 $0 jantoven 1 $0 PRADAXA 2 $0 warfarin sodium 1 $0 XARELTO 2 $0 XARELTO STARTER PACK 2 $0 HEMATOPOIETIC GROWTH FACTORS 血液細胞生長因子 GRANIX 2 $0 NM, PA MOZOBIL 2 $0 NM, PA NEUPOGEN 2 $0 NM, PA 60

73 PROCRIT 2 $0 NM, PA IRON 鐵質 ferate 3 $0 NM; * ferosul 3 $0 NM; * ferrous fumarate TABS 324mg 3 $0 NM; * ferrous gluconate TABS 324mg 3 $0 NM; * FERROUS GLUCONATE TABS 3 $0 NM; * 324mg ferrous sulfate ELIX 3 $0 NM; * FERROUS SULFATE LIQD 3 $0 NM; * ferrous sulfate SOLN 3 $0 NM; * FERROUS SULFATE SYRP 3 $0 NM; * ferrous sulfate TABS 325mg 3 $0 NM; * FERROUS SULFATE TBEC 324mg 3 $0 NM; * ferrous sulfate TBEC 325mg 3 $0 NM; * ferrousul 3 $0 NM; * iferex $0 NM; * INFED 3 $0 NM; * sodium ferric gluconate complex in 3 $0 NM; * sucrose VENOFER 3 $0 NM; * MISCELLANEOUS 其他藥物 anagrelide hcl 1 $0 cilostazol 1 $0 CINRYZE 2 $0 QL (20 vials / 30 days), NM, LA, PA ENDARI 2 $0 NM, LA, PA FIRAZYR 2 $0 QL (9 syringes / 30 days), NM, PA HAEGARDA 2000unit 2 $0 QL (30 vials / 30 days), NM, LA, PA HAEGARDA 3000unit 2 $0 QL (20 vials / 30 days), NM, LA, PA pentoxifylline TBCR 1 $0 PROMACTA 12.5mg 2 $0 QL (360 tabs / 30 days), NM, LA, PA PROMACTA 25mg 2 $0 QL (180 tabs / 30 days), NM, LA, PA PROMACTA 50mg 2 $0 QL (90 tabs / 30 days), NM, LA, PA PROMACTA 75mg 2 $0 QL (60 tabs / 30 days), NM, LA, PA 61

74 tranexamic acid SOLN; TABS 1 $0 PLATELET AGGREGATION INHIBITORS 血小板聚集抑制因子 aspirin-dipyridamole 1 $0 BRILINTA 2 $0 clopidogrel tab 75mg 1 $0 prasugrel hcl 1 $0 ZONTIVITY 2 $0 IMMUNOLOGIC AGENTS - 治療免疫系統障礙藥物 DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - 治療風濕性 關節炎藥物 HUMIRA 10mg/0.1ml, 20mg/0.2ml 2 $0 QL (2 syringes / 28 days), NM, PA HUMIRA 40mg/0.4ml 2 $0 QL (6 syringes / 28 days), NM, PA HUMIRA INJ 10MG/0.2ML 2 $0 QL (2 syringes / 28 days), NM, PA HUMIRA KIT 20MG/0.4ML 2 $0 QL (2 syringes / 28 days), NM, PA HUMIRA KIT 40MG/0.8ML 2 $0 QL (6 syringes / 28 days), NM, PA HUMIRA PEDIATRIC CROHNS 2 $0 NM, PA DISEASE HUMIRA PEN 2 $0 QL (6 pens / 28 days), NM, PA HUMIRA PEN CD/UC/HS STARTER 2 $0 NM, PA HUMIRA PEN INJ PS/UV STARTER 2 $0 NM, PA HUMIRA PEN-PS/UV STARTER 2 $0 NM, PA HUMIRA-PEN CD/UC/HS STARTER 2 $0 NM, PA hydroxychloroquine sulfate 1 $0 leflunomide TABS 1 $0 methotrexate sodium tabs 1 $0 REMICADE 2 $0 NM, PA XATMEP 2 $0 B/D XELJANZ 2 $0 QL (60 tabs / 30 days), NM, PA XELJANZ XR 2 $0 QL (30 tabs / 30 days), NM, PA IMMUNOGLOBULINS 免疫球蛋白 BIVIGAM 2 $0 NM, PA CARIMUNE NANOFILTERED 2 $0 NM, PA FLEBOGAMMA DIF 2 $0 NM, PA 62

75 GAMASTAN S/D 2 $0 B/D, NM GAMMAGARD LIQUID 2 $0 NM, PA GAMMAGARD S/D 2 $0 NM, PA GAMMAKED 2 $0 NM, PA GAMMAPLEX 2 $0 NM, PA GAMMAPLEX 10GM/100ML 2 $0 NM, PA GAMUNEX-C 2 $0 NM, PA OCTAGAM 2 $0 NM, PA PRIVIGEN 2 $0 NM, PA IMMUNOMODULATORS 免疫調節劑 ACTIMMUNE 2 $0 NM, LA, PA ARCALYST 2 $0 NM, PA INTRON-A INJ 10MU 2 $0 B/D, NM INTRON-A INJ 18MU 2 $0 B/D, NM INTRON-A INJ 25MU 2 $0 B/D, NM INTRON-A INJ 50MU 2 $0 B/D, NM IMMUNOSUPPRESSANTS 免疫抑制劑 AZATHIOPRINE SOLR 2 $0 B/D azathioprine TABS 1 $0 B/D BENLYSTA 2 $0 NM, PA cyclosporine CAPS; SOLN 1 $0 B/D cyclosporine modified (for 1 $0 B/D microemulsion) gengraf 1 $0 B/D mycophenolate mofetil CAPS; 1 $0 B/D TABS mycophenolate mofetil SUSR 2 $0 B/D mycophenolate sodium 1 $0 B/D NULOJIX 2 $0 B/D RAPAMUNE SOLN 2 $0 B/D SANDIMMUNE SOLN 100mg/ml 2 $0 B/D sirolimus TABS 2mg 2 $0 B/D sirolimus TABS.5mg, 1mg 1 $0 B/D tacrolimus CAPS 1 $0 B/D ZORTRESS TAB 0.5MG 2 $0 B/D ZORTRESS TAB 0.25MG 2 $0 B/D ZORTRESS TAB 0.75MG 2 $0 B/D VACCINES 疫苗 ACTHIB 2 $0 ADACEL 2 $0 63

76 BCG VACCINE 2 $0 BEXSERO 2 $0 BOOSTRIX 2 $0 DAPTACEL 2 $0 DIPHTHERIA/TETANUS TOXOID 2 $0 B/D ENGERIX-B SUSP 2 $0 B/D GARDASIL 9 2 $0 HAVRIX 2 $0 HIBERIX 2 $0 IMOVAX RABIES (H.D.C.V.) 2 $0 INFANRIX 2 $0 IPOL INACTIVATED IPV 2 $0 IXIARO 2 $0 KINRIX 2 $0 M-M-R II 2 $0 MENACTRA 2 $0 MENVEO 2 $0 PEDIARIX 2 $0 PEDVAX HIB 2 $0 PENTACEL 2 $0 PROQUAD 2 $0 QUADRACEL 2 $0 RABAVERT 2 $0 RECOMBIVAX HB 2 $0 B/D ROTARIX 2 $0 ROTATEQ 2 $0 SHINGRIX 2 $0 QL (2 vials per lifetime) SYNAGIS 2 $0 NM TENIVAC 2 $0 B/D TETANUS/DIPHTHERIA TOXOID 2 $0 B/D TRUMENBA 2 $0 TWINRIX INJ 2 $0 TYPHIM VI 2 $0 VAQTA 2 $0 VARIVAX 2 $0 YF-VAX 2 $0 ZOSTAVAX 2 $0 QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS - 維他命與健康補充品 ELECTROLYTES 電解液 klor-con 8 1 $0 64

77 klor-con 10 1 $0 klor-con m10 1 $0 KLOR-CON M15 2 $0 klor-con m20 1 $0 klor-con pak 20meq 1 $0 klor-con spr cap 8meq 1 $0 klor-con spr cap 10meq 1 $0 MAGNESIUM SULFATE SOLN 2 $0 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 2 $0 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50% MAGNESIUM SULFATE IN D5W 2 $0 magnesium sulfate in dextrose 2 $0 PEDIALYTE SOLN 3 $0 NM; * potassium chloride CPCR 1 $0 potassium chloride PACK 1 $0 potassium chloride SOLN 10%, 1 $0 20% potassium chloride TBCR 1 $0 potassium chloride microencapsulated crystals er 1 $0 potassium chloride tab cr 10 meq 1 $0 sm pediatric electrolyte 3 $0 NM; * sodium chloride SOLN 2.5meq/ml 1 $0 sodium fluoride chew; tab; 1.1 (0.51 $0 f) mg/ml soln tpn electrolytes 2 $0 B/D IV NUTRITION 靜脈輸注營養 AMINOSYN 2 $0 B/D AMINOSYN 7%/ELECTROLYTES 2 $0 B/D aminosyn 8.5%/electrolyte 2 $0 B/D aminosyn ii 8.5%/electrol 2 $0 B/D AMINOSYN II INJ 8.5% 2 $0 B/D AMINOSYN II INJ 10% 2 $0 B/D AMINOSYN M 2 $0 B/D AMINOSYN-HBC 2 $0 B/D AMINOSYN-PF 7% 2 $0 B/D AMINOSYN-PF INJ 10% 2 $0 B/D AMINOSYN-RF 2 $0 B/D 65

78 CLINIMIX 2.75%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 5% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 25% 2 $0 B/D CLINIMIX 5%/DEXTROSE 15% 2 $0 B/D CLINIMIX 5%/DEXTROSE 20% 2 $0 B/D CLINIMIX 5%/DEXTROSE 25% 2 $0 B/D CLINIMIX INJ 4.25/D10 2 $0 B/D CLINIMIX INJ 4.25/D20 2 $0 B/D FREAMINE HBC 6.9% 2 $0 B/D FREAMINE III 2 $0 B/D hepatamine 2 $0 B/D INTRALIPID 30% 2 $0 B/D intralipid inj 20% 2 $0 B/D NEPHRAMINE 2 $0 B/D nutrilipid inj 20% 2 $0 B/D premasol sol 6% 1 $0 B/D PREMASOL SOL 10% 2 $0 B/D PROCALAMINE 2 $0 B/D PROSOL 2 $0 B/D TRAVASOL 2 $0 B/D TROPHAMINE INJ 10% 2 $0 B/D IV REPLACEMENT SOLUTIONS 靜脈輸注補充品溶液 dextrose 2.5%/nacl 0.45% 1 $0 dextrose 5% 1 $0 DEXTROSE 5% /ELECTROLYTE 2 $0 dextrose 5%/lactated ring 1 $0 dextrose 5%/nacl 0.2% 1 $0 DEXTROSE 5%/NACL 0.3% 2 $0 dextrose 5%/nacl 0.9% 1 $0 dextrose 5%/nacl 0.33% 1 $0 dextrose 5%/nacl 0.45% 1 $0 dextrose 5%/nacl 0.225% 1 $0 dextrose 5%/potassium chl 1 $0 dextrose 10% flex contain 1 $0 DEXTROSE 10%/NACL 0.2% 2 $0 dextrose 10%/nacl 0.45% 1 $0 dextrose 50% 1 $0 dextrose inj 70% 1 $0 IONOSOL-MB/DEXTROSE 5% 2 $0 ISOLYTE P 2 $0 ISOLYTE S 2 $0 66

79 kcl0.15%/d5w/nacl0.2% 1 $0 KCL 0.3%/D5W/NACL 0.9% 2 $0 kcl 0.3%/d5w/nacl 0.45% 1 $0 kcl 0.15%/d5w/nacl 0.9% 1 $0 KCL 0.15%/D5W/NACL 0.225% 2 $0 kcl 0.075%/d5w/nacl 0.45% 1 $0 kcl/d5w inj 0.3% 1 $0 kcl/d5w/nacl inj 0.22%/0.45% 1 $0 kcl/d5w/nacl inj.15/.33% 1 $0 kcl/d5w/nacl inj.15/.45% 1 $0 kcl/nacl inj $0 kcl/nacl inj 0.15%-0.9% 1 $0 lactated ringer's inj 1 $0 NORMOSOL-M IN D5W 2 $0 NORMOSOL-R 2 $0 NORMOSOL-R IN D5W 2 $0 PLASMA-LYTE A 2 $0 PLASMA-LYTE $0 pot chloride inj 2meq/ml 1 $0 potassium chloride SOLN 1 $0.4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl 1 $0 ringer's 1 $0 sodium chloride SOLN 3%, 5% 1 $0 sodium chloride 0.45% 1 $0 sodium chloride inj 0.9% 1 $0 MINERALS 礦物質 calcitrate 3 $0 NM; * calcium 500/d 3 $0 NM; * calcium carbonate TABS 600mg, 1250mg 3 $0 NM; * calcium carbonate (antacid) SUSP 3 $0 NM; * calcium carbonate-cholecalciferol 3 $0 NM; * calcium carbonate-vitamin d 3 $0 NM; * CALCIUM GLUCONATE TABS 3 $0 NM; * 500mg MAG64 3 $0 NM; * MAGNEBIND $0 NM; * magnesium TABS 250mg 3 $0 NM; * 67

80 magnesium oxide (mg supplement) 3 $0 NM; * NU-MAG 3 $0 NM; * os-cal extra d3 3 $0 NM; * oysco $0 NM; * oysco 500+d TABS 3 $0 NM; * oyster shell 3 $0 NM; * oyster shell calcium + vi 3 $0 NM; * oyster shell calcium+d 3 $0 NM; * sm oyster shell calcium/v 3 $0 NM; * sodium chloride TABS 3 $0 NM; * VITAMINS 維他命 animal shapes 3 $0 NM; * animal shapes + iron 3 $0 NM; * aquadeks LIQD 3 $0 NM; * ascorbic acid CHEW 3 $0 NM; * ascorbic acid TABS 250mg, 500mg3 $0 NM; * b-complex vitamins 3 $0 NM; * balanced b-50 TABS 3 $0 NM; * balanced b-100 TABS 3 $0 NM; * biotin CAPS 5000mcg 3 $0 NM; * biotin TABS 5mg, 300mcg 3 $0 NM; * biotin/maximum strength 3 $0 NM; * calcitriol CAPS 1 $0 B/D calcitriol inj 1 $0 B/D calcitriol oral soln 1 mcg/ml 1 $0 B/D calcium carbonate TABS 1250mg 3 $0 NM; * CERTAVITE SENIOR/ANTIOXID 3 $0 NM; * certavite/antioxidants 3 $0 NM; * cholecalciferol CAPS; LIQD; TABS 3 $0 NM; * cyanocobalamin SOLN; TABS 3 $0 NM; * ELDERTONIC 3 $0 NM; * ergocalciferol CAPS; SOLN 3 $0 NM; * eye vitamins & minerals 3 $0 NM; * folic acid SOLN 3 $0 NM; * folic acid TABS 1mg, 400mcg 3 $0 NM; * GNP PRENATAL 3 $0 NM; * hydroxocobalamin acetate 3 $0 NM; * icaps mv 3 $0 NM; * MEPHYTON 3 $0 NM; * meribin 3 $0 NM; * multiple vitamins w/ minerals 3 $0 NM; * 68

81 NASCOBAL 3 $0 NM; * niacin CPCR 500mg 3 $0 NM; * niacin TABS 500mg 3 $0 NM; * niacin TBCR 500mg 3 $0 NM; * niacinamide TABS 500mg 3 $0 NM; * NIVA-PLUS 1 $0 O-CAL FA 1 $0 ocuvite/lutein 3 $0 NM; * ONCOVITE 3 $0 NM; * one daily 3 $0 NM; * one daily mens 3 $0 NM; * paricalcitol CAPS 1 $0 B/D phytonadione SOLN 3 $0 NM; * PNV FOLIC ACID + IRON MUL 1 $0 PNV PRENATAL PLUS 1 $0 poly-vita drops 3 $0 NM; * poly-vita/iron drops 3 $0 NM; * PRENATAL 1 $0 PRENATAL 3 $0 NM; * PRENATAL PLUS 1 $0 PRENATAL PLUS LOW IRON 1 $0 prenatal vitamin/folic acid > 0.8 mg 1 $0 (generic) PREPLUS 1 $0 prosight 3 $0 NM; * pyridoxine hcl SOLN 3 $0 NM; * pyridoxine hcl TABS 50mg, 100mg3 $0 NM; * RAYALDEE 2 $0 renal vitamin 3 $0 NM; * stress formula 3 $0 NM; * stress formula w/iron 3 $0 NM; * stress formula/zinc 3 $0 NM; * superplex-t 3 $0 NM; * tab-a-vite 3 $0 NM; * tab-a-vite w/beta caroten 3 $0 NM; * tab-a-vite/iron 3 $0 NM; * THERA 3 $0 NM; * THERA M PLUS 3 $0 NM; * THERA-M 3 $0 NM; * thiamine hcl SOLN; TABS 3 $0 NM; * total b/c 3 $0 NM; * 69

82 TRI-VI-SOL 3 $0 NM; * tri-vita 3 $0 NM; * TRICARE 1 $0 vita-bee/c 3 $0 NM; * vitamin a CAPS 10000unit 3 $0 NM; * VOL-PLUS 1 $0 OPHTHALMIC - 治療眼睛病況的藥物 ANTI-INFECTIVE/ANTI-INFLAMMATORY - 治療感染與炎症的藥物 bacitracin-poly-neomycin-hc 1 $0 BLEPHAMIDE OINT 2 $0 neomycin-polymy-dexameth 1 $0 neomycin-polymyxin-hc (ophth) 1 $0 sulfacetamide sod-prednisolone 1 $0 TOBRADEX OINT 2 $0 TOBRADEX ST 2 $0 tobramycin-dexamethasone 1 $0 ZYLET 2 $0 ANTI-INFECTIVES - 治療感染的藥物 AZASITE 2 $0 bacitracin (ophthalmic) 1 $0 bacitracin-polymyxin b (ophth) 1 $0 BESIVANCE 2 $0 CILOXAN OINT 2 $0 ciprofloxacin hcl (ophth) 1 $0 erythromycin (ophth) 1 $0 gatifloxacin (ophth) 1 $0 gentak 1 $0 gentamicin sulfate soln (ophth) 1 $0 MOXEZA 2 $0 moxifloxacin hcl (ophth) 1 $0 NATACYN 2 $0 neomycin-bacitracin zn-polymyxin 1 $0 neomycin-polymyxin-gramicidin 1 $0 ofloxacin (ophth) 1 $0 polymyxin b-trimethoprim 1 $0 sulfacet sod oin 10% op 1 $0 sulfacetamide sodium (ophth) 1 $0 tobramycin (ophth) 1 $0 trifluridine SOLN 1 $0 ZIRGAN 2 $0 70

83 ANTI-INFLAMMATORIES - 治療炎症的藥物 ALREX 2 $0 bromfenac sodium (ophth) 1 $0 BROMSITE 2 $0 dexamethasone sodium phosphate 1 $0 (ophth) diclofenac sodium (ophth) 1 $0 DUREZOL 2 $0 fluorometholone 1 $0 flurbiprofen sodium 1 $0 ILEVRO 2 $0 ketorolac tromethamine (ophth) 1 $0 LOTEMAX 2 $0 prednisolone acetate (ophth) 1 $0 PREDNISOLONE SODIUM 2 $0 PHOSPHATE (OPHTH) PROLENSA 2 $0 ANTIALLERGICS - 治療過敏的藥物 azelastine drop 0.05% 1 $0 BEPREVE 2 $0 cromolyn sodium (ophth) 1 $0 LASTACAFT 2 $0 olopatadine hcl 0.2% 1 $0 PAZEO 2 $0 ANTIGLAUCOMA - 治療青光眼的藥物 ALPHAGAN P SOL 0.1% 2 $0 AZOPT 2 $0 betaxolol hcl (ophth) 1 $0 BETOPTIC-S 2 $0 brimonidine sol 0.2% 1 $0 brimonidine sol 0.15% 1 $0 carteolol hcl (ophth) 1 $0 COMBIGAN 2 $0 dorzolamide hcl 1 $0 dorzolamide hcl-timolol maleate 1 $0 latanoprost SOLN 1 $0 levobunolol hcl 1 $0 LUMIGAN 2 $0 metipranolol 1 $0 PHOSPHOLINE IODIDE 2 $0 pilocarpine hcl SOLN 1 $0 71

84 SIMBRINZA 2 $0 timolol maleate (ophth) soln 1 $0 timolol maleate gel 1 $0 timolol maleate ophth soln 0.5% 1 $0 (once-daily) TRAVATAN Z 2 $0 MISCELLANEOUS 其他藥物 akwa tears 3 $0 NM; * artificial tears OINT 3 $0 NM; * artificial tears SOLN 1.4% 3 $0 NM; * bion tears 3 $0 NM; * cvs lubricant gel drops 3 $0 NM; * CYSTARAN 2 $0 NM, LA, PA eq gentle lubricant 3 $0 NM; * GENTEAL SEVERE 3 $0 NM; * genteal tears liquid drop 3 $0 NM; * genteal tears mild 3 $0 NM; * gnp lubricating plus eye 3 $0 NM; * goodsense lubricating plu 3 $0 NM; * hm lubricating plus 3 $0 NM; * hm lubricating tears 3 $0 NM; * liquitears 3 $0 NM; * lubricant eye drops 3 $0 NM; * lubricant eye drops dry e 3 $0 NM; * lubricating eye drops 3 $0 NM; * lubrifresh p.m. 3 $0 NM; * MURO 128 SOLN 2% 3 $0 NM; * natures tears 3 $0 NM; * optics mini drops 3 $0 NM; * proparacaine hcl SOLN 1 $0 REFRESH CELLUVISC 3 $0 NM; * refresh lacri-lube 3 $0 NM; * REFRESH OPTIVE ADVANCED 3 $0 NM; * REFRESH OPTIVE SENSITIVE 3 $0 NM; * RESTASIS 2 $0 QL (64 single use vials / 30 days) RESTASIS MULTIDOSE 2 $0 QL (1 bottle / 30 days) sm lubricating tears 3 $0 NM; * sodium chloride hypertonic 3 $0 NM; * SYSTANE OVERNIGHT THERAPY 3 $0 NM; * tears naturale 3 $0 NM; * 72

85 tears naturale forte 3 $0 NM; * ultra lubricant eye drops 3 $0 NM; * RESPIRATORY - 治療呼吸障礙的藥物 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - 治療慢阻肺的藥物 ANORO ELLIPTA 2 $0 QL (60 blisters / 30 days) BEVESPI AEROSPHERE 2 $0 QL (1 inhaler / 30 days) COMBIVENT RESPIMAT 2 $0 QL (2 inhalers / 30 days) ipratropium-albuterol nebu 1 $0 B/D TRELEGY ELLIPTA 2 $0 QL (60 blisters / 30 days) ANTICHOLINERGICS - 治療慢阻肺的藥物 ATROVENT HFA 2 $0 QL (2 inhalers / 30 days) INCRUSE ELLIPTA 2 $0 QL (30 blisters / 30 days) ipratropium bromide SOLN 1 $0 B/D ipratropium bromide (nasal) 1 $0 ANTIHISTAMINES - 治療過敏的藥物 all day allergy TABS 3 $0 NM; * all day allergy childrens 3 $0 NM; * aller-chlor 3 $0 NM; * allergy TABS 3 $0 NM; * allergy 24-hr 3 $0 NM; * allergy non-drowsy 3 $0 NM; * allergy relief TABS 3 $0 NM; * allergy relief child 3 $0 NM; * allergy relief childrens SOLN 3 $0 NM; * allergy-time 3 $0 NM; * azelastine spr 0.1% 1 $0 azelastine spr 0.15% 1 $0 banophen CAPS; LIQD; TABS 3 $0 NM; * cetirizine hcl CHEW 10mg 3 $0 NM; * cetirizine hcl TABS 3 $0 NM; * cetirizine hcl allergy ch 3 $0 NM; * cetirizine hcl childrens SOLN 3 $0 NM; * cetirizine syrup 1 $0 childrens allergy 3 $0 NM; * childrens loratadine 3 $0 NM; * chlorpheniramine maleate TABS 3 $0 NM; * 73

86 cyproheptadine hcl SYRP; TABS 2 $0 PA; PA if 65 years and older diphenhist 3 $0 NM; * diphenhydramine hcl CAPS 3 $0 NM; * diphenhydramine hcl TABS 25mg 3 $0 NM; * diphenhydramine inj 1 $0 eq allergy relief TABS 3 $0 NM; * fexofenadine hcl TABS 3 $0 NM; * fexofenadine hcl children 3 $0 NM; * gnp all day allergy 3 $0 NM; * gnp all day allergy child 3 $0 NM; * gnp allergy 3 $0 NM; * gnp allergy relief TABS 3 $0 NM; * gnp loratadine 3 $0 NM; * goodsense all day allergy 3 $0 NM; * hm all day allergy 3 $0 NM; * hm allergy 3 $0 NM; * hm allergy childrens 3 $0 NM; * hm allergy relief CAPS; TABS 3 $0 NM; * hm allgery multi symptom 3 $0 NM; * hm cetirizine hcl childre 3 $0 NM; * hm fexofenadine hcl 3 $0 NM; * hm loratadine childrens 3 $0 NM; * hydroxyzine hcl SOLN; SYRP; TABS 2 $0 PA; PA if 65 years and older hydroxyzine pamoate CAPS 25mg, 2 $0 PA; PA if 65 years and 50mg older levocetirizine dihydrochloride 1 $0 loratadine TABS 3 $0 NM; * loratadine childrens SOLN; SYRP 3 $0 NM; * loratadine hives relief 3 $0 NM; * multi-symptom allergy 3 $0 NM; * pharbechlor 3 $0 NM; * pharbedryl 25mg 3 $0 NM; * q-dryl 3 $0 NM; * qc loratadine allergy rel 3 $0 NM; * sb allergy 3 $0 NM; * sb allergy medicine 3 $0 NM; * sb chlorpheniramine 3 $0 NM; * siladryl allergy 3 $0 NM; * silphen cough 3 $0 NM; * 74

87 sm all day allergy 3 $0 NM; * sm all day allergy childr 3 $0 NM; * sm allergy 4 hour 3 $0 NM; * sm allergy relief CAPS; LIQD 3 $0 NM; * sm allergy relief loratad 3 $0 NM; * sm childrens loratadine 3 $0 NM; * sm fexofenadine hcl 3 $0 NM; * sm loratadine 3 $0 NM; * BETA AGONISTS - 治療哮喘與慢阻肺的藥物 albuterol sulfate NEBU 1 $0 B/D albuterol sulfate SYRP; TABS; TB12 1 $0 levalbuterol hcl NEBU 1.25mg/3ml1 $0 B/D levalbuterol hcl soln nebu conc $0 B/D mg/0.5ml levalbuterol tartrate hfa 1 $0 QL (2 inhalers / 30 days) SEREVENT DISKUS 2 $0 QL (60 inhalations / 30 days) terbutaline sulfate TABS 1 $0 VENTOLIN HFA 2 $0 QL (2 inhalers / 30 days) COUGH AND COLD 咳嗽與感冒藥物 all day allergy-d 3 $0 NM; * allergy & congestion reli 3 $0 NM; * allergy relief d-24 3 $0 NM; * allergy relief/nasal deco 3 $0 NM; * ambi 60pse/400gfn 3 $0 NM; * aprodine 3 $0 NM; * benzonatate 3 $0 NM; * brotapp 3 $0 NM; * BROTAPP DM 3 $0 NM; * cetirizine-pseudoephedrine 3 $0 NM; * chest congestion relief 3 $0 NM; * chest congestion relief p 3 $0 NM; * childrens cold & allergy 3 $0 NM; * childrens mucus relief co 3 $0 NM; * childrens mucus relief ex 3 $0 NM; * childrens silfedrine 3 $0 NM; * cold/allergy childrens 3 $0 NM; * cold/cough childrens 3 $0 NM; * 75

88 cough & cold 3 $0 NM; * cough syrup 3 $0 NM; * coughtab 3 $0 NM; * cromolyn sodium (nasal) 3 $0 NM; * dextromethorphan-guaifenesin 3 $0 NM; * diabetic siltussin das-na 3 $0 NM; * diabetic siltussin-dm 3 $0 NM; * dimaphen childrens 3 $0 NM; * dimaphen dm cold & cough 3 $0 NM; * ed a-hist TABS 3 $0 NM; * endacof-dm 3 $0 NM; * eql mucus-er maximum stre 3 $0 NM; * extra action cough 3 $0 NM; * gnp all day allergy-d 3 $0 NM; * gnp cold & allergy childr 3 $0 NM; * gnp cold & cough children 3 $0 NM; * gnp cold head congestion TABS 3 $0 NM; * gnp loratadine-d 12hr 3 $0 NM; * gnp loratadine-d 24 hour 3 $0 NM; * gnp mucus relief 3 $0 NM; * gnp mucus relief dm 3 $0 NM; * gnp mucus relief pe 3 $0 NM; * gnp mucus-er 3 $0 NM; * gnp nasal decongestant 3 $0 NM; * gnp sinus & allergy pe 3 $0 NM; * gnp tussin 3 $0 NM; * gnp tussin cf cough & col 3 $0 NM; * gnp tussin dm 3 $0 NM; * gnp tussin dm max 3 $0 NM; * guaifenesin LIQD; TB12 3 $0 NM; * hm allergy complete-d 3 $0 NM; * hm allergy relief & nasal 3 $0 NM; * hm chest congestion relie 3 $0 NM; * hm mucus er 3 $0 NM; * hm nasal decongestant 3 $0 NM; * hm tussin adult 3 $0 NM; * hm tussin adult cough & c 3 $0 NM; * kidkare cough/cold 3 $0 NM; * loratadine-d 12hr 3 $0 NM; * loratadine-d 24hr 3 $0 NM; * MUCINEX 3 $0 NM; * 76

89 mucinex fast-max dm max 3 $0 NM; * mucus relief 3 $0 NM; * mucus relief childrens 3 $0 NM; * mucus relief cough childr 3 $0 NM; * mucus relief dm 3 $0 NM; * mucus-dm 3 $0 NM; * mucusrelief sinus 3 $0 NM; * NASAL DECONGESTANT LIQD; 3 $0 NM; * SYRP nasal decongestant TABS 3 $0 NM; * nasal decongestant pe 3 $0 NM; * nasal decongestant pe max 3 $0 NM; * nasal decongestant spray 3 $0 NM; * nasal relief 3 $0 NM; * nasal spray 12 hour 3 $0 NM; * no drip nasal spray 3 $0 NM; * nrs nasal relief 3 $0 NM; * organ-i nr 3 $0 NM; * pedia relief cough/cold 3 $0 NM; * pediatric cough/cold 3 $0 NM; * pseudoephedrine hcl TABS 30mg 3 $0 NM; * q-tussin 3 $0 NM; * q-tussin dm 3 $0 NM; * qc suphedrine 3 $0 NM; * qc tussin cf 3 $0 NM; * robafen 3 $0 NM; * robafen cf multi-symptom 3 $0 NM; * robafen dm 3 $0 NM; * robafen dm cough clear 3 $0 NM; * robafen dm cough/chest co 3 $0 NM; * sb 12hr nasal spray 3 $0 NM; * sb allerfed cold & allerg 3 $0 NM; * sb cough control 3 $0 NM; * sb cough control cf 3 $0 NM; * sb coughtab 3 $0 NM; * sb mucus relief dm 3 $0 NM; * siltussin dm das 3 $0 NM; * siltussin sa 3 $0 NM; * siltussin-dm 3 $0 NM; * sinus relief nasal spray 3 $0 NM; * sm all day allergy-d 3 $0 NM; * 77

90 sm chest congestion relie 3 $0 NM; * sm cold & allergy childre 3 $0 NM; * sm cold & allergy pe 3 $0 NM; * sm lorata-dine d 3 $0 NM; * sm mucus relief cough chi 3 $0 NM; * sm nasal decongestant max 3 $0 NM; * sm nasal spray 3 $0 NM; * sm nasal spray 12 hour 3 $0 NM; * sm sinus & allergy pe max 3 $0 NM; * sm tussin cf 3 $0 NM; * sm tussin dm 3 $0 NM; * sm tussin dm cough/chest 3 $0 NM; * sm tussin mucus + chest c 3 $0 NM; * sudogest 30mg 3 $0 NM; * sudogest pe 3 $0 NM; * sudogest sinus & allergy 3 $0 NM; * tabtussin $0 NM; * tabtussin dm 3 $0 NM; * tusnel diabetic 3 $0 NM; * tussin cf 3 $0 NM; * tussin cf cough & cold 3 $0 NM; * tussin dm 3 $0 NM; * tussin dm clear 3 $0 NM; * tussin dm max 3 $0 NM; * tussin dm max adult 3 $0 NM; * LEUKOTRIENE MODULATORS 過敏反應物質白三烯調節劑 montelukast sodium CHEW; 1 $0 PACK; TABS zafirlukast 1 $0 MAST CELL STABILIZERS - 治療過敏的藥物 cromolyn sodium nebu 1 $0 B/D MISCELLANEOUS 其他藥物 acetylcysteine SOLN 10%, 20% 1 $0 B/D ARALAST NP 2 $0 NM, LA, PA DALIRESP 2 $0 deep sea nasal spray 3 $0 NM; * epinephrine (anaphylaxis) 1 $0 (generic of Adrenaclick).15mg/0.15ml,.3mg/0.3ml ESBRIET 2 $0 NM, PA KALYDECO 2 $0 NM, PA 78

91 OFEV 2 $0 NM, PA ORKAMBI 2 $0 NM, PA PROLASTIN-C 2 $0 NM, LA, PA PULMOZYME 2 $0 NM, PA sea soft nasal mist 3 $0 NM; * SYMDEKO 2 $0 NM, LA, PA XOLAIR 2 $0 NM, LA, PA ZEMAIRA 2 $0 NM, LA, PA NASAL STEROIDS - DRUGS TO TREAT ALLERGIES 治療過敏的藥物 flunisolide (nasal) 1 $0 QL (3 bottles / 30 days) fluticasone propionate (nasal) 1 $0 QL (1 bottle / 30 days) STEROID INHALANTS - DRUGS TO TREAT ASTHMA 治療哮喘的藥物 ARNUITY ELLIPTA 2 $0 QL (30 inhalations / 30 days) budesonide (inhalation) 1 $0 B/D.25mg/2ml,.5mg/2ml FLOVENT DISKUS 50mcg/blist, 100mcg/blist 2 $0 QL (120 inhalations / 30 days) FLOVENT DISKUS 250mcg/blist 2 $0 QL (240 inhalations / 30 days) FLOVENT HFA 2 $0 QL (2 inhalers / 30 days) PULMICORT FLEXHALER 2 $0 QL (2 inhalers / 30 days) STEROID/BETA-AGONIST COMBINATIONS - 治療哮喘與慢阻肺的藥物 ADVAIR DISKUS 2 $0 QL (60 inhalations / 30 days) ADVAIR HFA 2 $0 QL (1 inhaler / 30 days) BREO ELLIPTA 2 $0 QL (60 blisters / 30 days) SYMBICORT 2 $0 QL (1 inhaler / 30 days) XANTHINES - 治療慢阻肺的藥物 aminophylline inj 1 $0 THEO-24 2 $0 theophylline 1 $0 TOPICAL - 治療耳朵與皮膚狀況的藥物 DERMATOLOGY, ACNE 粉刺用藥 acne medication 5 GEL 3 $0 NM; * acne medication 10 GEL 3 $0 NM; * amnesteem 1 $0 PA avita 1 $0 PA 79

92 benzoyl peroxide GEL 10% 3 $0 NM; * benzoyl peroxide-erythromycin 1 $0 claravis 1 $0 PA clindacin-p 1 $0 clindamycin phosphate (topical) 1 $0 GEL; LOTN; SOLN; SWAB ery pad 2% 1 $0 erythromycin (acne aid) 1 $0 isotretinoin CAPS 1 $0 PA myorisan 1 $0 PA sulfacetamide sodium (acne) 1 $0 tretinoin CREA 1 $0 PA tretinoin GEL.01%,.025% 1 $0 PA zenatane 1 $0 PA DERMATOLOGY, ANTIBIOTICS 抗菌素 bacitracin (topical) 3 $0 NM; * bacitracin zinc OINT 3 $0 NM; * castellani paint 3 $0 NM; * gentamicin sulfate (topical) 1 $0 gnp bacitracin zinc 3 $0 NM; * hm bacitracin 3 $0 NM; * mafenide acetate PACK 1 $0 mupirocin OINT 1 $0 silver sulfadiazine CREA 1 $0 sm antibiotic 3 $0 NM; * ssd 1 $0 SULFAMYLON 2 $0 tolnaftate SOLN 3 $0 NM; * triple antibiotic 3 $0 NM; * DERMATOLOGY, ANTIFUNGALS 抗真菌藥物 ALEVAZOL 3 $0 NM; * anti-fungal powder 3 $0 NM; * antifungal CREA 3 $0 NM; * carrington antifungal 3 $0 NM; * ciclopirox CREA; GEL; SUSP 1 $0 ciclopirox shampoo 1% 1 $0 clotrimazole (topical) CREA 1% 1 $0 clotrimazole (topical) CREA 1% 3 $0 NM; * clotrimazole (topical) SOLN 1 $0 clotrimazole anti-fungal 3 $0 NM; * gnp athletes foot 3 $0 NM; * 80

93 gnp terbinafine hydrochlo 3 $0 NM; * ketoconazole cream 1 $0 lamisil af defense 3 $0 NM; * miconazole nitrate (topical) 3 $0 NM; * nyamyc 1 $0 nystatin (topical) 1 $0 nystatin pow $0 nystop 1 $0 qc tolnaftate 3 $0 NM; * sm antifungal clotrimazol 3 $0 NM; * sm antifungal tolnaftate 3 $0 NM; * sm athletes foot 3 $0 NM; * soothe & cool inzo antifu 3 $0 NM; * terbinafine hcl (topical) 3 $0 NM; * tolnaftate CREA; POWD 3 $0 NM; * DERMATOLOGY, ANTIPSORIATICS 抗銀屑病藥物 acitretin 2 $0 PA calcipotriene CREA; SOLN 1 $0 tazarotene CREA 1 $0 PA TAZORAC CREA.05% 2 $0 PA DERMATOLOGY, ANTISEBORRHEICS 抗脂溢性皮炎藥物 ketoconazole shampoo 1 $0 selenium sulfide LOTN 1 $0 DERMATOLOGY, CORTICOSTEROIDS 皮脂類固醇 ala-cort 1 $0 alclometasone dipropionate 1 $0 anti-itch maximum strengt CREA 3 $0 NM; * betamethasone dipropionate 1 $0 (topical) betamethasone dipropionate 1 $0 augmented betamethasone valerate CREA; LOTN; OINT 1 $0 desoximetasone CREA; GEL; OINT 1 $0 fluocinolone acetonide CREA; OIL; 1 $0 OINT; SOLN fluocinolone acetonide oil body 1 $0 fluocinonide CREA.05% 1 $0 fluocinonide GEL 1 $0 fluocinonide SOLN 1 $0 fluocinonide emulsified base 1 $0 81

94 fluticasone propionate CREA; 1 $0 OINT gnp hydrocortisone maximu 3 $0 NM; * gnp hydrocortisone/aloe 3 $0 NM; * halobetasol propionate 1 $0 hm hydrocortisone plus 3 $0 NM; * hm hydrocortisone/aloe ma 3 $0 NM; * hydrocortisone (topical) CREA 1% 3 $0 NM; * hydrocortisone (topical) CREA 1%, 1 $0 2.5% hydrocortisone (topical) LOTN 1 $0 hydrocortisone (topical) OINT 1% 3 $0 NM; * hydrocortisone (topical) OINT 1%, 1 $0 2.5% hydrocortisone butyrate cream 0.1% 1 $0 hydrocortisone butyrate oint 0.1% 1 $0 hydrocortisone butyrate soln 0.1% 1 $0 hydrocortisone maximum st 3 $0 NM; * hydrocortisone valerate 1 $0 hydrocortisone-aloe vera 3 $0 NM; * hydroskin 3 $0 NM; * mometasone furoate CREA; OINT; 1 $0 SOLN sb hydrocortisone maximum 3 $0 NM; * sm hydrocortisone CREA 1% 3 $0 NM; * sm hydrocortisone maximum 3 $0 NM; * TEXACORT SOLN 2.5% 2 $0 triamcinolone acetonide (topical) CREA; LOTN; OINT 1 $0 DERMATOLOGY, LOCAL ANESTHETICS 局部痲醉藥物 glydo 1 $0 QL (30 ml / 30 days), PA lidocaine PTCH 1 $0 QL (3 patches / 1 day), PA lidocaine hcl GEL 1 $0 QL (30 ml / 30 days), PA lidocaine hcl SOLN 4% 1 $0 QL (50 ml / 30 days), PA lidocaine oint 5% 1 $0 QL (50 gm / 30 days), PA 82

95 lidocaine-prilocaine 1 $0 QL (30 gm / 30 days), PA DERMATOLOGY, 各種皮膚與黏膜用藥 ABREVA 3 $0 NM; * ammonium lactate CREA; LOTN 1 $0 COLEMAN BOTANICALS INSECT 3 $0 NM; * COLEMAN INSECT REPELLENT/ 3 $0 NM; * COLEMAN SKINSMART INSECT 3 $0 NM; * CUTTER BACKWOODS 3 $0 NM; * CUTTER BACKWOODS DRY 3 $0 NM; * CUTTER LEMON EUCALYPTUS 3 $0 NM; * CUTTER SKINSATIONS 3 $0 NM; * CVS INSECT REPELLENT 3 $0 NM; * CVS TOTAL HOME INSECT REP 3 $0 NM; * diclofenac sodium (topical) 1% gel 1 $0 PA doxepin hcl (antipruritic) 1 $0 fluorouracil (topical) CREA 5% 1 $0 fluorouracil (topical) SOLN 1 $0 imiquimod CREA 1 $0 metronidazole (topical) CREA; 1 $0 LOTN metronidazole gel 0.75% 1 $0 NATRAPEL 12-HOUR TICK & I 3 $0 NM; * OFF ACTIVE 3 $0 NM; * OFF DEEP WOODS 3 $0 NM; * OFF DEEP WOODS DRY 3 $0 NM; * OFF FAMILYCARE UNSCENTED 3 $0 NM; * OFF SMOOTH & DRY 3 $0 NM; * PANRETIN 2 $0 PICATO 2 $0 podofilox SOLN 1 $0 procto-med hc 1 $0 procto-pak 1 $0 proctosol hc cre 2.5% 1 $0 proctozone-hc 1 $0 REPEL $0 NM; * REPEL FAMILY 3 $0 NM; * REPEL FAMILY DRY 3 $0 NM; * REPEL HUNTERS FORMULA 3 $0 NM; * REPEL SPORTSMEN 3 $0 NM; * REPEL SPORTSMEN DRY 3 $0 NM; * 83

96 REPEL SPORTSMEN MAX 3 $0 NM; * rosadan 1 $0 tacrolimus (topical) 1 $0 TARGRETIN GEL 2 $0 NM, PA ULTRATHON INSECT REPELLEN 3 $0 NM; * LOTN VALCHLOR 2 $0 NM, LA, PA zinc oxide (topical) 3 $0 NM; * DERMATOLOGY, 疥癬藥與虱蟎類用藥 gnp lice treatment 3 $0 NM; * hm lice treatment 3 $0 NM; * lice killing maximum stre 3 $0 NM; * malathion 1 $0 permethrin cre 5% 1 $0 sm lice killing maximum s 3 $0 NM; * sm lice treatment 3 $0 NM; * DERMATOLOGY, 創傷護理用藥 acetic acid.25% 1 $0 REGRANEX 2 $0 PA SANTYL 2 $0 sodium chlor sol 0.9% irr 1 $0 sterile water irrigation 1 $0 MOUTH/THROAT/DENTAL AGENTS 口腔 / 喉嚨 / 牙齒用藥 cevimeline hcl 1 $0 chlorhexidine gluconate 1 $0 (mouth-throat) clotrimazole LOZG 1 $0 lidocaine hcl (mouth-throat) 1 $0 nystatin (mouth-throat) 1 $0 paroex sol 0.12% 1 $0 periogard 1 $0 pilocarpine hcl (oral) 1 $0 triamcinolone acetonide (mouth) 1 $0 OTIC - 治療耳朵狀況的藥物 acetic acid (otic) 1 $0 CIPRODEX 2 $0 fluocinolone acetonide (otic) 1 $0 neomycin-polymyxin-hc (otic) 1 $0 ofloxacin (otic) 1 $0 84

97 B 部份糖尿病測試儀與試紙 Breeze 2 Kits, Strips Contour Kits, Strips Contour Next EZ Kits, Strips Contour Next USB Kits, Strips 85

98 Index 8 8 hour pain relief... 2 A abacavir sulfate... 9 abacavir sulfate-lamivudine abacavir sulfate-lamivudine-zidovudine10 ABELCET... 8 ABILIFY MAINTENA ABRAXANE ABREVA acamprosate calcium acarbose acebutolol hcl acephen... 1 acetaminophen... 1 acetaminophen extra stren... 1 acetaminophen w/ codeine... 4 acetazolamide acetic acid acetic acid (otic) acetylcysteine acid gone acid reducer acid reducer maximum stre acitretin acne medication acne medication ACTHIB ACTIMMUNE acyclovir acyclovir sodium ADACEL ADAGEN ADCIRCA adefovir dipivoxil ADEMPAS adriamycin adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ aftera akwa tears ala-cort ALBENZA... 7 albuterol sulfate alclometasone dipropionate ALCOHOL SWABS ALDURAZYME ALECENSA alendronate sodium ALEVAZOL alfuzosin hcl ALIMTA ALINIA... 7 all day allergy all day allergy childrens all day allergy-d aller-chlor allergy allergy & congestion reli allergy 24-hr allergy non-drowsy allergy relief allergy relief child allergy relief childrens allergy relief d allergy relief/nasal deco allergy-time allopurinol tab... 1 almacone almacone double strength alosetron hcl ALPHAGAN P SOL 0.1% alprazolam tab 0.25mg alprazolam tab 0.5mg alprazolam tab 1mg alprazolam tab 2mg ALREX altavera tab ALUMINUM HYDROXIDE ALUNBRIG alyacen 1/ amantadine hcl ambi 60pse/400gfn AMBISOME... 8 amikacin sulfate... 6 amiloride & hydrochlorothiazide amiloride hcl aminophylline inj AMINOSYN AMINOSYN 7%/ELECTROLYTES

99 aminosyn 8.5%/electrolyte aminosyn ii 8.5%/electrol AMINOSYN II INJ 10% AMINOSYN II INJ 8.5% AMINOSYN M AMINOSYN-HBC AMINOSYN-PF 7% AMINOSYN-PF INJ 10% AMINOSYN-RF amiodarone hcl AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl amlodipine besylate amlodipine besylate-olmesartan medoxomil amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine--benazepril hcl cap mg amlodipine-benazepril hcl cap 10-40mg amlodipine-benazepril hcl cap mg amlodipine-benazepril hcl cap 5-10 mg 20 amlodipine-benazepril hcl cap 5-20 mg 20 amlodipine-benazepril hcl cap 5-40 mg 20 amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg ammonium lactate amnesteem amoxapine tab 100mg amoxapine tab 150mg amoxapine tab 25mg amoxapine tab 50mg amoxicillin amoxicillin & pot clavulanate amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg amphetamine-dextroamphetamine cap sr 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphotericin b... 8 ampicillin & sulbactam sodium ampicillin cap 250mg ampicillin cap 500mg ampicillin inj ampicillin sodium ampicillin susp AMPYRA ANADROL anagrelide hcl anastrozole ANDRODERM ANDROGEL 1.62% ANDROGEL PUMP animal shapes animal shapes + iron ANORO ELLIPTA antacid antacid anti-gas maximum

100 antacid calcium extra st antacid calcium regular s antacid extra strength antacid fast acting antacid fast relief antacid maximum strength antacid plus anti-gas fas antacid plus anti-gas rel antacid regular strength anti-diarrheal antifungal anti-fungal powder anti-itch maximum strengt APOKYN aprepitant aprepitant pak 80mg & 125mg apri APRISO aprodine APTIOM APTIVUS... 9 aquadeks ARALAST NP aranelle ARCALYST aripiprazole odt aripiprazole oral solution 1 mg/ml aripiprazole tab ARISTADA ARISTADA INITIO armodafinil ARNUITY ELLIPTA arthritis pain relief... 1 arthritis pain reliever... 1 artificial tears ascorbic acid aspir aspirin... 1 aspirin adult low strengt... 1 aspirin ec low dose... 1 aspirin low dose... 1 aspirin low strength... 1 aspirin-dipyridamole aspir-low... 1 atazanavir sulfate... 9 atenolol atenolol & chlorthalidone atomoxetine hcl atorvastatin calcium atovaquone... 7 atovaquone-proguanil hcl... 9 ATRIPLA ATROVENT HFA aubra AURYXIA AUSTEDO AVASTIN aviane avita azacitidine AZACTAM IN ISO-OSMOTIC DE... 7 AZACTAM/DEX INJ... 7 AZASITE azathioprine AZATHIOPRINE azelastine drop 0.05% azelastine spr 0.1% azelastine spr 0.15% azithromycin AZOPT aztreonam... 7 B bacitracin (ophthalmic) bacitracin (topical) bacitracin zinc bacitracin-polymyxin b (ophth) bacitracin-poly-neomycin-hc baclofen balanced b balanced b balsalazide disodium balziva banophen BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE BASAGLAR KWIKPEN BCG VACCINE b-complex vitamins BD ULTRAFINE INSULIN SYRINGE BD ULTRAFINE/NANO PEN NEEDLES bekyree BELEODAQ benazepril & hydrochlorothiazide benazepril hcl

101 BENDEKA BENLYSTA benzonatate benzoyl peroxide benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate (topical).. 81 betamethasone dipropionate augmented betamethasone valerate BETASERON betaxolol hcl (ophth) bethanechol chloride BETOPTIC-S BEVESPI AEROSPHERE bexarotene BEXSERO bicalutamide BICILLIN L-A BIKTARVY BILTRICIDE... 7 bion tears biotin biotin/maximum strength bisac-evac bisacodyl bisacodyl ec biscolax bismatrol bismuth subsalicylate bisoprolol & hydrochlorothiazide bisoprolol fumarate BIVIGAM bleomycin sulfate BLEPHAMIDE blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX BORTEZOMIB BOSULIF BRAFTOVI BREO ELLIPTA briellyn BRILINTA brimonidine sol 0.15% brimonidine sol 0.2% BRIVIACT bromfenac sodium (ophth) bromocriptine mesylate BROMSITE brotapp BROTAPP DM budesonide (inhalation) budesonide ec bumetanide buprenorphine hcl buprenorphine hcl-naloxone hcl sl bupropion hcl bupropion hcl (smoking deterrent) buspirone hcl busulfan butorphanol tartrate... 4 BUTRANS... 4 BYDUREON BCISE BYDUREON INJ BYDUREON PEN BYETTA BYSTOLIC C cabergoline CABOMETYX calcipotriene calcitonin (salmon) calcitrate calcitriol calcitriol inj calcitriol oral soln 1 mcg/ml calcium 500/d calcium acetate (phosphate binder) calcium antacid calcium antacid extra str calcium antacid ultra calcium antacid ultra max calcium carbonate... 52, 67, 68 calcium carbonate (antacid)... 52, 67 calcium carbonate-cholecalciferol calcium carbonate-vitamin d CALCIUM GLUCONATE calcium polycarbophil cal-gest antacid CALQUENCE camila CANASA CANCIDAS

102 candesartan cilexetil candesartan cilexetil-hydrochlorothiazide CAPASTAT SULFATE CAPRELSA captopril captopril & hydrochlorothiazide CARBAGLU carbamazepine carbidopa/levodopa/entacapone carbidopa-levodopa carboplatin CARIMUNE NANOFILTERED carisoprodol carrington antifungal carteolol hcl (ophth) cartia xt cap 120/24hr cartia xt cap 180/24hr cartia xt cap 240/24hr cartia xt cap 300/24hr carvedilol caspofungin acetate... 8 CASPOFUNGIN ACETATE... 8 castellani paint CAYSTON... 7 caziant pak cefaclor CEFACLOR MONOHYDRATE ER cefadroxil CEFAZOLIN IN DEXTROSE 2GM/100ML-4% cefazolin inj cefazolin sodium CEFAZOLIN SODIUM 1 GM/50ML cefdinir cefepime hcl cefixime cefotaxime sodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME/DEXTROSE ceftriaxone sodium cefuroxime axetil cefuroxime sodium celecoxib... 3 CELONTIN cephalexin CERDELGA CEREZYME CERTAVITE SENIOR/ANTIOXID certavite/antioxidants cetirizine hcl cetirizine hcl allergy ch cetirizine hcl childrens cetirizine syrup cetirizine-pseudoephedrine cevimeline hcl CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTER PACK CHEMET chest congestion relief chest congestion relief p chewable antacid childrens acetaminophen... 1 childrens allergy childrens aspirin... 1 childrens aspirin low str... 1 childrens cold & allergy childrens ibuprofen... 3 childrens loratadine childrens mucus relief co childrens mucus relief ex childrens pain reliever... 1 childrens silapap... 1 childrens silfedrine childs ibuprofen... 3 chlorhexidine gluconate (mouth-throat) chloroquine phosphate... 9 chlorothiazide tabs chlorpheniramine maleate chlorpromazine hcl CHLORPROMAZINE INJ chlorthalidone cholecalciferol cholestyramine cholestyramine light ciclopirox ciclopirox shampoo 1% cilostazol CILOXAN CIMDUO CINRYZE

103 CIPRODEX ciprofloxacin ciprofloxacin hcl (ophth) ciprofloxacin hcl tab ciprofloxacin in d5w cisplatin citalopram hydrobromide cladribine claravis clarithromycin clarithromycin er clarithromycin for susp clearlax clindacin-p clindamycin cap 300mg... 7 clindamycin cap 75mg... 7 clindamycin hcl cap 150 mg... 7 clindamycin phosphate (topical) clindamycin phosphate in d5w... 7 CLINDAMYCIN PHOSPHATE IN NACL... 7 clindamycin phosphate inj... 7 clindamycin phosphate vaginal clindamycin soln 75mg/5ml... 7 CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D clomipramine hcl clonazepam... 27, 28 clonidine hcl clonidine hcl ptwk clopidogrel tab 75mg clorazepate dipotassium clotrimazole clotrimazole (topical) clotrimazole anti-fungal clotrimazole vaginal clozapine odt... 33, 34 clozapine tab 100mg clozapine tab 200mg clozapine tab 25mg clozapine tab 50mg COARTEM... 9 colchicine w/ probenecid... 1 COLCRYS... 1 cold/allergy childrens cold/cough childrens COLEMAN BOTANICALS INSECT COLEMAN INSECT REPELLENT/ COLEMAN SKINSMART INSECT colesevelam hcl colestipol hcl gran colestipol hcl pack colestipol hcl tabs colistimethate sodium... 7 colocort enema 100mg COMBIGAN COMBIVENT RESPIMAT COMETRIQ COMPLERA compro constulose CORLANOR cortisone acetate COTELLIC cough & cold cough syrup coughtab COUMADIN CREON CRIXIVAN... 9 cromolyn sodium (mastocytosis) cromolyn sodium (nasal) cromolyn sodium (ophth) cromolyn sodium nebu cryselle CUTTER BACKWOODS CUTTER BACKWOODS DRY CUTTER LEMON EUCALYPTUS CUTTER SKINSATIONS CVS INSECT REPELLENT cvs lubricant gel drops CVS TOTAL HOME INSECT REP cyanocobalamin cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl cyclophosphamide CYCLOPHOSPHAMIDE cycloserine cyclosporine cyclosporine modified (for microemulsion) 91

104 cyproheptadine hcl cyred tab CYSTADANE CYSTAGON CYSTARAN cytarabine D dacarbazine DAKLINZA dalfampridine DALIRESP danazol dantrolene sodium dapsone... 7 DAPTACEL daptomycin... 7 dasetta 1/ dasetta 7/7/ deblitane deep sea nasal spray DELESTROGEN delyla DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA INJ 400/ML DESCOVY desipramine hcl desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml desogestrel & ethinyl estradiol desogestrel-ethinyl estradiol (biphasic) 45 desoximetasone desvenlafaxine succinate dexamethasone DEXAMETHASONE dexamethasone sodium phosphate dexamethasone sodium phosphate (ophth) DEXILANT dexrazoxane dextromethorphan-guaifenesin dextrose 10% flex contain DEXTROSE 10%/NACL 0.2% dextrose 10%/nacl 0.45% dextrose 2.5%/nacl 0.45% dextrose 5% DEXTROSE 5% /ELECTROLYTE dextrose 5%/lactated ring dextrose 5%/nacl 0.2% dextrose 5%/nacl 0.225% DEXTROSE 5%/NACL 0.3% dextrose 5%/nacl 0.33% dextrose 5%/nacl 0.45% dextrose 5%/nacl 0.9% dextrose 5%/potassium chl dextrose 50% dextrose inj 70% diabetic siltussin das-na diabetic siltussin-dm DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam diazepam gel diazepam intensol diclofenac potassium... 3 diclofenac sodium... 3 diclofenac sodium (ophth) diclofenac sodium (topical) 1% gel dicloxacillin sodium dicyclomine hcl didanosine... 9 DIFICID diflunisal... 3 digitek digox digoxin digoxin inj digoxin sol 50mcg/ml dihydroergotamine mesylate 1mg/ml.. 38 dihydroergotamine mesylate nasal DILANTIN DILANTIN-125 SUS 125/5ML diltiazem cap 120mg cd diltiazem cap 180mg cd diltiazem cap 240mg cd diltiazem cap 300mg cd diltiazem cap 360mg cd diltiazem cap er/12hr diltiazem hcl diltiazem hcl cap sr 24hr diltiazem hcl coated beads cap sr 24hr 24 92

105 diltiazem hcl extended release beads cap sr diltiazem inj dilt-xr cap dimaphen childrens dimaphen dm cold & cough diocto diphenhist diphenhydramine hcl diphenhydramine inj diphenoxylate w/ atropine DIPHTHERIA/TETANUS TOXOID disopyramide phosphate disulfiram divalproex sodium docetaxel DOCETAXEL... 15, 16 docqlace doc-q-lax docu docusate sodium docusil DOCUSOL MINI dofetilide dok donepezil hydrochloride dorzolamide hcl dorzolamide hcl-timolol maleate doxazosin mesylate doxepin hcl doxepin hcl (antipruritic) doxorubicin hcl doxorubicin hcl liposomal inj 2mg/ml doxorubicin hcl soln 2mg/ml doxy doxycycline (monohydrate) doxycycline hyclate driminate dronabinol drospirenone-ethinyl estradiol DROXIA ducodyl duloxetine hcl DUREZOL dutasteride dutasteride-tamsulosin hcl E e.e.s econtra ez ecpirin... 1 ed a-hist EDURANT... 9 efavirenz... 9 ELDERTONIC eletriptan hydrobromide ELIQUIS ELIQUIS STARTER PACK ELITEK ELLA EMCYT EMEND emoquette EMSAM EMTRIVA... 9 EMVERM... 7 enalapril maleate enalapril maleate & hydrochlorothiazide endacof-dm ENDARI endocet... 4 ENEMEEZ MINI ENEMEEZ PLUS ENGERIX-B enoxaparin sodium enpresse enskyce entacapone entecavir ENTRESTO enulose EPCLUSA epinephrine (anaphylaxis) epirubicin hcl epitol EPIVIR HBV eplerenone eq allergy relief eq gentle lubricant eql mucus-er maximum stre ergocalciferol ergotamine w/ caffeine ERIVEDGE ERLEADA errin ertapenem sodium

106 ery pad 2% ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin (acne aid) erythromycin (ophth) erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate ESBRIET escitalopram oxalate esomeprazole magnesium esomeprazole sodium inj estarylla tab estradiol estradiol vaginal cream estradiol vaginal tab estradiol valerate eszopiclone ethambutol hcl ethosuximide ethynodiol diacet & eth estrad ethynodiol tab etodolac... 3 etodolac er... 3 etoposide EVOTAZ exemestane extra action cough extra strength pain relie... 1 eye vitamins & minerals ezetimibe F FABRAZYME fallback solo falmina famciclovir famotidine famotidine inj FANAPT FANAPT TITRATION PACK FARESTON FARXIGA FARYDAK FASLODEX felbamate felodipine femynor fenofibrate fenofibrate micronized fentanyl citrate... 4 fentanyl patch 100 mcg/hr... 5 fentanyl patch 12 mcg/hr... 4 fentanyl patch 25 mcg/hr... 5 fentanyl patch 50 mcg/hr... 5 fentanyl patch 75 mcg/hr... 5 FENTORA... 5 ferate ferosul ferrous fumarate ferrous gluconate FERROUS GLUCONATE ferrous sulfate FERROUS SULFATE ferrousul FETZIMA FETZIMA TITRATION PACK feverall adults... 1 feverall childrens... 1 FEVERALL INFANTS... 1 feverall junior strength... 1 fexofenadine hcl fexofenadine hcl children FIASP FIASP FLEXTOUCH fiber laxative fiber-caps fiber-lax finasteride FIRAZYR FLEBOGAMMA DIF flecainide acetate FLEET BISACODYL fleet laxative FLOVENT DISKUS FLOVENT HFA fluconazole... 8 fluconazole in dextrose... 8 FLUCONAZOLE INJ NACL fluconazole inj nacl fluconazole inj nacl flucytosine... 8 fludarabine phosphate fludrocortisone acetate flunisolide (nasal) fluocinolone acetonide

107 fluocinolone acetonide (otic) fluocinolone acetonide oil body fluocinonide fluocinonide emulsified base fluorometholone fluorouracil fluorouracil (topical) fluoxetine cap 10mg fluoxetine cap 20mg fluoxetine cap 40mg fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurbiprofen... 3 flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate (nasal) fluvoxamine maleate folic acid fondaparinux sodium FORTEO fosamprenavir tab 700 mg... 9 fosinopril sodium fosinopril sodium & hydrochlorothiazide FREAMINE HBC 6.9% FREAMINE III furosemide furosemide inj FUZEON... 9 fyavolv tab 1-5mg FYCOMPA G gabapentin... 28, 29 GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMMAPLEX 10GM/100ML GAMUNEX-C ganciclovir inj 500mg GANCICLOVIR INJ 500MG/10ML GARDASIL gatifloxacin (ophth) GATTEX GAUZE PADS gavilax gavilyte-c gavilyte-g gavilyte-n/flavor pack GAVISCON GAVISCON EXTRA STRENGTH R gemcitabine inj soln gemcitabine inj solr gemfibrozil generlac gengraf gentak gentamicin in saline... 6 gentamicin sulfate... 6 gentamicin sulfate (topical) gentamicin sulfate soln (ophth) GENTEAL SEVERE genteal tears liquid drop genteal tears mild GENVOYA GEODON gianvi gildagia GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG glatiramer acetate 20mg/ml glatiramer acetate 40mg/ml glatopa GLEOSTINE glimepiride glip/metform tab mg glip/metform tab mg glip/metform tab 5-500mg glipizide glipizide xl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glyburide glyburide micronized glycerin infants & childr glycolax glycopyrrolate glycopyrrolate inj

108 glydo gnp acid reducer maximum gnp adult aspirin low str... 1 gnp all day allergy gnp all day allergy child gnp all day allergy-d gnp allergy gnp allergy relief gnp antacid anti-gas gnp antacid extra strengt gnp anti-diarrheal gnp arthritis pain relief... 1 gnp aspirin... 1 gnp athletes foot gnp bacitracin zinc gnp bisa-lax gnp childrens ibuprofen... 3 gnp childrens pain relief... 1 gnp clearlax gnp cold & allergy childr gnp cold & cough children gnp cold head congestion gnp fiber-caps gnp heartburn relief gnp hydrocortisone maximu gnp hydrocortisone/aloe gnp ibuprofen... 3 gnp lansoprazole gnp laxative gnp lice treatment gnp loratadine gnp loratadine-d 12hr gnp loratadine-d 24 hour gnp lubricating plus eye gnp masanti regular stren gnp miconazole gnp milk of magnesia gnp motion sickness relie gnp mucus relief gnp mucus relief dm gnp mucus relief pe gnp mucus-er gnp nasal decongestant gnp nicotine mini lozenge gnp nicotine polacrilex gnp nicotine polacrilex m gnp nighttime sleep aid GNP OMEPRAZOLE gnp pain & fever children... 1 gnp pain relief... 2 gnp pain relief extra str... 2 GNP PRENATAL gnp senna plus gnp senna-lax gnp sinus & allergy pe gnp stool softener gnp stool softener/stimul gnp terbinafine hydrochlo gnp tussin gnp tussin cf cough & col gnp tussin dm gnp tussin dm max GOLYTELY goodsense all day allergy goodsense arthritis pain... 2 goodsense aspirin... 2 goodsense ibuprofen... 3 goodsense ibuprofen child... 3 goodsense lubricating plu goodsense nicotine gum goodsense nicotine polacr goodsense pain & fever ch... 2 goodsense pain & fever in... 2 goodsense pain relief... 2 goodsense pain relief ext... 2 goodsense senna laxative granisetron hcl GRANIX griseofulvin microsize... 8 griseofulvin ultramicrosize... 8 guaifenesin guanfacine er (adhd) H HAEGARDA halobetasol propionate haloperidol haloperidol conc 2mg/ml haloperidol decanoate haloperidol inj 5mg/ml haloperidol lactate inj 5 mg/ml HARVONI HAVRIX healthylax heartburn antacid extra s heartburn relief heartburn relief 150 maxi

109 heartburn treatment 24 ho heather heparin sod (porcine) in d5w heparin sod inj 1000/ml heparin sod inj 10000/ml heparin sod inj 20000/ml heparin sod inj 5000/ml heparin sodium/d5w HEPARIN SODIUM/NACL 0.45% hepatamine HERCEPTIN HETLIOZ HEXALEN HIBERIX hm acid reducer hm advanced antacid maxim hm all day allergy hm allergy hm allergy childrens hm allergy complete-d hm allergy relief hm allergy relief & nasal hm allgery multi symptom hm antacid hm antacid anti-gas extra hm antacid/antigas hm anti-diarrheal hm arthritis pain relief... 2 hm aspirin... 2 hm aspirin ec... 2 hm aspirin ec low dose... 2 hm bacitracin hm calcium antacid hm calcium antacid extra hm calcium antacid smooth hm cetirizine hcl childre hm chest congestion relie hm clearlax hm enema ready-to-use hm enema saline laxative hm famotidine hm fexofenadine hcl hm fiber HM GLUCOSE hm hydrocortisone plus hm hydrocortisone/aloe ma hm ibuprofen... 3 hm ibuprofen childrens... 3 hm ibuprofen ib... 3 hm lansoprazole hm laxative hm lice treatment hm loratadine childrens hm lubricating plus hm lubricating tears hm milk of magnesia hm mucus er hm nasal decongestant hm nicotine transdermal s HM OMEPRAZOLE hm pain & fever childrens... 2 hm pain & fever infants... 2 hm pain relief extra stre... 2 hm pain reliever... 2 hm senna hm stool softener hm tussin adult hm tussin adult cough & c HUMIRA HUMIRA INJ 10MG/0.2ML HUMIRA KIT 20MG/0.4ML HUMIRA KIT 40MG/0.8ML HUMIRA PEDIATRIC CROHNS DISEASE 62 HUMIRA PEN HUMIRA PEN CD/UC/HS STARTER HUMIRA PEN INJ PS/UV STARTER HUMIRA PEN-PS/UV STARTER HUMIRA-PEN CD/UC/HS STARTER HUMULIN R INJ U HUMULIN R U-500 KWIKPEN hydralazine hcl hydrochlorothiazide hydroco/apap tab mg... 5 hydroco/apap tab 5-325mg... 5 hydroco/apap tab hydrocodone-acetaminophen mg/15ml... 5 hydrocodone-ibuprofen tab mg 5 hydrocortisone hydrocortisone (enema) hydrocortisone (topical) hydrocortisone butyrate cream 0.1%.. 82 hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone maximum st hydrocortisone valerate

110 hydrocortisone-aloe vera hydromorphone hcl... 5 hydroskin hydroxocobalamin acetate hydroxychloroquine sulfate hydroxyprogesterone caproate (antineoplastic) hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYSINGLA ER... 5 I IBRANCE ibu tabs 600mg... 3 ibu tabs 800mg... 3 ibu ibuprofen... 3, 4 ibuprofen childrens... 4 icaps mv ICLUSIG IDHIFA iferex IFEX INJ 3GM ifosfamide inj 1gm ifosfamide inj 1gm/20ml IFOSFAMIDE INJ 3GM ifosfamide inj 3gm/60ml ILEVRO imatinib mesylate IMBRUVICA imipenem-cilastatin... 7 imipramine hcl imiquimod IMOVAX RABIES (H.D.C.V.) incassia INCRELEX INCRUSE ELLIPTA indapamide INFANRIX infants pain relief... 2 INFED INLYTA INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE INTELENCE... 9 INTRALIPID 30% intralipid inj 20% INTRON-A INJ 10MU INTRON-A INJ 18MU INTRON-A INJ 25MU INTRON-A INJ 50MU introvale INVANZ... 7 INVEGA SUST INJ 117 MG/0.75 ML INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234 MG/1.5 ML INVEGA SUST INJ 39 MG/0.25 ML INVEGA SUST INJ 78 MG/0.5 ML INVEGA TRINZA INVIRASE... 9 INVOKAMET TAB MG INVOKAMET TAB MG INVOKAMET TAB MG INVOKAMET TAB MG INVOKAMET XR TAB MG INVOKAMET XR TAB MG INVOKAMET XR TAB MG INVOKAMET XR TAB MG INVOKANA IONOSOL-MB/DEXTROSE 5% IPOL INACTIVATED IPV ipratropium bromide ipratropium bromide (nasal) ipratropium-albuterol nebu irbesartan irbesartan-hydrochlorothiazide IRESSA irinotecan hcl ISENTRESS... 9 ISENTRESS HD... 9 isibloom ISOLYTE P ISOLYTE S isoniazid isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml isosorb mononitrate tab isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate er isotretinoin isradipine itraconazole... 8 ivermectin... 7 IXIARO

111 J JADENU JADENU SPRINKLE JAKAFI jantoven JANUMET JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA JENTADUETO JENTADUETO TAB XR MG JENTADUETO TAB XR MG jinteli jolessa tab mg jolivette juleber JULUCA junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ JUXTAPID K KADCYLA KALETRA TAB MG KALETRA TAB MG KALYDECO kao-tin kariva kcl 0.075%/d5w/nacl 0.45% KCL 0.15%/D5W/NACL 0.225% kcl 0.15%/d5w/nacl 0.9% kcl 0.3%/d5w/nacl 0.45% KCL 0.3%/D5W/NACL 0.9% kcl/d5w inj 0.3% kcl/d5w/nacl inj.15/.33% kcl/d5w/nacl inj.15/.45% kcl/d5w/nacl inj 0.22%/0.45% kcl/nacl inj 0.15%-0.9% kcl/nacl inj kcl0.15%/d5w/nacl0.2% kelnor 1/ kelnor 1/ ketoconazole... 8 ketoconazole cream ketoconazole shampoo ketoprofen... 4 ketorolac tromethamine (ophth) KEYTRUDA kidkare cough/cold kimidess KINRIX kionex sus 15gm/60ml KISQALI KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE klor-con klor-con klor-con m KLOR-CON M klor-con m klor-con pak 20meq klor-con spr cap 10meq klor-con spr cap 8meq konsyl KONSYL KONSYL DAILY FIBER konsyl fiber KONSYL-D KORLYM kurvelo KUVAN KYNAMRO L labetalol hcl lactated ringer's inj lactulose lactulose (encephalopathy) lamisil af defense lamivudine... 9 lamivudine (hbv) lamivudine-zidovudine lamotrigine lansoprazole larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ larissia tab LASTACAFT latanoprost LATUDA laxative laxative feminine

112 leena leflunomide LENVIMA 10 MG DAILY DOSE LENVIMA 12MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 4 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE lessina LETAIRIS letrozole leucovorin calcium LEUKERAN leuprolide inj 1mg/ levalbuterol hcl levalbuterol hcl soln nebu conc 1.25 mg/0.5ml levalbuterol tartrate hfa LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in sodium chloride levetiracetam oral soln 100 mg/ml levobunolol hcl levocarnitine (metabolic modifiers) levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml levoleucovorin calcium LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM 175MG levoleucovorin calcium 50mg levonest levonor/ethi tab levonorgestrel & eth estradiol levonorgestrel (emergency oc) levonorgestrel-ethinyl estradiol (91-day) levora 0.15/ levo-t levothyroxine sodium levoxyl LEXIVA... 9 lice killing maximum stre lidocaine lidocaine hcl lidocaine hcl (mouth-throat) lidocaine inj 0.5%... 6 lidocaine inj 0.5% preservative free (pf) 6 lidocaine inj 1%... 6 lidocaine inj 1% preservative free (pf).. 6 lidocaine inj 1.5% preservative free (pf) 6 lidocaine inj 2%... 6 lidocaine oint 5% lidocaine-prilocaine linezolid... 7 linezolid in sodium chloride... 7 LINZESS liothyronine sodium liquitears lisinopril lisinopril & hydrochlorothiazide lithium carbonate lithium carbonate er LITHIUM SOLN 8MEQ/5ML LONSURF loperamide hcl... 53, 58 lopinavir-ritonavir loratadine loratadine childrens loratadine hives relief loratadine-d 12hr loratadine-d 24hr lorazepam lorazepam intensol lorcet hd tab mg... 5 lorcet plus tab loryna losartan potassium losartan-hydrochlorothiazide LOTEMAX lovastatin low-ogestrel loxapine succinate lubricant eye drops lubricant eye drops dry e lubricating eye drops lubrifresh p.m LUMIGAN LUMIZYME LUPRON DEPOT (1-MONTH) LUPRON DEPOT INJ 11.25MG (3-MONTH) 100

113 LUPRON DEP-PED INJ 11.25MG LUPRON DEP-PED INJ 11.25MG (3-MONTH) LUPRON DEP-PED INJ 15MG LUPRON DEP-PED INJ 30MG (3-MONTH) LUPRON DEP-PED INJ 7.5MG lutera LYNPARZA LYRICA LYRICA CR LYSODREN lyza M mafenide acetate MAG mag-al plus MAGNEBIND magnesium magnesium citrate magnesium oxide magnesium oxide (mg supplement) magnesium sulfate MAGNESIUM SULFATE MAGNESIUM SULFATE IN D5W magnesium sulfate in dextrose malathion mapap... 2 mapap arthritis pain... 2 mapap childrens... 2 mapap extra strength... 2 maprotiline hcl marlissa MARPLAN TAB 10MG MATULANE MAVYRET meclizine hcl medroxyprogesterone acetate (contraceptive) medroxyprogesterone acetate tab mefloquine hcl... 9 megestrol ac sus 40mg/ml megestrol ac tab 20mg megestrol ac tab 40mg megestrol sus 625mg/5ml MEKINIST MEKTOVI meloxicam... 4 melphalan hcl memantine hcl cp memantine hcl soln memantine hcl tabs MENACTRA MENVEO MEPHYTON mercaptopurine meribin meropenem... 7 mesalamine mesalamine w/ cleanser mesna MESNEX metadate er tab 20mg metformin er metformin hcl methadone hcl... 5 methadone hcl 10mg... 5 methadone hcl 5mg... 5 methadone hcl intensol... 5 methazolamide methenamine hippurate... 7 methimazole methocarbamol methotrexate sodium inj methotrexate sodium tabs methyclothiazide methylphenidate hcl methylphenidate hcl oral soln methylphenidate tab 10mg er methylphenidate tab 20mg er methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 125mg methylpr ss inj 1gm methylpr ss inj 40mg methylpred pak 4mg methylpred tab 16mg methylpred tab 32mg methylpred tab 4mg methylpred tab 8mg metipranolol metoclopramide hcl metoclopramide inj metolazone metoprolol & hctz tab mg

114 metoprolol & hctz tab mg metoprolol & hctz tab 50-25mg metoprolol succinate metoprolol tartrate metronidazole... 7 metronidazole (topical) metronidazole gel 0.75% metronidazole in nacl... 7 metronidazole vaginal mexiletine hcl MIACALCIN mi-acid MI-ACID mi-acid maximum strength miconazole miconazole nitrate (topical) miconazole nitrate vaginal microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ midodrine hcl migergot miglustat mili milk of magnesia mineral oil minitran minocycline hcl minoxidil mintox mintox plus mirtazapine... 31, 32 misoprostol MITIGARE... 1 mitomycin mitoxantrone hcl M-M-R II moderiba tab 200mg moexipril hcl moexipril-hydrochlorothiazide mometasone furoate mono-linyah tab mononessa montelukast sodium morgidox cap 1x50mg morphine ext-rel tab... 5 morphine sul inj 10mg/ml... 5 morphine sul inj 1mg/ml... 5 MORPHINE SUL INJ 4MG/ML... 5 morphine sulfate... 6 MORPHINE SULFATE... 5 morphine sulfate oral sol... 6 motion-time MOVANTIK MOVIPREP MOXEZA moxifloxacin hcl moxifloxacin hcl (ophth) MOZOBIL MUCINEX mucinex fast-max dm max mucus relief mucus relief childrens mucus relief cough childr mucus relief dm mucus-dm mucusrelief sinus MULTAQ multiple vitamins w/ minerals multi-symptom allergy mupirocin MURO MUSTARGEN my way MYCAMINE... 8 mycophenolate mofetil mycophenolate sodium MYLOTARG myorisan MYRBETRIQ myzilra N nabumetone... 4 nadolol nafcillin sodium NAGLAZYME nalbuphine hcl... 4 naloxone inj 0.4mg/ml naloxone inj 1mg/ml naltrexone hcl NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC naproxen... 4 naproxen dr

115 naproxen sodium... 4 naratriptan hcl NARCAN nasal decongestant NASAL DECONGESTANT nasal decongestant pe nasal decongestant pe max nasal decongestant spray nasal relief nasal spray 12 hour NASCOBAL NATACYN nateglinide NATPARA NATRAPEL 12-HOUR TICK & I natural fiber therapy natures tears NEBUPENT... 7 necon 0.5/ necon 1/ necon 7/7/ nefazodone hcl neomycin sulfate... 6 neomycin-bacitracin zn-polymyxin neomycin-polymy-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc (ophth) neomycin-polymyxin-hc (otic) NEPHRAMINE NERLYNX NEUPOGEN NEUPRO nevirapine susp 50 mg/5ml... 9 nevirapine tab 100mg... 9 nevirapine tab 200mg... 9 nevirapine tab 400mg er... 9 NEXAVAR next choice one dose niacin niacin er (antihyperlipidemic) niacinamide niacor nicardipine hcl nicorelief nicotine nicotine polacrilex nicotine transdermal syst NICOTROL INHALER NICOTROL NS nifedical xl nifedipine nifedipine er night time sleep aid nighttime sleep aid nikki nilutamide nimodipine NINLARO NIPENT NITRO-BID NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystal... 7 nitrofurantoin monohyd macro... 8 nitroglycerin nitroglycerin td patch NIVA-PLUS no drip nasal spray nora-be tab NORDITROPIN FLEXPRO norethindrone (contraceptive) norethindrone acet & eth estra norethindrone acetate norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg norgest/ethi tab 0.25/ norgestimate-ethinyl estradiol (triphasic) / / mg-mcg norgestimate-ethinyl estradiol (triphasic) / / mg-mcg norlyroc NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W NORPACE CR NORTHERA nortrel 0.5/35 (28) nortrel 1/ nortrel 7/7/ nortriptyline hcl NORVIR... 9 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG 70/30 FLEXPEN

116 NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG PENFILL NOXAFIL... 8 nrs nasal relief NUCYNTA ER... 6 NUEDEXTA NULOJIX NULYTELY/FLAVOR PACKS NU-MAG NUPLAZID CAP 34MG NUPLAZID TAB 10MG NUPLAZID TAB 17MG nutrilipid inj 20% NUVARING nyamyc NYMALIZE nystatin... 8 nystatin (mouth-throat) nystatin (topical) nystatin pow nystop O O-CAL FA ocella tab mg OCTAGAM octreotide acetate ocuvite/lutein ODEFSEY ODOMZO OFEV OFF ACTIVE OFF DEEP WOODS OFF DEEP WOODS DRY OFF FAMILYCARE UNSCENTED OFF SMOOTH & DRY ofloxacin (ophth) ofloxacin (otic) olanzapine... 34, 35 olmesartan medoxomil olmesartan medoxomil-amlodipine-hydrochlorothiazi de olmesartan medoxomil-hydrochlorothiazide olopatadine hcl 0.2% omega-3-acid ethyl esters OMEPRAZOLE omeprazole cap 10mg omeprazole cap 20mg omeprazole cap 40mg ONCOVITE ondansetron hcl ondansetron hcl inj ondansetron hcl oral soln ondansetron odt one daily one daily mens ONFI opcicon one-step OPSUMIT optics mini drops option ORFADIN organ-i nr ORKAMBI orsythia os-cal extra d oseltamivir phosphate oxacillin sodium oxaliplatin inj 100mg oxaliplatin inj 100mg/20ml oxaliplatin inj 50mg oxaliplatin inj 50mg/10ml oxandrolone oxcarbazepine oxybutynin chloride oxycodone hcl... 6 oxycodone w/ acetaminophen mg... 6 oxycodone w/ acetaminophen mg... 6 oxycodone w/ acetaminophen 5-325mg 6 oxycodone w/ acetaminophen mg... 6 OXYCONTIN... 6 oysco oysco 500+d oyster shell oyster shell calcium + vi oyster shell calcium+d OZEMPIC INJ 0.25 OR 0.5MG/DOSE OZEMPIC INJ 1MG/DOSE P pacerone paclitaxel

117 pain & fever... 2 pain & fever childrens... 2 pain & fever extra streng... 2 pain & fever infants... 2 pain relief... 2 pain relief childrens... 2 pain relief extra strengt... 2 pain reliever extra stren... 2 paliperidone pamidronate disodium PAMIDRONATE DISODIUM pamidronate inj 30mg pamidronate inj 90mg PANRETIN pantoprazole sodium tbec paricalcitol paroex sol 0.12% paromomycin sulfate... 6 paroxetine hcl tabs PASER D/R PAXIL PAZEO pedia relief cough/cold PEDIALYTE PEDIARIX pediatric cough/cold PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350-potassium chloride-sod bicarbonate-sod chloride PEGANONE PEGASYS PEGASYS PROCLICK PENICILLIN G POT IN DEXTROSE 2MU. 14 PENICILLIN G POT IN DEXTROSE 3MU. 14 PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium penicilln gk inj 20mu penicilln gk inj 5mu PENTACEL PENTAM pentoxifylline peptic relief perindopril erbumine periogard permethrin cre 5% perphenazine pfizerpen-g inj 20mu pfizerpen-g inj 5mu pharbechlor pharbedryl pharbetol... 2 pharbetol extra strength... 2 phenelzine sulfate phenobarbital phenobarbital sodium PHENOBARBITAL SODIUM PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended philith PHOSPHOLINE IODIDE phytonadione PICATO pilocarpine hcl pilocarpine hcl (oral) pimozide pimtrea pindolol pink bismuth pioglitazone hcl PIPER/TAZOBA INJ GM piper/tazoba inj gm piper/tazoba inj gm piper/tazoba inj gm piper/tazoba inj 4-0.5gm pirmella 1/ piroxicam... 4 PLASMA-LYTE A PLASMA-LYTE PNV FOLIC ACID + IRON MUL PNV PRENATAL PLUS podofilox polyethylene glycol polymyxin b-trimethoprim poly-vita drops poly-vita/iron drops POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG portia

118 pot chloride inj 2meq/ml potassium chloride... 65, 67 potassium chloride in nacl potassium chloride microencapsulated crystals er potassium chloride tab cr 10 meq potassium citrate (alkalinizer) er tabs.. 59 PRADAXA PRALUENT pramipexole tab 0.125mg pramipexole tab 0.25mg pramipexole tab 0.5mg pramipexole tab 0.75mg pramipexole tab 1.5mg pramipexole tab 1mg prasugrel hcl pravastatin sodium praziquantel... 8 prazosin hcl pred sod pho sol 5mg/5ml prednisolone acetate (ophth) prednisolone sodium phosphate PREDNISOLONE SODIUM PHOSPHATE (OPHTH) prednisolone sol 15mg/5ml prednisolone sol 25mg/5ml PREDNISONE CON 5MG/ML prednisone pak 10mg prednisone pak 5mg prednisone sol 5mg/5ml prednisone tab 10mg prednisone tab 1mg prednisone tab 2.5mg prednisone tab 20mg prednisone tab 50mg prednisone tab 5mg PREMASOL SOL 10% premasol sol 6% PRENATAL PRENATAL PLUS PRENATAL PLUS LOW IRON prenatal vitamin/folic acid > 0.8 mg (generic) PREPLUS prevalite previfem PREZCOBIX PREZISTA... 9 PRIFTIN PRIMAQUINE PHOSPHATE... 9 primidone PRIVIGEN probenecid... 1 PROCALAMINE prochlorperazine inj prochlorperazine maleate prochlorperazine supp PROCRIT procto-med hc procto-pak proctosol hc cre 2.5% proctozone-hc PROGLYCEM SUS 50MG/ML PROLASTIN-C PROLENSA PROLIA PROMACTA promethazine hcl propafenone hcl propafenone hcl 12hr proparacaine hcl propranolol & hydrochlorothiazide propranolol cap er propranolol hcl propranolol oral sol propylthiouracil PROQUAD prosight PROSOL protriptyline hcl provil... 4 pseudoephedrine hcl psyllium PULMICORT FLEXHALER PULMOZYME PURIXAN pyrazinamide pyridostigmine tab 60mg pyridoxine hcl Q qc acid controller maximu qc antacid qc antacid/anti-gas qc anti-diarrheal qc arthritis pain relief... 2 qc aspirin

119 qc chewable aspirin low d... 2 qc childrens ibuprofen... 4 qc enema qc ibuprofen... 4 qc loratadine allergy rel qc milk of magnesia qc non-aspirin extra stre... 2 qc suphedrine qc tolnaftate qc tussin cf q-dryl q-pap... 2 q-pap childrens... 2 q-pap extra strength... 2 q-tussin q-tussin dm QUADRACEL quasense quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... 9 R RABAVERT rabeprazole sodium raloxifene hcl ramipril RANEXA ranitidine hcl ranitidine hcl inj ranitidine syrup RAPAMUNE rasagiline mesylate RAYALDEE react REBETOL SOLN reclipsen RECOMBIVAX HB REFRESH CELLUVISC refresh lacri-lube REFRESH OPTIVE ADVANCED REFRESH OPTIVE SENSITIVE REGRANEX reguloid RELENZA DISKHALER RELISTOR REMICADE REMODULIN renal vitamin repaglinide REPEL REPEL FAMILY REPEL FAMILY DRY REPEL HUNTERS FORMULA REPEL SPORTSMEN REPEL SPORTSMEN DRY REPEL SPORTSMEN MAX RESCRIPTOR... 9 RESTASIS RESTASIS MULTIDOSE RETROVIR IV INFUSION... 9 REVLIMID REXULTI REYATAZ ribasphere ribavirin 200mg rifabutin rifampin RIFATER riluzole rimantadine hydrochloride ringer's RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone ritonavir RITUXAN RITUXAN HYCELA rivastigmine tartrate rivastigmine td patch 24hr 13.3 mg/24hr rivastigmine td patch 24hr 4.6 mg/24hr rivastigmine td patch 24hr 9.5 mg/24hr rizatriptan benzoate rizatriptan benzoate odt robafen robafen cf multi-symptom robafen dm robafen dm cough clear robafen dm cough/chest co

120 ropinirole tab 0.25mg ropinirole tab 0.5mg ropinirole tab 1mg ropinirole tab 2mg ropinirole tab 3mg ropinirole tab 4mg ropinirole tab 5mg rosadan rosuvastatin calcium ROTARIX ROTATEQ roweepra roweepra xr RUBRACA rulox RYDAPT S SABRIL SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS sb 12hr nasal spray sb allerfed cold & allerg sb allergy sb allergy medicine sb antacid sb antacid anti-gas doubl sb antacid extra strength sb antacid/antigas sb anti-diarrhea sb aspirin... 2 sb aspirin adult low stre... 3 sb bisacodyl laxative ec sb bismuth sb childrens ibuprofen... 4 sb chlorpheniramine sb cough control sb cough control cf sb coughtab sb docusate sodium sb gentle laxative womens sb hydrocortisone maximum sb ibuprofen... 4 sb low dose asa ec... 3 sb milk of magnesia sb motion sickness sb mucus relief dm sb non-aspirin... 3 sb non-aspirin extra stre... 3 sb pain reliever extra st... 3 sb peptic relief sb sleep scopolamine patch sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senexon-s senna lax senna laxative senna plus senna-lax sennalax-s senna-time senna-time s senno sennosides sennosides-docusate sodium SENSIPAR SEREVENT DISKUS sertraline hcl setlakin tab sevelamer carbonate sharobel SHINGRIX SIGNIFOR silace siladryl allergy sildenafil citrate (pulmonary hypertension) SILENOR silphen cough siltussin dm das siltussin sa siltussin-dm silver sulfadiazine SIMBRINZA simvastatin sinus relief nasal spray sirolimus SIRTURO SIVEXTRO... 8 sleep tabs sm 8 hour pain relief

121 sm acid reducer sm acid reducer maximum s sm all day allergy sm all day allergy childr sm all day allergy-d sm allergy 4 hour sm allergy relief sm allergy relief loratad sm antacid advanced sm antacid anti-gas sm antacid maximum streng sm antacid/antigas sm antibiotic sm anti-diarrheal sm antifungal clotrimazol sm antifungal tolnaftate sm arthritis pain relief... 3 sm aspirin... 3 sm aspirin adult low stre... 3 sm aspirin low dose... 3 sm athletes foot sm calcium antacid sm calcium antacid extra sm chest congestion relie sm childrens aspirin... 3 sm childrens ibuprofen... 4 sm childrens loratadine sm clearlax sm cold & allergy childre sm cold & allergy pe sm fexofenadine hcl sm fiber sm fiber laxative sm gas relief extra stren sm gentle laxative SM GLUCOSE sm hydrocortisone sm hydrocortisone maximum sm ibuprofen... 4 sm ibuprofen ib... 4 sm lice killing maximum s sm lice treatment sm loratadine sm lorata-dine d sm lubricating tears sm miconazole sm milk of magnesia sm mineral oil sm motion sickness relief sm mucus relief cough chi sm nasal decongestant max sm nasal spray sm nasal spray 12 hour sm natural laxative plus sm nicotine sm nicotine polacrilex sm nicotine transdermal s SM OMEPRAZOLE sm oyster shell calcium/v sm pain & fever childrens... 3 sm pain reliever extra st... 3 sm pediatric electrolyte sm senna laxative sm senna laxative maximum sm senna-s sm sinus & allergy pe max sm sleep aid night time sm stomach relief sm stool softener sm tussin cf sm tussin dm sm tussin dm cough/chest sm tussin mucus + chest c sodium bicarbonate (antacid) sodium chlor sol 0.9% irr sodium chloride... 65, 67, 68 sodium chloride 0.45% sodium chloride hypertonic sodium chloride inj 0.9% sodium ferric gluconate complex in sucrose sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln sodium phenylbutyrate sodium phosphates sodium polystyrene sulfonate SOLIQUA 100/ SOLTAMOX soluble fiber SOLU-CORTEF SOMATULINE DEPOT SOMAVERT soothe & cool inzo antifu sorine sotalol hcl sotalol hcl (afib/afl)

122 SOVALDI spironolactone spironolactone & hydrochlorothiazide.. 26 sprintec SPRITAM SPRYCEL sps susp 15gm/60ml sronyx ssd stavudine sterile water irrigation STIMATE stimulant laxative STIVARGA stomach relief stool softener stool softener extra stre streptomycin sulfate... 6 stress formula stress formula w/iron stress formula/zinc STRIBILD SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG subvenite tab sucralfate sudogest sudogest pe sudogest sinus & allergy sulfacet sod oin 10% op sulfacetamide sodium (acne) sulfacetamide sodium (ophth) sulfacetamide sod-prednisolone SULFADIAZINE... 6 sulfamethoxazole-trimethop ds... 8 sulfamethoxazole-trimethoprim... 8 sulfamethoxazole-trimethoprim inj... 8 SULFAMYLON sulfasalazine sulfasalazine ec sulindac... 4 sumatriptan sumatriptan inj 4mg/0.5ml sumatriptan inj 6mg/0.5ml sumatriptan succinate superplex-t SUPRAX SUPREP BOWEL PREP KIT SUSTIVA SUTENT syeda SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYMBICORT SYMDEKO SYMFI SYMFI LO SYMTUZA SYNAGIS SYNAREL SYNERCID... 8 SYNRIBO SYNTHROID SYPRINE SYSTANE OVERNIGHT THERAPY T tab-a-vite tab-a-vite w/beta caroten tab-a-vite/iron TABLOID tabtussin tabtussin dm tacrolimus tacrolimus (topical) tactinal... 3 tactinal extra strength... 3 tadalafil (pulmonary hypertension) TAFINLAR TAGRISSO take action tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN tarina fe 1/ TASIGNA TAXOTERE tazarotene tazicef TAZORAC taztia xt tears naturale tears naturale forte

123 TECENTRIQ TEFLARO TEGRETOL TEGRETOL-XR TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazide temazepam TENIVAC tenofovir disoproxil fumarate terazosin hcl terbinafine hcl... 8 terbinafine hcl (topical) terbutaline sulfate terconazole vaginal testosterone testosterone cypionate testosterone enanthate TETANUS/DIPHTHERIA TOXOID tetrabenazine TEXACORT SOLN 2.5% THALOMID... 17, 18 THEO theophylline THERA THERA M PLUS THERA-M thiamine hcl thioridazine hcl thiothixene thrive tiagabine hcl TIBSOVO tigecycline... 8 TIGECYCLINE... 8 tilia fe timolol maleate timolol maleate (ophth) soln timolol maleate gel timolol maleate ophth soln 0.5% (once-daily) TIVICAY tizanidine hcl TOBRADEX TOBRADEX ST tobramycin... 6 tobramycin (ophth) tobramycin inj 1.2 gm/30ml... 6 tobramycin inj 1.2gm... 7 tobramycin inj 10mg/ml... 7 tobramycin inj 40mg/ml... 7 tobramycin inj 80mg/2ml... 7 tobramycin-dexamethasone tolnaftate... 80, 81 tolterodine tartrate cap er tolterodine tartrate tabs topiramate toposar topotecan inj 4mg TOPOTECAN INJ 4MG/4ML torsemide tabs total b/c TOVIAZ tpn electrolytes TRACLEER TRADJENTA tramadol hcl... 4 tramadol-acetaminophen... 4 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVASOL TRAVATAN Z travel sickness trazodone hcl TRECATOR TRELEGY ELLIPTA TRELSTAR DEP INJ 3.75MG TRELSTAR LA INJ 11.25MG TRESIBA FLEXTOUCH tretinoin tretinoin (chemotherapy) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide cap mg triamterene & hydrochlorothiazide tabs26 tri-buffered aspirin... 3 TRICARE trientine hcl trifluoperazine hcl trifluridine trihexyphenidyl hcl tri-legest fe

124 tri-linyah tri-lo marzia tri-lo-estarylla tri-lo-sprintec trilyte trimethoprim... 8 tri-mili trimipramine maleate trinessa trinessa lo TRINTELLIX triple antibiotic tri-previfem TRISENOX tri-sprintec TRIUMEQ TRI-VI-SOL tri-vita trivora tri-vylibra TROGARZO TROPHAMINE INJ 10% trospium chloride TRULICITY TRUMENBA TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB tulana tums freshers tums smoothies tusnel diabetic tussin cf tussin cf cough & cold tussin dm tussin dm clear tussin dm max tussin dm max adult TWINRIX INJ TYBOST TYKERB TYPHIM VI TYSABRI U ULORIC... 1 ultra lubricant eye drops ULTRATHON INSECT REPELLEN unithroid ursodiol V valacyclovir hcl VALCHLOR valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide vancomycin hcl... 8 VANCOMYCIN IN NACL... 8 vandazole VAQTA VARIVAX VASCEPA VELCADE velivet VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl VENOFER VENTAVIS VENTOLIN HFA verapamil cap er verapamil hcl verapamil hcl tab er VERSACLOZ VERZENIO VESICARE vestura VICTOZA VIDEX EC VIDEX PEDIATRIC vienva vigabatrin powd pack 500mg VIIBRYD STARTER PACK VIIBRYD TAB VIMPAT vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate viorele VIRACEPT VIRAMUNE VIREAD

125 vita-bee/c vitamin a VIVITROL VOL-PLUS voriconazole... 9 VOSEVI VOTRIENT VRAYLAR VRAYLAR THERAPY PACK vyfemla vylibra W warfarin sodium WELCHOL womans laxative X XALKORI XARELTO XARELTO STARTER PACK XATMEP XELJANZ XELJANZ XR XGEVA XIFAXAN XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB 5-500MG XOLAIR XTANDI xulane XULTOPHY 100/ XYREM Y YERVOY YF-VAX yuvafem vaginal tablet 10 mcg Z zafirlukast zarah ZAVESCA ZEJULA ZELBORAF ZEMAIRA zenatane zenchent ZENPEP ZEPATIER ZERIT zidovudine cap 100mg zidovudine syp 50mg/5ml zidovudine tab 300mg zinc oxide (topical) ziprasidone hcl ZIRGAN zoledronic acid zoledronic inj 4mg/5ml ZOLINZA zolmitriptan zolmitriptan odt zolpidem tartrate zonisamide ZONTIVITY ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZOSTAVAX zovia 1/35e zovia 1/50e ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYPREXA RELPREVV INJ 210MG ZYTIGA

126 Call Healthfirst toll free today at: Healthfirst FIDA Participant Services PO Box 5165 New York, NY 參保者服務部 TTY/TDD 711 ( 聽力語言殘障服務專線 ) 每週七天, 每天上午 8 時至晚上 8 時 本處方藥一覽表資料更新於 2018 年 10 月 23 日 如需最新的資訊或其他問題, 請聯絡第一保健誠康護理 FIDA 計劃的參保者服務部, 電話號碼 , 聽力語言殘障用戶請撥打 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 或者登錄網站 healthfirst.org/mmp