1.877.ICS 行 政 辦 公 室 Independence Care System 257 Park Ave. South 2nd Floor New York, NY 會 員 中 心 400 East Fordham Road 10th fl

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1 承 保 藥 物 清 單 Community Care Plus FIDA-MMP ICS ICS_ _A2TC_G_EFF _ _174025_Comprehensive_R _Approved

2 1.877.ICS 行 政 辦 公 室 Independence Care System 257 Park Ave. South 2nd Floor New York, NY 會 員 中 心 400 East Fordham Road 10th floor Bronx, New York Elm Place 5th Floor Brooklyn, NY 11201

3 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 2015 承 保 药 物 清 单 ( 处 方 集 ) 此 文 件 列 明 了 参 与 者 能 够 在 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 中 获 得 的 药 物 清 单 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 是 一 项 管 理 中 的 护 理 计 划, 与 Medicare 及 纽 约 州 卫 生 部 (Medicaid) 签 定 合 约, 通 过 全 面 整 合 特 惠 计 划 (FIDA) 示 范 项 目 向 参 与 者 提 供 两 个 计 划 的 福 利 在 一 年 当 中 以 及 每 年 的 1 月 1 日, 有 关 福 利 承 保 药 物 清 单 及 药 房 与 医 疗 保 健 提 供 者 网 络 可 能 会 不 时 变 化 您 可 随 时 访 问 在 线 查 看 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 最 新 承 保 药 物 清 单, 或 致 电 ICS COMMUNITY CARE PLUS FIDA- MMP 计 划 参 与 者 服 务 部, 电 话 号 码 为 ICS.2525 可 能 会 适 用 相 关 限 制 和 规 定 更 多 详 情, 请 致 电 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 参 与 者 服 务 部 或 阅 读 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 参 与 者 手 册 承 保 药 物 没 有 共 付 额 您 可 以 其 他 形 式 免 费 获 得 此 资 料 ( 例 如 盲 文 版 或 大 字 版 ) 致 电 ICS.2525 此 为 免 费 电 话 您 可 免 费 获 得 所 有 这 些 信 息 的 其 他 语 言 版 本 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 You can get this information for free in other languages. Call ICS.2525 and TTY ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday. The call is free. Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону ICS.2525 и телетайпу ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный.? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 1

4 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a ICS al ICS.2525 y a la línea TTY ICS.4TTY, entre las 8 a. m. y las 8 p. m., de lunes a viernes. La llamada es gratuita. Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan ICS.2525 ak TTY ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis. 이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8 시~오후 8 시 사이에 ICS.2525 및 TTY(청각 장애인용 전화) ICS.4TTY 로 ICS 에 전화해 주십시오. 이 전화는 무료입니다. Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri ICS.2525 e TTY ICS.4TTY tra le 8:00 e le dal lunedì al venerdì. La chiamata è gratuita. 纽 约 州 成 立 了 名 为 独 立 消 费 者 倡 导 网 络 (ICAN) 的 参 与 者 监 察 专 员 计 划, 就 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 所 提 供 的 服 务 为 参 与 者 提 供 免 费 协 助, 并 为 您 保 密 您 可 拨 打 免 费 电 话 或 在 线 访 问 联 系 ICAN? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 2

5 常 见 问 题 (FAQ) 如 您 对 此 承 保 药 物 清 单 有 任 何 疑 问, 可 于 下 文 寻 找 回 答 您 可 通 读 FAQ 全 文 了 解 详 情, 或 查 找 问 题 及 回 答 1. 承 保 药 物 清 单 包 含 哪 些 处 方 药? ( 承 保 药 物 清 单 下 文 简 称 为 药 物 清 单 ) 从 第 15 页 开 始 的 承 保 药 物 清 单 中 的 药 物, 为 ICS COMMUNITY CARE PLUS FIDA- MMP 计 划 的 保 障 范 围 内 药 物 这 些 药 物 在 我 们 的 网 络 内 药 房 均 有 提 供 如 药 房 与 我 们 签 定 协 议, 同 意 与 我 们 合 作 及 向 您 提 供 服 务, 则 该 药 房 即 属 于 我 们 的 网 络 我 们 将 此 类 药 房 称 为 网 络 内 药 房 在 下 列 情 况 中,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 将 承 保 药 物 清 单 中 的 所 有 药 物 : 您 的 医 生 或 其 他 网 络 处 方 人 表 示 您 需 要 有 关 药 物 进 行 治 疗 或 保 持 健 康, 就 您 的 情 况 而 言, 该 药 物 在 医 疗 上 属 必 需, 及 您 在 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 网 络 内 药 房 填 写 处 方 对 于 某 些 药 物 的 获 取,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 设 置 额 外 步 骤 ( 参 见 下 文 问 题 5) 在 某 些 情 况 下, 您 在 获 得 药 物 前 可 能 需 要 采 取 某 些 行 动, 例 如 首 先 尝 试 其 他 药 物 您 亦 可 访 问 我 们 的 网 站 查 看 我 们 的 最 新 承 保 药 物 清 单, 或 致 电 参 与 者 服 务 部, 电 话 号 码 为 ICS 药 物 清 单 会 不 时 变 化 吗? 会 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 在 这 一 年 里 对 药 物 清 单 的 药 物 进 行 增 减 一 般 而 言, 仅 会 在 以 下 情 况 下 修 改 药 物 清 单 : 出 现 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 的 新 药, 或 我 们 获 悉 某 种 药 物 不 安 全 我 们 亦 可 能 会 修 改 我 们 的 药 物 规 定 例 如, 我 们 会 :? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 3

6 决 定 某 一 药 物 是 否 需 要 预 审 批 ( 预 审 批 是 指 在 您 获 得 药 物 前 获 得 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 许 可 ) 增 加 或 修 改 您 可 获 得 药 物 的 数 量 ( 称 为 数 量 上 限 ) 增 加 或 修 改 一 种 药 物 的 阶 梯 疗 法 限 制 ( 阶 梯 疗 法 是 指 您 须 首 先 尝 试 一 种 药 物, 然 后 我 们 才 会 承 保 另 一 种 药 物 ) ( 有 关 药 物 规 定 的 更 多 详 情, 请 参 见 第 5 页 ) 如 您 所 使 用 的 药 物 何 时 从 药 物 清 单 中 删 除, 我 们 将 告 诉 您 如 我 们 修 改 某 一 药 物 的 承 保 规 定, 亦 会 通 知 您 下 文 问 题 3 4 和 7 载 有 关 于 药 物 清 单 变 更 时 的 更 多 信 息 您 可 随 时 访 问 在 线 查 看 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 最 新 药 物 清 单 您 亦 可 致 电 参 与 者 服 务 部, 查 看 最 新 药 物 清 单, 电 话 号 码 为 ICS 如 出 现 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 并 且 价 格 更 低 的 药 物, 会 出 现 什 么 情 况? 如 有 一 种 与 药 物 清 单 中 的 某 一 现 有 药 物 具 有 相 同 效 果 并 且 价 格 更 低 的 药 物 : 您 的 药 剂 师 可 能 会 在 您 下 次 按 方 抓 药 时 向 您 提 供 这 种 价 格 更 低 的 药 物 如 您 及 您 的 医 疗 保 健 提 供 者 认 为 这 种 药 物 虽 然 价 格 更 低, 但 不 适 合 您, 您 的 医 疗 保 健 提 供 者 可 指 示 药 剂 师 继 续 向 您 提 供 您 目 前 使 用 的 药 物 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 会 作 出 将 贵 价 药 物 从 药 物 清 单 中 删 去 的 决 定 如 我 们 因 出 现 一 种 效 果 相 同 但 价 格 更 低 的 药 物, 而 将 您 正 在 使 用 的 药 物 从 药 物 清 单 中 删 除, 我 们 会 在 将 其 从 药 物 清 单 中 删 除 或 您 要 求 补 充 药 物 前 至 少 提 前 60 天 通 知 您 这 样 您 可 在 药 物 清 单 变 更 前 获 得 60 天 的 药 物 供 应 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 将 通 过 信 件 向 会 员 通 知 有 关 变 更, 当 中 将 载 有 提 交 投 诉 上 诉 或 例 外 申 报 的 相 关 信 息 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 亦 将 在 我 们 的 网 站 张 贴 有 关 信 息 ( 网 址 为 并 每 年 向 会 员 通 报 我 们 的 最 新 处 方 集 有 关 信 息 有 其 他 格 式 可 供 索 要? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 4

7 4. 如 我 们 发 现 一 种 药 物 不 安 全, 会 出 现 什 么 情 况? 如 食 品 及 药 物 监 督 管 理 局 (FDA) 声 明 您 正 在 使 用 的 一 种 药 物 不 安 全, 我 们 将 立 即 将 其 从 药 物 清 单 中 剔 除 我 们 将 通 过 信 件 及 电 话 告 诉 您 不 安 全 药 物 已 从 药 物 清 单 中 剔 除, 并 告 诉 您 尽 快 与 处 方 医 师 联 系, 获 得 关 于 取 代 停 用 药 物 的 指 示 您 亦 可 向 您 的 护 理 管 理 人 寻 求 协 助 5. 药 物 承 保 范 围 是 否 有 任 何 限 制 或 限 定? 或 者 是 否 需 要 采 取 某 些 行 动 才 能 获 得 某 些 药 物? 是 的, 某 些 药 物 有 承 保 范 围 规 定, 或 者 对 您 能 够 获 得 的 数 量 有 限 定 在 某 些 情 况 下, 您 须 在 获 得 药 物 前 采 取 一 些 行 动 例 如 : 预 审 批 ( 或 预 授 权 ): 对 于 某 些 药 物, 您 或 您 的 医 生 或 其 他 处 方 人 须 在 您 按 方 抓 药 前 通 过 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 审 批 如 您 没 有 获 得 批 准,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 可 能 不 会 承 保 该 药 物 数 量 上 限 : 有 些 时 候,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 会 限 定 您 可 以 获 得 的 药 物 数 量 阶 梯 疗 法 : 有 些 时 候,ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 会 要 求 您 采 用 阶 梯 疗 法 这 意 味 着 您 须 按 照 一 定 顺 序 就 您 的 病 情 尝 试 药 物 您 可 能 须 首 先 尝 试 一 种 药 物, 然 后 我 们 才 会 承 保 另 一 种 药 物 如 您 的 医 生 认 为 第 一 种 药 物 对 您 不 起 作 用, 我 们 将 承 保 第 二 种 药 物 您 可 查 看 从 第 15 页 开 始 的 表 格, 了 解 您 的 药 物 是 否 有 其 他 要 求 或 限 定 您 亦 可 访 问 我 们 的 网 站 了 解 更 多 信 息 我 们 已 在 网 站 上 张 贴 有 关 文 件, 解 释 我 们 的 预 授 权 及 阶 梯 疗 法 限 制 您 亦 可 要 求 我 们 向 您 发 送 一 份 副 本 您 还 可 就 有 关 限 定 申 报 例 外 情 形 更 多 例 外 情 形 详 情, 请 参 见 问 题 11 如 您 入 住 疗 养 院 或 其 他 长 期 护 理 设 施, 并 且 需 要 一 种 不 在 药 物 清 单 中 的 药 物, 或 如 您 无 法 轻 松 获 得 您 所 需 的 药 物, 我 们 可 以 提 供 帮 助 无 论 您 是 否 是 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 的 新 参 与 者, 我 们 都 将 对 您 所 需 药 物 提 供 31 天 紧 急 供 应 承 保 ( 除 非 您 的 处 方 用 药 时 间 更 短 ) 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 他 们 可 帮 助 您 决 定 药 物 清 单 是 否 有 一 种 您 可 以 使 用 的 类 似 药 物, 还 是 申 报 例 外 情 形 更 多 例 外 情 形 详 情, 请 参 见 问 题 11? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 5

8 6. 您 如 何 知 道 您 所 需 的 药 物 是 否 有 限 制 或 者 是 否 需 要 采 取 某 些 行 动 才 能 获 得 该 药 物? 从 第 15 页 开 始 的 承 保 药 物 清 单 有 一 列 标 为 用 药 的 必 要 行 动 限 制 或 限 定 7. 如 我 们 修 改 某 些 药 物 的 承 保 规 定, 会 出 现 什 么 情 况? 例 如, 如 我 们 对 某 一 药 物 增 设 预 授 权 ( 审 批 ) 数 量 上 限 及 / 或 阶 梯 疗 法 限 制 如 我 们 对 某 一 药 物 增 设 预 审 批 数 量 上 限 及 / 或 阶 梯 疗 法 限 制, 将 通 知 您 我 们 将 在 增 设 限 制 或 您 下 一 次 申 请 药 物 补 充 前 至 少 提 前 60 天 通 知 您 这 样 您 可 在 药 物 清 单 变 更 前 获 得 60 天 的 药 物 供 应 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 下 一 步 该 怎 么 办 8. 您 如 何 在 药 物 清 单 上 查 找 药 物? 查 找 药 物 有 两 种 方 法 您 可 按 字 母 顺 序 搜 索 ( 如 您 知 道 药 物 如 何 拼 写 ), 或 您 可 按 病 情 搜 索 按 字 母 顺 序 搜 索, 请 前 往 第 I-1 页 的 索 引 然 后 在 清 单 中 查 找 您 的 药 物 名 称 按 病 情 搜 索, 请 于 第 15 页 找 到 病 情 分 类 药 物 清 单 然 后 找 到 您 的 病 情 例 如, 如 您 有 心 脏 病, 您 应 在 相 应 类 别 中 查 找 您 将 在 该 类 别 中 找 到 治 疗 心 脏 病 的 药 物 9. 如 您 想 要 的 药 物 不 在 药 物 清 单 之 中 怎 么 办? 如 您 没 有 在 药 物 清 单 中 找 到 您 的 药 物, 请 拨 打 ICS.2525 咨 询 参 与 者 服 务 部 如 您 了 解 到 ICS COMMUNITY CARE PLUS FIDA-MMP 计 划 不 承 保 该 药 物, 您 可 采 取 下 列 行 动 : 向 参 与 者 服 务 部 索 要 与 您 所 希 望 获 得 药 物 类 似 的 药 物 清 单 然 后 将 清 单 拿 给 您 的 医 生 或 其 他 处 方 人 看 他 们 可 开 具 与 您 所 希 望 获 得 药 物 类 似 的 药 物 清 单 中 药 物 或 您 可 向 计 划 或 您 的 跨 领 域 团 队 (IDT) 申 报 例 外 情 形, 对 您 的 药 物 进 行 承 保 更 多 例 外 情 形 详 情, 请 参 见 问 题 11? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 6

9 10. 如 您 是 ICS 社 区 护 理 增 值 FIDA-MMP 计 划 的 新 参 与 者, 并 且 在 药 物 清 单 没 有 找 到 您 的 药 物, 或 者 在 获 得 药 物 方 面 存 在 困 难, 该 怎 么 办? 我 们 可 为 您 提 供 帮 助 在 您 成 为 ICS Community Care Plus FIDA-MMP 计 划 参 与 者 的 前 90 天, 我 们 可 在 必 要 情 况 下 承 保 不 超 过 90 天 的 临 时 供 药 这 将 让 您 有 时 间 与 医 生 或 其 他 处 方 人 协 商 他 们 可 帮 助 您 决 定 药 物 清 单 是 否 有 一 种 您 可 以 使 用 的 类 似 药 物, 还 是 申 报 例 外 情 形 如 您 满 足 以 下 条 件, 我 们 将 承 保 不 超 过 90 天 的 临 时 供 药 : 您 所 使 用 药 物 不 在 我 们 的 药 物 清 单 之 列, 或 健 康 计 划 规 定 让 您 无 法 获 得 您 的 处 方 人 开 具 的 数 量, 或 药 物 需 要 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 的 预 审 批, 或 您 正 在 使 用 的 药 物 属 于 某 一 阶 梯 疗 法 限 制 的 一 部 分 如 您 入 住 疗 养 院 或 其 他 长 期 护 理 设 施, 您 的 按 方 补 药 时 间 可 长 达 98 天 您 可 在 这 98 天 内 进 行 多 次 药 物 补 充 这 将 让 您 的 处 方 人 有 时 间 将 您 的 药 物 变 更 为 药 物 清 单 中 药 物, 或 申 报 例 外 情 形 如 您 现 为 参 与 者, 而 护 理 级 别 从 一 种 治 疗 改 为 另 一 种, 则 您 有 资 格 获 得 不 超 过 90 天 的 非 药 物 清 单 所 列 药 物 的 供 药, 以 便 让 您 的 医 生 或 处 方 人 有 时 间 寻 找 一 种 清 单 中 药 物, 或 者 申 报 例 外 情 形 如 您 符 合 以 下 条 件, 您 可 能 有 资 格 获 得 护 理 级 别 过 渡 供 药 : 离 开 医 院 或 其 他 环 境, 入 住 长 期 护 理 (LTC) 设 施 离 开 LTC 设 施, 返 回 社 区 出 院 回 家 结 束 Medicare A 部 下 承 保 的 专 业 疗 养 院 住 院 ( 包 括 药 房 费 用 ), 回 归 D 部 下 的 承 保 范 围 由 安 养 院 状 态 回 归 标 准 Medicare A 部 及 B 部 福 利 或 从 精 神 病 医 院 出 院, 并 获 得 高 度 个 性 化 的 药 物 治 疗 方 案? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 7

10 11. 您 能 否 申 报 例 外 情 形, 要 求 对 您 的 药 物 进 行 承 保? 会 您 可 向 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 申 报 例 外 情 形, 要 求 对 不 在 药 物 清 单 中 的 药 物 进 行 承 保 您 可 要 求 ICS Community Care Plus FIDA-MMP 计 划 或 您 的 IDT 修 改 您 的 药 物 相 关 规 定 例 如,ICS Community Care Plus FIDA-MMP 计 划 可 限 定 我 们 的 承 保 药 物 数 量 如 您 的 药 物 有 限 定, 您 可 向 我 们 或 您 的 IDT 提 出 申 请, 要 求 修 改 限 定 及 提 高 承 保 数 量 其 他 例 子 : 您 可 向 我 们 或 您 的 IDT 提 出 申 请, 要 求 取 消 阶 梯 疗 法 限 制 或 预 审 批 要 求 12. 申 报 例 外 情 形 需 要 多 长 时 间? 首 先,ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 须 收 到 来 自 您 的 处 方 人 关 于 支 持 您 的 例 外 情 形 申 报 的 声 明 在 我 们 接 获 声 明 后, 您 将 在 72 小 时 内 获 悉 关 于 您 例 外 情 形 申 报 的 决 定 如 您 或 您 的 处 方 人 认 为 等 待 72 小 时 将 对 您 的 健 康 造 成 损 害, 您 可 申 请 加 快 例 外 情 形 申 报 加 快 申 报 的 决 定 时 间 更 短 如 您 的 处 方 人 支 持 您 的 申 请, 您 将 在 我 们 收 到 您 的 处 方 人 支 持 声 明 后 的 24 小 时 内 获 悉 决 定 13. 您 如 何 申 报 例 外 情 形? 申 报 例 外 情 形, 请 致 电 您 的 护 理 管 理 人 您 的 护 理 管 理 人 将 与 您 及 您 的 医 疗 保 健 提 供 者 一 起 帮 助 您 申 报 例 外 情 形 14. 什 么 是 通 用 名 药 物? 通 用 名 药 物 是 由 与 品 牌 药 相 同 成 分 制 成 的 药 物 它 们 的 价 格 往 往 低 于 品 牌 药, 但 是 药 名 不 出 名 通 用 名 药 物 经 食 品 及 药 物 监 督 管 理 局 (FDA) 审 批 ICS Community Care Plus FIDA-MMP 计 划 中 既 有 品 牌 药, 也 有 通 用 名 药 物? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 8

11 15. 什 么 是 OTC 药 物? OTC 全 称 为 over-the-counter ( 非 处 方 药 ) ICS Community Care Plus FIDA-MMP 计 划 承 保 部 分 OTC 药 物, 前 提 是 您 的 医 疗 保 健 提 供 者 开 出 有 关 书 面 处 方 您 可 阅 读 ICS Community Care Plus FIDA-MMP 计 划 药 物 清 单, 查 看 哪 些 OTC 药 物 获 得 承 保 16. ICS Community Care Plus FIDA-MMP 计 划 是 否 承 保 OTC 非 药 物 产 品? ICS Community Care Plus FIDA-MMP 计 划 承 保 部 分 OTC 非 药 物 产 品, 例 如 纱 布 绷 带 酒 精 拭 片 / 棉 片 胰 岛 素 注 射 器 与 针 头 等, 前 提 是 您 的 医 疗 保 健 提 供 者 开 出 有 关 处 方 您 可 阅 读 ICS Community Care Plus FIDA-MMP 计 划 药 物 清 单, 查 看 哪 些 OTC 非 药 物 产 品 获 得 承 保 17. 您 的 共 付 额 是 多 少? 药 物 清 单 中 药 物 不 收 取 共 付 额 18. 什 么 是 药 物 层 级? 层 级 是 指 不 同 组 别 的 药 物 计 划 药 物 清 单 中 的 每 种 药 物 均 属 于 4 个 层 级 之 一 您 无 需 就 任 何 层 级 中 的 药 物 支 付 任 何 费 用 1 级 :Medicare 承 保 的 通 用 名 药 物 2 级 :Medicare 承 保 的 品 牌 药 及 特 殊 剂 型 药 物 3 级 :Medicaid 承 保 的 非 D 部 通 用 名 药 物 及 品 牌 药 4 级 :Medicaid 承 保 的 非 处 方 (OTC) 药? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 9

12 承 保 药 物 清 单 从 下 页 开 始 的 承 保 药 物 清 单 将 为 您 提 供 关 于 ICS Community Care Plus FIDA-MMP 计 划 承 保 药 物 的 信 息 如 您 在 清 单 中 没 有 找 到 您 的 药 物, 请 翻 至 从 第 I-1 页 开 始 的 索 引 图 表 第 一 列 为 药 物 名 称 品 牌 药 采 用 大 写 ( 例 如 AVONEX), 通 用 名 药 物 采 用 斜 体 小 写 ( 例 如 阿 莫 西 林 ) 用 药 的 必 要 行 动 限 制 或 限 定 一 栏 将 告 诉 您 ICS Community Care Plus FIDA-MMP 计 划 是 否 对 您 的 药 物 设 有 任 何 承 保 规 定 缩 略 词 与 符 号 本 文 可 能 出 现 的 缩 略 词 如 下 缩 略 词 说 明 解 释 使 用 管 理 限 制 PA PA BvD PA NSO 预 授 权 限 制 B 部 与 D 部 决 定 预 授 权 限 制 仅 适 用 于 新 会 员 的 预 授 权 限 制 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 获 得 ICS Community Care Plus FIDA- MMP 计 划 的 预 授 权 未 经 预 审 批,ICS 社 区 护 理 增 值 FIDA-MMP 计 划 可 能 不 会 承 保 此 药 物 此 药 物 可 能 符 合 Medicare B 部 或 D 部 下 的 支 付 条 件 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 向 ICS Community Care Plus FIDA-MMP 计 划 取 得 预 授 权, 以 决 定 该 药 物 在 Medicare D 部 下 是 否 承 保 未 经 预 审 批,FIDA Care Complete 可 能 不 会 承 保 此 药 物 如 您 是 新 会 员, 或 您 之 前 没 有 用 过 此 药, 在 按 方 抓 药 前, 您 ( 或 您 的 医 师 ) 须 获 得 ICS Community Care Plus FIDA-MMP 计 划 的 预 授 权 未 经 预 审 批,FIDA Care Complete 可 能 不 会 承? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 10

13 缩 略 词 说 明 解 释 保 此 药 物 QL ST 数 量 上 限 限 制 阶 梯 疗 法 限 制 ICS Community Care Plus FIDA-MMP 计 划 对 每 张 处 方 承 保 的 药 物 数 量 或 者 一 段 时 间 范 围 内 承 保 的 药 物 数 量 设 有 限 定 在 ICS Community Care Plus FIDA- MMP 计 划 为 药 物 提 供 承 保 前, 您 须 首 先 尝 试 另 一 种 药 物 来 治 疗 您 的 病 情 如 其 他 药 物 对 您 不 起 作 用, 可 能 仅 会 承 保 此 药 物 * 非 D 部 药 物 LA GC 限 量 药 物 缺 口 承 保 其 他 承 保 缩 略 词 该 药 物 为 Medicaid 承 保 的 非 D 部 药 物 可 能 仅 有 部 分 药 房 提 供 此 处 方 更 多 信 息, 请 查 看 您 的 药 房 通 讯 录, 或 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA-MMP 计 划, 电 话 号 码 为 ICS.2525 此 电 话 免 费 更 多 详 情, 请 访 问 我 们 在 承 保 缺 口 中 为 此 处 方 药 提 供 承 保 此 项 承 保 的 更 多 信 息 请 参 见 我 们 的 承 保 范 围 说 明 书 注 意 : 药 物 旁 边 的 星 号 (*) 表 示 该 药 物 不 是 D 部 药 物 此 类 药 物 有 着 不 同 的 上 诉 规 定 上 诉 是 申 请 审 核 及 更 改 您 认 为 存 在 错 误 的 承 保 决 定 的 一 种 正 式 途 径 例 如,ICS Community Care Plus FIDA-MMP 计 划 或 您 的 跨 领 域 团 队 (IDT) 可 能 会 决 定 您 想 要 获 得 的 药 物 不 获 得 或 不 再 获 得 Medicare 或 Medicaid 承 保 如 您 或 您 的 医 生 或 其 他 处 方 人 不 同 意 此 决 定, 您 可 以 上 诉 了 解 上 诉 相 关 说 明, 请 致 电 参 与 者 服 务 部 ( 电 话 号 码 为 ICS.2525) 或 致 电 独 立 消 费 者 倡 导 网 络 (ICAN)( 电 话 号 码 为 ) 您 亦 可 阅 读 参 与 者 手 册, 了 解 如 何 对 决 定 提 起 上 诉? 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA- MMP 计 划, 电 话 号 码 为 ICS.2525, 听 障 专 线 (TTY) 为 ICS.4TTY 此 为 免 费 电 话 更 多 详 11

14 Analgesics Analgesics, Miscellaneous acephen * (Acetaminophen) acetaminophen * oral (Acetaminophen) acetaminophen * oral (Tylenol 8 Hour) acetaminophen * rectal suppository 120 mg, 650 mg (Acetaminophen) acetaminophen-codeine oral (Acetaminophen solution with Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine mg No.3) buprenorphine hcl injection butalb-acetaminophen-caffeine oral capsule mg butalbital-acetaminop-caf-cod butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule (Buprenorphine HCl) (Esgic) (Fioricet with Codeine) (Tencon) (Esgic) (Fiorinal) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (5 per 28 days) butorphanol tartrate nasal (Butorphanol Tartrate) BUTRANS QL (4 per 28 days) children's mapap * (Acetaminophen) children's non-aspirin * oral (Acetaminophen) children's pain & fever relief * oral (Infants' Tylenol) 14

15 children's pain & fever relief * oral tablet,chewable (Acetaminophen) children's pain reliever * oral (Acetaminophen) children's pain reliever * oral (Acetaminophen) children's silapap * (Tylenol Sore Throat) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 days) codeine-butalbital-asa-caffein oral (Fiorinal with PA-HRM; QL (180 per capsule mg Codeine #3) 30 days) DURAMORPH (PF) fentanyl citrate (Actiq) PA; QL (120 per 30 days) fentanyl transdermal patch 72 hour PA; QL (20 per 30 days) (Duragesic) 100 mcg/hr fentanyl transdermal patch 72 hour PA; QL (10 per 30 days) 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 (Duragesic) mcg/hour, 75 mcg/hr, 87.5 mcg/hour feverall * rectal suppository 120 mg, 325 mg, 650 mg (Acetaminophen) hydrocodone-acetaminophen oral QL (2700 per 30 days) (Hycet) solution (includes Vicodin, hydrocodone-acetaminophen oral Vicodin ES and Vicodin tablet mg, mg, (Norco) HP); QL (390 per mg days) hydrocodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Norco) mg, mg hydrocodone-ibuprofen (Ibudone) QL (150 per 30 days) hydromorphone (pf) injection (Hydromorphone solution 10 mg/ml HCl/PF) 15

16 hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 (Hydromorphone mg/ml HCl) hydromorphone oral liquid (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg hydromorphone oral tablet 8 mg (Dilaudid) QL (240 per 30 days) infant acetaminophen * (Acetaminophen) infantaire * (Acetaminophen) infant's pain reliever * (Acetaminophen) jr. acetaminophen * (Acetaminophen) junior mapap * (Acetaminophen) LAZANDA PA; QL (30 per 30 days) levorphanol tartrate (Levorphanol QL (180 per 30 days) Tartrate) mapap (acetaminophen) * oral (Acetaminophen) mapap (acetaminophen) * oral (Acetaminophen) mapap (acetaminophen) * oral (Tylenol Sore liquid 500 mg/15 ml Throat) mapap (acetaminophen) * oral (Infants' Tylenol) mapap (acetaminophen) * oral (Tylenol) mapap (acetaminophen) * oral (Acetaminophen) mapap arthritis pain * (Tylenol 8 Hour) mapap extra strength * (Tylenol) methadone hcl oral tablet,soluble QL (90 per 30 days) (Diskets) 40 mg methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 days) methadone oral (Diskets) QL (360 per 30 days) 16

17 morphine concentrate oral solution (Msir) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 10 mg/ml, 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Msir) QL (300 per 30 days) MORPHINE ORAL TABLET QL (180 per 30 days) morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 100 mg, 30 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg, 200 mg morphine rectal (Morphine Sulfate) non-aspirin extra strength * oral (Acetaminophen) non-aspirin extra strength * oral (Tylenol Sore Throat) non-aspirin jr strength * (Acetaminophen) nortemp * oral (Acetaminophen) NUCYNTA QL (181 per 30 days) NUCYNTA ER QL (60 per 30 days) (Oxycodone QL (1800 per 30 days) oxycodone hcl-acetaminophen oral HCl/Acetaminophe solution mg/5 ml n) oxycodone hcl-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg 17

18 oxycodone hcl-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 days) oxycodone oral (Oxycodone HCl) QL (180 per 30 days) oxycodone oral (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral (Percolone) QL (180 per 30 days) oxycodone-acetaminophen oral QL (360 per 30 days) tablet mg, mg, (Xolox) mg, mg oxycodone-acetaminophen oral QL (180 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-aspirin (Percodan) QL (360 per 30 days) OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 days) oxymorphone oral tablet extended QL (60 per 30 days) release 12 hr 10 mg, 15 mg, 20 mg, (Opana ER) 5 mg, 7.5 mg oxymorphone oral tablet extended QL (120 per 30 days) (Opana ER) release 12 hr 30 mg, 40 mg pain relief adult * (Tylenol Sore Throat) pain relief * oral capsule (Acetaminophen) pain relief * oral tablet extended release (Tylenol 8 Hour) 18

19 pain reliever jr strength * (Acetaminophen) pain reliever * oral (Acetaminophen) pharbetol * (Tylenol) q-pap extra strength * (Tylenol) q-pap * oral drops (Acetaminophen) q-pap * oral liquid (Tylenol Sore Throat) q-pap * oral tablet (Tylenol) silapap * (Acetaminophen) tactinal * (Tylenol) tactinal extra strength * (Tylenol) tramadol oral tablet (Ultram) QL (240 per 30 days) tramadol-acetaminophen (Ultracet) QL (240 per 30 days) xylon 10 (Ibudone) QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents advil * oral tablet (Motrin Ib) advil * oral tablet,chewable (Ibuprofen) aspirin * oral tablet (Ecotrin) aspirin * oral tablet,chewable (Bayer Chewable Aspirin) aspirin * oral tablet,delayed release (Ecotrin) (dr/ec) 325 mg, 500 mg, 81 mg aspirin * rectal (Aspirin) aspirin, buffered * (Aspirin/Calcium Carbonate/Mag) aspir-low * (Ecotrin) bufferin * oral tablet 325 mg (Aspirin/Calcium Carbonate/Mag) CALDOLOR INTRAVENOUS RECON SOLN CELEBREX QL (60 per 30 days) celecoxib (Celebrex) QL (60 per 30 days) 19

20 (Children'S children's advil * Motrin) (Choline Sal/Mag choline,magnesium salicylate Salicylate) COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR) diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) Sodium) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) e.c. prin * (Ecotrin) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR PA flurbiprofen (Ansaid) ibuprofen * 100 mg/5 ml susp (Children'S children's (otc) Motrin) ibuprofen jr strength * (Ibuprofen) ibuprofen * oral (Advil) ibuprofen oral suspension 100 mg/5 (Ibuprofen) ml ibuprofen * oral tablet 100 mg, 200 mg (Motrin Ib) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) 20

21 indomethacin oral capsule 25 mg (Indomethacin) PA-HRM; QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (120 per 30 days) indomethacin oral capsule, PA-HRM; QL (60 per 30 (Indomethacin) extended release days) indomethacin sodium (Indocin I.V.) PA-HRM infant's ibuprofen * (Infants' Motrin) INFANT'S MOTRIN * 3 $0 ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac injection cartridge 15 QL (40 per 30 days) (Toradol) mg/ml ketorolac injection cartridge 30 QL (20 per 30 days) (Toradol) mg/ml ketorolac injection solution 15 (Ketorolac QL (40 per 30 days) mg/ml Tromethamine) ketorolac injection solution 30 (Ketorolac QL (20 per 30 days) mg/ml (1 ml) Tromethamine) ketorolac intramuscular solution (Ketorolac QL (20 per 30 days) Tromethamine) ketorolac oral (Ketorolac QL (20 per 30 days) Tromethamine) mefenamic acid (Ponstel) meloxicam (Mobic) nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) naproxen oral tablet,delayed release (dr/ec) (Ec-Naprosyn) 21

22 naproxen sodium oral tablet 275 mg, 550 mg (Anaprox) piroxicam (Feldene) salsalate (Salsalate) st joseph aspirin * (Bayer Chewable Aspirin) st. joseph aspirin * (Ecotrin) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) tri-buffered aspirin * (Aspirin/Calcium Carbonate/Mag) VOLTAREN TOPICAL wal-profen * oral (Advil) Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) lidocaine hcl injection solution (Xylocaine) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA PA BvD; (PA for ESRD Only) 22

23 lidocaine-prilocaine topical (EMLA) lidocaine-prilocaine topical kit (Lidocaine/Prilocai ne) LIDODERM PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) PA BvD; (PA for ESRD Only) PA BvD buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 days) (Buprenorphine PA; QL (90 per 30 days) buprenorphine-naloxone HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX QL (168 per 84 days) CHANTIX CONTINUING QL (56 per 28 days) MONTH PAK CHANTIX STARTING MONTH QL (53 per 28 days) BOX disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICODERM CQ * QL (168 per 365 days) TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 21 MG/24 HR NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 7 MG/24 HR nicorelief * buccal gum (Nicorette) nicorette * buccal gum 2 mg (Nicorette) nicotine (polacrilex) * (Nicorette) 23

24 nicotine * transdermal patch 24 hour 11 mg/24 hr, 21 mg/24 hr, 22 (Nicoderm Cq) mg/24 hr nicotine * transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr (Nicoderm Cq) NICOTROL ZUBSOLV SUBLINGUAL TABLET MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines QL (168 per 365 days) QL (180 per 365 days) PA; QL (90 per 30 days) PA; QL (60 per 30 days) alprazolam oral tablet (Xanax) QL (90 per 30 days) alprazolam oral tablet extended QL (90 per 30 days) (Xanax XR) release 24 hr 0.5 mg alprazolam oral tablet extended QL (60 per 30 days) (Xanax XR) release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral QL (90 per 30 days) (Alprazolam) tablet,disintegrating chlordiazepoxide hcl (Chlordiazepoxide QL (120 per 30 days) HCl) clonazepam oral tablet 0.5 mg, 1 QL (90 per 30 days) (Klonopin) mg clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) clonazepam oral QL (90 per 30 days) tablet,disintegrating mg, 0.25 (Clonazepam) mg, 0.5 mg, 1 mg clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (120 per 30 days) (Tranxene T-Tab) 15 mg 24

25 clorazepate dipotassium oral tablet QL (60 per 30 days) (Tranxene T-Tab) 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG diazepam injection (Diazepam) QL (10 per 28 days) diazepam intensol (Diazepam) QL (1200 per 30 days) diazepam oral solution (Diazepam) QL (1200 per 30 days) diazepam oral tablet (Valium) QL (120 per 30 days) diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) estazolam oral tablet 2 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) 25

26 flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) lorazepam injection solution (Ativan) QL (2 per 30 days) lorazepam injection syringe (Lorazepam) QL (2 per 30 days) lorazepam oral (Ativan) QL (90 per 30 days) midazolam (pf) injection (Midazolam QL (2 per 30 days) HCl/PF) midazolam (pf) injection syringe 2 (Midazolam QL (2 per 30 days) mg/2 ml (1 mg/ml) HCl/PF) midazolam oral syrup 2 mg/ml (Midazolam HCl) QL (10 per 30 days) ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG days) PA NSO; QL (60 per 30 days) 26

27 temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Restoril) temazepam oral capsule 7.5 mg (Restoril) triazolam oral tablet mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) 27

28 triazolam oral tablet 0.25 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) Antibacterials Aminoglycosides BETHKIS PA BvD gentamicin in nacl (iso-osm) (Gentamicin In intravenous piggyback Nacl, Iso-Osm) gentamicin injection solution (Garamycin) gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION QL (224 per 28 days) tobramycin in % nacl (Tobi) PA BvD (Tobramycin/Sodiu tobramycin in 0.9 % nacl m Chloride) tobramycin sulfate injection (Nebcin) solution Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) 28

29 clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate) nitrofurantoin macrocrystal oral capsule (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous (Vancomycin piggyback HCl/D5W) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) PA BvD; (PA for ESRD Only) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; QL (120 per 30 days) PA BvD; (PA for ESRD Only) 29

30 vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION ZYVOX ORAL Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 (Cefazolin Sodium) ml cefazolin in dextrose (iso-os) (Cefazolin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefazolin injection recon soln (Ancef) cefazolin injection recon soln 100 gram, 300 g (Cefazolin Sodium) cefazolin intravenous (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) PA; QL (9 per 30 days) ST; QL (60 per 30 days) 30

31 cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Mefoxin) cefoxitin in dextrose, iso-osm (Cefoxitin intravenous piggyback 2 gram/50 Sodium/Dextrose, ml Iso) cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime intravenous recon soln 1 gram, 2 gram (Ceftazidime) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os (Ceftriaxone Na/Dextrose, Iso) ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous (Ceftriaxone Na/Dextrose, Iso) cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous (Zinacef) 31

32 (Cefuroxime cefuroxime-dextrose (iso-osm) Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) cephalexin oral suspension for reconstitution (Cephalexin) cephalexin oral tablet (Cephalexin) MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 24 hr (Biaxin XL) DIFICID QL (20 per 10 days) ERYTHROCIN erythromycin base oral (Erythromycin tablet,delayed release (dr/ec) 250 Base) mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution (Eryped 200) erythromycin ethylsuccinate oral (Erythromycin tablet Ethylsuccinate) 32

33 erythromycin oral capsule,delayed (Erythromycin release(dr/ec) Base) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet (Erythromycin 250 mg Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for reconstitution (Amoxil) amoxicillin oral tablet (Amoxicillin) amoxicillin oral tablet,chewable 125 mg, 250 mg (Amoxicillin) amoxicillin-pot clavulanate oral suspension for reconstitution (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet extended release 12 hr (Augmentin XR) amoxicillin-pot clavulanate oral (Amoxicillin/Potas tablet,chewable sium Clav) ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) 33

34 ampicillin sodium intravenous recon soln (Totacillin-N) ampicillin-sulbactam injection recon soln (Unasyn) ampicillin-sulbactam intravenous recon soln (Unasyn) BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) nafcillin intravenous recon soln (Nallpen) (Oxacillin oxacillin in dextrose(iso-osm) Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) (Pen G penicillin g pot in dextrose Pot/Dextrose-Wate r) penicillin g potassium injection (Penicillin G recon soln Potassium) (Penicillin G penicillin g procaine Procaine) (Penicillin V penicillin v potassium Potassium) piperacillin-tazobactam intravenous (Zosyn) recon soln Quinolones ciprofloxacin (Cipro) 34

35 ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate intravenous solution 400 mg/40 ml (Cipro I.V.) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral (Levaquin) moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous Trimethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension Trimethoprim) sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/ Trimethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) 35

36 doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet (Morgidox) (Adoxa) (Doryx) (Adoxa) (Vibramycin) (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) ARRANON ARZERRA PA NSO PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) 36

37 AVASTIN PA NSO azacitidine (Vidaza) BELEODAQ PA NSO bicalutamide (Casodex) (Bleomycin PA BvD bleomycin Sulfate) PA NSO; QL (140 per BLINCYTO 365 days) BOSULIF ORAL TABLET 100 PA NSO; QL (120 per 30 MG days) BOSULIF ORAL TABLET 500 PA NSO; QL (30 per 30 MG days) CAPRELSA ORAL TABLET 100 PA NSO; QL (60 per 30 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution (Carboplatin) cisplatin (Cisplatin) days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 COMETRIQ days) cyclophosphamide intravenous (Cyclophosphamid PA BvD recon soln e) CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE (Cyclophosphamid PA BvD; ST cyclophosphamide oral tablet e) CYRAMZA PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) dactinomycin (Dactinomycin) 37

38 decitabine (Dacogen) doxorubicin hcl intravenous recon PA BvD (Doxorubicin HCl) soln 10 mg doxorubicin hcl peg-liposomal PA BvD (Doxil) intravenous suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) PA BvD DROXIA ELIGARD SUBCUTANEOUS QL (1 per 84 days) SYRINGE 22.5 MG ELIGARD SUBCUTANEOUS QL (1 per 112 days) SYRINGE 30 MG ELIGARD SUBCUTANEOUS QL (1 per 168 days) SYRINGE 45 MG ELIGARD SUBCUTANEOUS QL (1 per 28 days) SYRINGE 7.5 MG EMCYT epirubicin intravenous solution 50 mg/25 ml (Ellence) ERBITUX INTRAVENOUS PA NSO SOLUTION ERIVEDGE PA NSO; QL (30 per 30 days) ETOPOPHOS etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) 38

39 fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil) mg/10 ml flutamide (Flutamide) GAZYVA gemcitabine intravenous recon soln 1 gram (Gemzar) GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG HALAVEN PA BvD PA NSO; QL (40 per 28 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (24 per 28 days) HERCEPTIN PA NSO HEXALEN hydroxyurea (Hydrea) ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 days) ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna PA BvD ) IMBRUVICA PA NSO; QL (120 per 30 days) INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 days) 39

40 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 days) ISTODAX PA NSO IXEMPRA JAKAFI JEVTANA KADCYLA INTRAVENOUS RECON SOLN KEYTRUDA INTRAVENOUS RECON SOLN KYPROLIS PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (6 per 28 days) letrozole (Femara) LEUKERAN leuprolide (Leuprolide Acetate) lomustine (Gleostine) LUPRON DEPOT QL (1 per 28 days) LUPRON DEPOT (3 MONTH) QL (1 per 84 days) LUPRON DEPOT (4 MONTH) QL (1 per 84 days) LUPRON DEPOT (6 MONTH) QL (1 per 168 days) LUPRON DEPOT-PED (3 QL (1 per 84 days) MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED QL (1 per 28 days) INTRAMUSCULAR KIT LYNPARZA PA NSO; QL (480 per 30 days) LYSODREN MARQIBO PA NSO; QL (4 per 28 days) 40

41 MATULANE MEGACE ES megestrol oral suspension (Megace) megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 PA NSO; QL (90 per 30 MG days) MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 days) melphalan hcl intravenous (Alkeran) mercaptopurine (Purinethol) methotrexate sodium (pf) injection (Methotrexate PA BvD recon soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate PA BvD solution Sodium) methotrexate sodium injection (Methotrexate PA BvD Sodium) methotrexate sodium oral (Methotrexate PA BvD; ST Sodium) mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Novantrone) MUSTARGEN NEXAVAR PA NSO; QL (120 per 30 days) NILANDRON ONCASPAR PA NSO OPDIVO INTRAVENOUS PA NSO SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel (Paclitaxel) PERJETA PA NSO 41

42 POMALYST PROLEUKIN PURIXAN REVLIMID PA NSO; QL (21 per 28 days) PA NSO; QL (21 per 28 days) RITUXAN PA NSO SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 PA NSO; QL (30 per 30 days) MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 days) STIVARGA PA NSO; QL (84 per 28 days) SUTENT PA NSO; QL (30 per 30 days) SYLVANT PA NSO SYNRIBO PA NSO; QL (28 per 28 days) TABLOID TAFINLAR PA NSO; QL (120 per 30 days) tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 PA NSO; QL (60 per 30 MG, 25 MG days) TARCEVA ORAL TABLET 150 PA NSO; QL (90 per 30 MG days) TARGRETIN ORAL PA NSO; QL (420 per 30 days) 42

43 TARGRETIN TOPICAL PA NSO; QL (60 per 28 days) TASIGNA PA NSO; QL (112 per 28 days) TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous (Etoposide) topotecan intravenous (Hycamtin) TORISEL PA BvD; QL (4 per 28 days) TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL (1 per 84 days) SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 28 days) SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) (capsule: 10mg) TREXALL PA BvD; ST TYKERB VALSTAR VECTIBIX INTRAVENOUS PA NSO SOLUTION VELCADE PA NSO vinblastine intravenous (Vinblastine PA BvD Sulfate) 43

44 (Vincristine vincristine Sulfate) vincristine sulfate intravenous (Vincristine solution 1 mg/ml Sulfate) vinorelbine intravenous solution (Navelbine) VOTRIENT XALKORI XTANDI YERVOY INTRAVENOUS SOLUTION ZALTRAP INTRAVENOUS SOLUTION ZELBORAF ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ZYDELIG ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) PA BvD PA BvD PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) 44

45 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline (Atropine Sulfate) (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ST BANZEL ST carbamazepine oral capsule, er multiphase 12 hr (Carbatrol) carbamazepine oral suspension (Tegretol) carbamazepine oral tablet extended release 12 hr (Tegretol XR) carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG DILANTIN divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr (Depakote ER) divalproex oral tablet,delayed release (dr/ec) (Depakote) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) 45

46 GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release 24hr (Lamictal XR) lamotrigine oral tablet, chewable dispersible (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous (Keppra) levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release 24 hr (Keppra XR) LUMINAL QL (2 per 30 days) LYRICA ORAL CAPSULE QL (90 per 30 days) LYRICA ORAL SOLUTION QL (900 per 30 days) oxcarbazepine oral suspension (Oxcarbazepine) oxcarbazepine oral tablet (Trileptal) OXTELLAR XR ST PEGANONE phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 days) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, (Phenobarbital) 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenobarbital sodium injection (Phenobarbital QL (2 per 30 days) solution Sodium) 46

47 phenytoin oral suspension 125 mg/5 (Dilantin-125) ml phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended (Dilantin) POTIGA ORAL TABLET 200 MG, ST; QL (90 per 30 days) 300 MG, 400 MG POTIGA ORAL TABLET 50 MG ST; QL (270 per 30 days) primidone (Mysoline) QUDEXY XR ST SABRIL tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) topiramate oral tablet (Topamax) TRILEPTAL ORAL SUSPENSION TROKENDI XR ST valproate sodium (Depacon) valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) VIMPAT INTRAVENOUS ST; QL (200 per 5 days) VIMPAT ORAL SOLUTION ST; QL (1200 per 30 days) VIMPAT ORAL TABLET ST; QL (60 per 30 days) zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 days) 47

48 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 days) EXELON TRANSDERMAL QL (30 per 30 days) PATCH 24 HOUR 4.6 MG/24 HR, 9.5 MG/24 HR galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr galantamine oral solution (Razadyne) QL (200 per 30 days) galantamine oral tablet (Razadyne) QL (60 per 30 days) NAMENDA ORAL SOLUTION QL (360 per 30 days) NAMENDA ORAL TABLET QL (60 per 30 days) NAMENDA TITRATION PAK QL (49 per 28 days) NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR rivastigmine tartrate (Exelon) QL (60 per 30 days) Antidepressants Antidepressants amitriptyline (Amitriptyline PA NSO-HRM HCl) amoxapine (Amoxapine) BRINTELLIX ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release, 150 mg (Wellbutrin SR) bupropion hcl oral tablet extended release 24 hr (Wellbutrin XL) citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) QL (30 per 30 days) clomipramine (Anafranil) PA NSO-HRM 48

49 desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed QL (60 per 30 days) (Cymbalta) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed QL (30 per 30 days) (Cymbalta) release(dr/ec) 30 mg EMSAM QL (30 per 30 days) escitalopram oxalate (Lexapro) FETZIMA ST fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) (Prozac Weekly) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 24hr (Luvox CR) fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM imipramine pamoate (Tofranil-Pm) PA NSO-HRM KHEDEZLA ST; QL (30 per 30 days) maprotiline (Maprotiline HCl) MARPLAN mirtazapine (Remeron) nefazodone (Nefazodone HCl) nortriptyline oral capsule (Pamelor) nortriptyline oral solution (Nortriptyline HCl) olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) 49

50 paroxetine hcl oral tablet extended release 24 hr (Paxil CR) PAXIL ORAL SUSPENSION (Perphenazine/Ami PA NSO-HRM perphenazine-amitriptyline triptyline HCl) phenelzine (Nardil) PRISTIQ ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 100 MG, 50 MG protriptyline (Vivactil) sertraline (Zoloft) SILENOR QL (30 per 30 days) SURMONTIL PA NSO-HRM tranylcypromine (Parnate) trazodone (Trazodone HCl) venlafaxine oral capsule,extended release 24hr (Effexor XR) venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 (Venlafaxine HCl) mg VIIBRYD Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) QL (90 per 30 days) BYDUREON QL (4 per 28 days) BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 days) INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML QL (1.2 per 28 days) 50

51 CYCLOSET QL (180 per 30 days) INVOKAMET ORAL TABLET ST; QL (60 per 30 days) 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET ST; QL (120 per 30 days) MG INVOKANA ORAL TABLET 100 ST; QL (60 per 30 days) MG INVOKANA ORAL TABLET 300 ST; QL (30 per 30 days) MG JANUMET QL (60 per 30 days) JANUMET XR ORAL TABLET, QL (30 per 30 days) ER MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, QL (60 per 30 days) ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA QL (30 per 30 days) JARDIANCE ST; QL (30 per 30 days) JENTADUETO QL (60 per 30 days) KORLYM PA; QL (112 per 28 days) metformin oral tablet 1,000 mg (Glucophage) QL (60 per 30 days) metformin oral tablet 500 mg (Glucophage) QL (120 per 30 days) metformin oral tablet 850 mg (Glucophage) QL (90 per 30 days) metformin oral tablet extended QL (120 per 30 days) (Glucophage XR) release 24 hr 500 mg metformin oral tablet extended QL (90 per 30 days) (Glucophage XR) release 24 hr 750 mg metformin oral tablet extended QL (60 per 30 days) (Fortamet) release 24hr nateglinide (Starlix) QL (90 per 30 days) pioglitazone (Actos) QL (30 per 30 days) 51

52 pioglitazone-glimepiride (Duetact) QL (30 per 30 days) pioglitazone-metformin (Actoplus Met) QL (90 per 30 days) PRANDIMET QL (150 per 30 days) repaglinide (Prandin) QL (240 per 30 days) SYMLINPEN 120 PA; QL (10.8 per 28 days) SYMLINPEN 60 PA; QL (6 per 28 days) TRADJENTA QL (30 per 30 days) TRULICITY QL (4 per 28 days) VICTOZA PA; QL (9 per 28 days) Insulins HUMALOG KWIKPEN QL (30 per 28 days) HUMALOG MIX QL (40 per 28 days) HUMALOG MIX QL (30 per 28 days) KWIKPEN HUMALOG MIX QL (40 per 28 days) HUMALOG MIX QL (30 per 28 days) KWIKPEN HUMALOG SUBCUTANEOUS QL (40 per 28 days) HUMULIN 70/30 QL (40 per 28 days) HUMULIN 70/30 KWIKPEN QL (30 per 28 days) HUMULIN 70/30 PEN QL (30 per 28 days) HUMULIN N QL (40 per 28 days) HUMULIN N KWIKPEN QL (30 per 28 days) HUMULIN N PEN QL (30 per 28 days) HUMULIN R QL (40 per 28 days) HUMULIN R U-500 QL (40 per 28 days) "CONCENTRATED" LANTUS QL (40 per 28 days) LANTUS SOLOSTAR QL (30 per 28 days) NOVOLIN 70/30 QL (40 per 28 days) 52

53 NOVOLIN N QL (40 per 28 days) NOVOLIN R QL (40 per 28 days) NOVOLOG QL (40 per 28 days) NOVOLOG FLEXPEN QL (30 per 28 days) NOVOLOG MIX QL (40 per 28 days) NOVOLOG MIX FLEXPEN QL (30 per 28 days) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) QL (30 per 30 days) glimepiride oral tablet 4 mg (Amaryl) QL (60 per 30 days) glipizide oral tablet 10 mg (Glucotrol) QL (120 per 30 days) glipizide oral tablet 5 mg (Glucotrol) QL (60 per 30 days) glipizide oral tablet extended QL (60 per 30 days) (Glucotrol XL) release 24hr 10 mg glipizide oral tablet extended QL (30 per 30 days) (Glucotrol XL) release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet (Glipizide/Metform QL (60 per 30 days) mg in HCl) glipizide-metformin oral tablet (Glipizide/Metform QL (120 per 30 days) mg, mg in HCl) glyburide micronized oral tablet 1.5 PA-HRM; QL (400 per (Glynase) mg 30 days) glyburide micronized oral tablet 3 PA-HRM; QL (180 per (Glynase) mg 30 days) glyburide micronized oral tablet 6 PA-HRM; QL (120 per (Glynase) mg 30 days) glyburide oral tablet 1.25 mg (Glyburide) PA-HRM; QL (280 per 30 days) glyburide oral tablet 2.5 mg (Glyburide) PA-HRM; QL (240 per 30 days) glyburide oral tablet 5 mg (Glyburide) PA-HRM; QL (120 per 30 days) 53

54 glyburide-metformin oral tablet PA-HRM; QL (240 per (Glucovance) mg 30 days) glyburide-metformin oral tablet PA-HRM; QL (120 per (Glucovance) mg, mg 30 days) tolazamide oral tablet 250 mg (Tolazamide) QL (120 per 30 days) tolazamide oral tablet 500 mg (Tolazamide) QL (60 per 30 days) tolbutamide (Tolbutamide) QL (180 per 30 days) Antifungals Antifungals 3 day vaginal * (Miconazole Nitrate) ABELCET PA BvD af * (Tinactin) aloe vesta * topical ointment 2 % (Miconazole Nitrate) AMBISOME PA BvD amphotericin b (Amphotericin B) PA BvD antifungal (tolnaftate) * topical (Tolnaftate) antifungal (tolnaftate) * topical (Tolnaftate) antifungal * topical solution (Undecylenic Acid) athlete's foot (clotrimazole) * (Lotrimin AF) baza antifungal * (Nuzole) CANCIDAS ciclopirox topical cream (Ciclodan) ciclopirox topical gel (Loprox) ciclopirox topical shampoo (Loprox) ciclopirox topical solution (Penlac) ciclopirox topical suspension (Ciclopirox Olamine) ciclopirox-ure-camph-menth-euc (Ciclodan) clotrimazole * 1% cream (otc) (Lotrimin AF) 54

55 clotrimazole * 1% solution (otc) (Clotrimazole) clotrimazole 3 day * (Gyne-Lotrimin) clotrimazole mucous membrane (Clotrimazole) clotrimazole topical cream 1 % (Clotrimazole) clotrimazole topical solution 1 % (Lotrimin) clotrimazole * vaginal cream (Gyne-Lotrimin) clotrimazole * vaginal tablet (Clotrimazole) clotrimazole-3 * (Gyne-Lotrimin) clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical (Clotrimazole/Beta lotion methasone Dip) critic-aid clear af * (Miconazole Nitrate) dermafungal * (Miconazole Nitrate) desenex * topical cream (Lotrimin AF) econazole topical (Econazole Nitrate) elon dual defense * (Undecylenic Acid) fluconazole (Diflucan) fluconazole in dextrose(iso-o) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) fluconazole in nacl (iso-osm) (Fluconazole In intravenous piggyback Nacl,Iso-Osm) flucytosine (Ancobon) fungi cure * (Clotrimazole) FUNGI-NAIL * TOPICAL fungoid-d * (Tinactin) griseofulvin microsize oral tablet (Grifulvin V) inzo antifungal * (Nuzole) itraconazole (Sporanox) ketoconazole oral (Ketoconazole) 55

56 ketoconazole topical cream (Ketoconazole) ketoconazole topical shampoo (Nizoral) LAMISIL (AEROSOL) * lamisil af * (Tolnaftate) LAMISIL AT * TOPICAL LOTRIMIN ULTRA * micatin * (Nuzole) miconazole 7 * vaginal suppository (Miconazole Nitrate) miconazole nitrate * topical cream (Nuzole) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal (Miconazole Nitrate) miconazole nitrate * vaginal kit 200 (Monistat 1) mg- 2 % (9 gram) miconazole nitrate vaginal suppository 200 mg (Monistat 3) MONISTAT 3 * VAGINAL COMB PACK,PREFILL APPL & CREAM MONISTAT 3 * VAGINAL KIT monistat 7 * vaginal (Miconazole Nitrate) myco nail a * (Undecylenic Acid) NOXAFIL ORAL nystatin (Nystatin) NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) 56

57 nystatin-triamcinolone (Nystatin/Triamcin ) podactin * (Tolnaftate) terbinafine hcl oral (Lamisil) terbinafine hcl * topical (Desenex) tolnaftate * topical (Tinactin) tolnaftate * topical (Tolnaftate) triple paste af * (Miconazole Nitrate) voriconazole intravenous (Vfend IV) voriconazole oral (Vfend) Antihistamines Antihistamines alavert d-12 allergy-sinus * (Claritin-D 12 Hour) aller-chlor * oral syrup (Chlorpheniramine Maleate) aller-chlor * oral tablet (Chlor-Trimeton) allerclear d-12hr * (Claritin-D 12 Hour) allerclear d-24hr * (Claritin-D 24 Hour) allergy (chlorpheniramine) * (Chlor-Trimeton) allergy relief (cetirizine) * oral (Zyrtec) allergy relief (loratadine) * oral (Claritin) allerhist-1 * (Tavist-1) aller-tec d * (Zyrtec-D) ambi 60pse-4cpm * (Pseudoephed/Chlo rpheniramine) aprodine * (Pseudoephedrine/ Triprolidine) banophen allergy * (Zzzquil) 57

58 banophen * oral capsule 25 mg (Benadryl) banophen * oral (Diphenhydramine HCl) benadryl allergy * oral tablet (Diphenhydramine HCl) cetirizine * oral solution (Cetirizine HCl) cetirizine * oral tablet (Zyrtec) cetirizine * oral tablet,chewable (Zyrtec) cetirizine-pseudoephedrine * (Zyrtec-D) child triaminic cold & allergy * (Dimetapp) child wal-tap cold-allergy * (Dimetapp) children's aller-tec * (Cetirizine HCl) children's cetirizine * oral tablet,chewable 5 mg (Zyrtec) CHILDREN'S CLARITIN * ORAL children's wal-dryl allergy * oral (Zzzquil) children's wal-zyr * oral (Zyrtec) CHILDREN'S ZYRTEC ALLERGY * CLARITIN * CLARITIN LIQUI-GEL * CLARITIN REDITABS * CLARITIN-D 12 HOUR * CLARITIN-D 24 HOUR * clemastine oral syrup (Clemastine Fumarate) clemastine * oral tablet 1.34 mg (Tavist-1) clemastine oral tablet 2.68 mg (Clemastine Fumarate) cold & cough * oral liquid (Phenylephrine/Dip henhydramine) PA-HRM PA-HRM 58

59 compoz * (Diphenhydramine HCl) cyproheptadine (Cyproheptadine HCl) dailyhist-1 * (Tavist-1) dayhist allergy * (Tavist-1) dimaphen (pe) * (Dimetapp) (Phenylephrine/Dip dimetapp cold-congestion * henhydramine) diphenhist * oral capsule (Benadryl) diphenhist * oral (Zzzquil) diphenhist * oral tablet 25 mg (Diphenhydramine HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) diphenhydramine hcl injection (Diphenhydramine syringe HCl) diphenhydramine hcl * oral capsule (Benadryl) diphenhydramine hcl * oral tablet (Diphenhydramine 50 mg HCl) ed chlorped jr * (Chlorpheniramine Maleate) levocetirizine (Xyzal) loradamed * (Claritin) loratadine * oral (Claritin) loratadine * oral (Claritin) loratadine-d * oral tablet extended (Claritin-D 12 release 12 hr Hour) loratadine-d * oral tablet extended (Claritin-D 24 release 24 hr Hour) phenylephrine-chlorpheniramine * (Phenylephrine/Chl oral tablet 4-10 mg orpheniramine) PA-HRM 59

60 promethazine oral syrup (Promethazine HCl) q-dryl * oral liquid (Zzzquil) q-tapp * (Pseudoephedrine/ Brompheniramin) siladryl sa * (Zzzquil) simply sleep * (Diphenhydramine HCl) (Pseudoephed/Chlo sinus & allergy (pseudoephed) * rpheniramine) sleep aid (diphenhydramine) * oral (Zzzquil) sleep-tabs * (Diphenhydramine HCl) sudogest cold & allergy * (Pseudoephed/Chlo rpheniramine) (Phenylephrine/Dip triaminic cold & cough nt (pe) * henhydramine) (Doxylamine ultra sleep (doxylamine succ) * Succinate) unisom sleepgels * (Benadryl) (Pseudoephedrine/ wal-act d cold & allergy * Triprolidine) wal-dryl allergy * oral (Benadryl) wal-dryl allergy * oral (Diphenhydramine HCl) wal-finate * (Chlor-Trimeton) wal-finate-d * (Pseudoephed/Chlo rpheniramine) wal-itin * (Claritin) wal-itin d * (Claritin-D 24 Hour) PA-HRM 60

61 wal-itin d 12 hour * (Claritin-D 12 Hour) wal-phed * oral tablet 4-60 mg (Pseudoephed/Chlo rpheniramine) (Phenylephrine/Chl wal-phed pe sinus & allergy * orpheniramine) wal-sleep z * oral capsule (Benadryl) wal-sleep z * oral liquid (Zzzquil) wal-sleep z * oral (Unisom tablet,disintegrating Sleepmelts) wal-som * oral capsule (Benadryl) wal-tap * (Dimetapp) wal-zyr (cetirizine) * oral (Cetirizine HCl) wal-zyr (cetirizine) * oral (Zyrtec) wal-zyr d * (Zyrtec-D) z-sleep * (Zzzquil) ZYRTEC * ORAL CAPSULE ZYRTEC * ORAL TABLET ZYRTEC * ORAL TABLET,DISINTEGRATING Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA * AVC VAGINAL clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole) Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) QL (30 per 28 days) 61

62 dihydroergotamine nasal (Migranal) QL (4 per 28 days) ERGOMAR QL (40 per 28 days) naratriptan (Amerge) QL (18 per 28 days) rizatriptan oral tablet (Maxalt) QL (18 per 28 days) rizatriptan oral QL (18 per 28 days) (Maxalt Mlt) tablet,disintegrating sumatriptan (Imitrex) QL (12 per 28 days) sumatriptan succinate oral (Imitrex) QL (18 per 28 days) sumatriptan succinate subcutaneous QL (4 per 28 days) (Imitrex) cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 days) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 days) zolmitriptan oral tablet (Zomig) QL (12 per 28 days) zolmitriptan oral tablet,disintegrating (Zomig Zmt) Antimycobacterials Antimycobacterials CAPASTAT dapsone (Dapsone) ethambutol (Myambutol) isoniazid oral (Isoniazid) PASER PRIFTIN pyrazinamide (Pyrazinamide) rifabutin (Mycobutin) rifampin (Rifadin) rifampin (Rifadin) RIFATER SIRTURO TRECATOR QL (12 per 28 days) PA; QL (188 per 168 days) 62

63 Antinausea Agents Antinausea Agents ambizine * (Meclizine HCl) dimenhydrinate injection solution (Dimenhydrinate) dramamine * oral tablet (Dimenhydrinate) driminate * (Dimenhydrinate) dronabinol (Marinol) EMEND INTRAVENOUS RECON SOLN EMEND ORAL CAPSULE 125 MG, 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK granisetron (pf) intravenous (Granisetron solution HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) (Kytril) granisetron hcl oral (Granisetron HCl) PA BvD meclizine * 12.5 mg tablet (otc) (Meclizine HCl) meclizine * 25 mg tablet (otc) (Meclizine HCl) meclizine oral tablet 12.5 mg, 25 mg (Antivert) motion sickness * (Dimenhydrinate) ondansetron (Zofran Odt) PA BvD ondansetron hcl (pf) injection (Ondansetron HCl/PF) ondansetron hcl oral (Zofran) PA BvD prochlorperazine edisylate injection (Compazine) solution prochlorperazine maleate (Compazine) QL (2 per 28 days) PA BvD; QL (1 per 1 day) PA BvD; QL (2 per 1 day) PA BvD; QL (3 per 1 day) 63

64 prochlorperazine maleate oral (Compazine) promethazine hcl (Phenergan) PA-HRM promethazine oral tablet (Promethazine PA-HRM HCl) promethazine rectal (Phenergan) PA-HRM TRANSDERM-SCOP QL (10 per 30 days) travel sickness (meclizine) * (Bonine) wal-dram * (Dimenhydrinate) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone (Mepron) atovaquone-proguanil (Malarone) BILTRICIDE chloroquine phosphate oral (Aralen Phosphate) COARTEM DARAPRIM hydroxychloroquine oral (Plaquenil) ivermectin oral (Stromectol) mefloquine (Mefloquine HCl) (Metronidazole/So metronidazole in nacl (iso-os) dium Chloride) metronidazole oral (Flagyl) NEBUPENT PA BvD paromomycin (Paromomycin Sulfate) PENTAM PRIMAQUINE QL (90 per 30 days) quinine sulfate (Qualaquin) PA; QL (42 per 7 days) STROMECTOL 64

65 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral (Amantadine HCl) APOKYN QL (60 per 30 days) AZILECT benztropine oral (Benztropine PA-HRM Mesylate) bromocriptine (Parlodel) cabergoline (Cabergoline) carbidopa (Lodosyn) carbidopa-levodopa oral tablet (Sinemet CR) carbidopa-levodopa oral tablet extended release (Sinemet CR) carbidopa-levodopa-entacapone (Stalevo 50) entacapone (Comtan) NEUPRO ST; QL (30 per 30 days) pramipexole oral tablet (Mirapex) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 hr (Requip XL) selegiline hcl oral capsule (Eldepryl) selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl PA-HRM HCl) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG QL (90 per 30 days) 65

66 ABILIFY DISCMELT ORAL QL (60 per 30 days) TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR QL (161.2 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) ABILIFY ORAL SOLUTION QL (900 per 30 days) ABILIFY ORAL TABLET 10 MG, QL (30 per 30 days) 15 MG, 20 MG, 30 MG, 5 MG ABILIFY ORAL TABLET 2 MG QL (60 per 30 days) chlorpromazine (Chlorpromazine HCl) clozapine oral tablet 100 mg (Clozaril) QL (270 per 30 days) clozapine oral tablet 200 mg (Clozaril) QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg (Clozaril) QL (90 per 30 days) clozapine oral tablet,disintegrating (Fazaclo) ST; QL (90 per 30 days) FANAPT ORAL TABLET ST; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE ST; QL (8 per 28 days) PACK FAZACLO ORAL ST; QL (180 per 30 days) TABLET,DISINTEGRATING 150 MG FAZACLO ORAL ST; QL (120 per 30 days) TABLET,DISINTEGRATING 200 MG fluphenazine decanoate (Fluphenazine Decanoate) fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 days) haloperidol (Haloperidol) haloperidol decanoate (Haloperidol intramuscular solution 100 mg/ml Decanoate) 66

67 haloperidol decanoate (Haldol Decanoate intramuscular solution 50 mg/ml 50) haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET ST; QL (60 per 30 days) EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA QL (0.75 per 28 days) INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA QL (1 per 28 days) INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA QL (1.5 per 28 days) INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA QL (0.25 per 28 days) INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 days) INTRAMUSCULAR SYRINGE 78 MG/0.5 ML LATUDA ORAL TABLET 120 ST; QL (30 per 30 days) MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 days) loxapine succinate (Loxitane) olanzapine intramuscular (Zyprexa) QL (30 per 30 days) olanzapine oral tablet (Zyprexa) QL (30 per 30 days) 67

68 olanzapine oral QL (30 per 30 days) tablet,disintegrating 10 mg, 15 mg, (Zyprexa Zydis) 5 mg olanzapine oral QL (31 per 30 days) (Zyprexa Zydis) tablet,disintegrating 20 mg ORAP perphenazine (Perphenazine) quetiapine (Seroquel) QL (90 per 30 days) RISPERDAL CONSTA QL (4 per 28 days) risperidone oral (Risperdal) QL (480 per 30 days) risperidone oral (Risperdal) QL (60 per 30 days) risperidone oral QL (60 per 30 days) tablet,disintegrating 0.25 mg, 0.5 (Risperdal M-Tab) mg, 1 mg, 2 mg risperidone oral QL (120 per 30 days) (Risperdal M-Tab) tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) ST; QL (60 per 30 days) SEROQUEL XR ORAL TABLET ST; QL (60 per 30 days) EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 200 MG thioridazine (Thioridazine HCl) PA NSO-HRM thiothixene (Navane) trifluoperazine (Trifluoperazine HCl) VERSACLOZ ST; QL (540 per 30 days) ziprasidone hcl (Geodon) QL (60 per 30 days) 68

69 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION Name of Drug Antivirals (Systemic) Antiretrovirals abacavir (Ziagen) abacavir-lamivudine-zidovudine (Trizivir) APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine (Videx EC) EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine (Epivir) lamivudine-zidovudine (Combivir) LEXIVA nevirapine oral suspension (Viramune) nevirapine oral tablet (Viramune) nevirapine oral tablet extended release 24 hr (Viramune XR) QL (2 per 28 days) 69

70 NORVIR PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine (Zerit) STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule (Retrovir) zidovudine oral syrup (Retrovir) zidovudine oral tablet (Zidovudine) Antivirals, Miscellaneous foscarnet (Foscavir) PA BvD RELENZA DISKHALER rimantadine (Flumadine) 70

71 SYNAGIS TAMIFLU ORAL CAPSULE 30 QL (84 per 180 days) MG TAMIFLU ORAL CAPSULE 45 QL (48 per 180 days) MG TAMIFLU ORAL CAPSULE 75 QL (42 per 180 days) MG TAMIFLU ORAL SUSPENSION QL (540 per 180 days) FOR RECONSTITUTION Hcv Antivirals HARVONI PA; QL (30 per 30 days) OLYSIO PA; QL (28 per 28 days) SOVALDI PA; QL (28 per 28 days) VIEKIRA PAK PA; QL (112 per 28 days) Interferons INTRON A INJECTION PA NSO PEGASYS PA PEGASYS PROCLICK PA SUBCUTANEOUS PEN INJECTOR PEGINTRON PA PEGINTRON REDIPEN PA SYLATRON PA NSO; QL (4 per 28 days) SYLATRON 4-PACK SUBCUTANEOUS KIT 200 MCG, PA NSO; QL (4 per 28 days) 300 MCG Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) 71

72 acyclovir sodium intravenous recon (Acyclovir PA BvD soln Sodium) acyclovir sodium intravenous (Acyclovir PA BvD solution Sodium) adefovir (Hepsera) BARACLUDE ORAL TABLET entecavir (Baraclude) famciclovir (Famvir) ganciclovir sodium (Cytovene) PA BvD ribavirin oral capsule 200 mg (Rebetol) ribavirin oral tablet 200 mg, 400 mg, 600 mg (Copegus) TYZEKA valacyclovir (Valtrex) VALCYTE ORAL TABLET valganciclovir (Valcyte) VIRAZOLE PA BvD Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution (Lovenox) QL (36 per 30 days) enoxaparin subcutaneous syringe QL (36 per 30 days) (Lovenox) 100 mg/ml enoxaparin subcutaneous syringe QL (27.2 per 30 days) (Lovenox) 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe QL (34 per 30 days) (Lovenox) 150 mg/ml enoxaparin subcutaneous syringe QL (18 per 30 days) (Lovenox) 30 mg/0.3 ml enoxaparin subcutaneous syringe QL (13.6 per 30 days) (Lovenox) 40 mg/0.4 ml 72

73 enoxaparin subcutaneous syringe 60 mg/0.6 ml (Lovenox) fondaparinux subcutaneous syringe 10 mg/0.8 ml (Arixtra) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml (Arixtra) fondaparinux subcutaneous syringe 5 mg/0.4 ml (Arixtra) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml (Arixtra) heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin Sodium 12,500 unit/250 ml, 20,000 unit/500 in 5% Dextrose) ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution (Heparin Sod,Pork 25,000 unit/250 ml(100 unit/ml), In 0.45% NaCl) 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) (Heparin intravenous parenteral solution Sodium,Porcine/Ns 1,000 unit/500 ml /PF) heparin (porcine) injection (Heparin Sodium,Porcine) heparin, porcine (pf) injection (Monoject Prefill Advanced) heparin, porcine (pf) intravenous (Monoject Prefill syringe 100 unit/ml Advanced) heparin-0.45% nacl 25,000 (Heparin Sod,Pork units/250 ml (100 units/ml) bag In 0.45% NaCl) latex-free, outer heparin-0.45% nacl 25,000 units/500 ml (50 units/ml) bag latex-free, outer (Heparin Sod,Pork In 0.45% NaCl) QL (20.4 per 30 days) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) 73

74 heparin-d5w 25,000 units/250 ml (Heparin Sodium (100 units/ml) bag excel container in 5% Dextrose) heparin-d5w 25,000 units/500 ml (Heparin Sodium (50 units/ml) bag excel container in 5% Dextrose) IPRIVASK PA; QL (24 per 28 days) jantoven (Coumadin) PRADAXA QL (60 per 30 days) warfarin (Coumadin) XARELTO Blood Formation Modifiers EPOGEN INJECTION SOLUTION PA; QL (12 per 28 days) 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA PA; QL (0.6 per 28 days) MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION PA; QL (12 per 28 days) SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION PA; QL (6 per 28 days) SOLUTION 40,000 UNIT/ML PROMACTA PA; QL (30 per 30 days) 74

75 Hematologic Agents, Miscellaneous aminocaproic acid oral (Amicar) anagrelide (Agrylin) protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral (Lysteda) QL (30 per 30 days) Platelet-Aggregation Inhibitors AGGRENOX QL (60 per 30 days) BRILINTA cilostazol (Pletal) clopidogrel (Plavix) EFFIENT QL (30 per 30 days) pentoxifylline (Pentoxifylline) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % 75

76 Caloric Agents Caloric Agents AMINO ACIDS 15 % PA BvD AMINOSYN 10 % PA BvD AMINOSYN 3.5 % PA BvD AMINOSYN 7 % PA BvD AMINOSYN 7 % WITH PA BvD ELECTROLYTES AMINOSYN 8.5 % PA BvD AMINOSYN 8.5 PA BvD %-ELECTROLYTES AMINOSYN II 10 % PA BvD AMINOSYN II 15 % PA BvD AMINOSYN II 7 % PA BvD AMINOSYN II 8.5 % PA BvD AMINOSYN II 8.5 PA BvD %-ELECTROLYTES AMINOSYN M 3.5 % PA BvD AMINOSYN-HBC 7% PA BvD AMINOSYN-PF 10 % PA BvD AMINOSYN-PF 7 % PA BvD (SULFITE-FREE) AMINOSYN-RF 5.2 % PA BvD CLINIMIX 5%/D15W SULFITE PA BvD FREE CLINIMIX 5%/D25W PA BvD SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%/D10W SULF PA BvD FREE 76

77 CLINIMIX 4.25%/D5W SULFIT PA BvD FREE CLINIMIX 4.25%-D20W PA BvD SULF-FREE CLINIMIX 4.25%-D25W PA BvD SULF-FREE CLINIMIX PA BvD 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL PA BvD FREE CLINIMIX E 2.75%/D5W SULF PA BvD FREE CLINIMIX E 4.25%/D10W SUL PA BvD FREE CLINIMIX E 4.25%/D25W SUL PA BvD FREE CLINIMIX E 4.25%/D5W SULF PA BvD FREE CLINIMIX E 5%/D15W SULFIT PA BvD FREE CLINIMIX E 5%/D20W SULFIT PA BvD FREE CLINIMIX E 5%/D25W SULFIT PA BvD FREE CLINISOL SF 15 % PA BvD cysteine (l-cysteine) intravenous PA BvD (Cysteine HCl) solution (Dextrose 10 % d10 % & 0.45 % sodium chloride and 0.45 % NaCl) (Dextrose 2.5 % d2.5 %-0.45 % sodium chloride and 0.45 % NaCl) (Dextrose 5 % and d5 % and 0.9 % sodium chloride 0.9 % NaCl) 77

78 d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dex4 glucose * oral tablet,chewable (Dextrose) dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in PA BvD intravenous Water) dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in PA BvD Water) dextrose 20 % in water (d20w) (Dextrose 20 % in PA BvD Water) dextrose 25 % in water (d25w) (Dextrose 25 % in PA BvD Water) dextrose 40 % in water (d40w) (Dextrose 40 % in PA BvD Water) dextrose 5 % in ringers (Dextrose 5% In Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) (Dextrose dextrose 5 %-lactated ringers 5%-Lactated Ringers) dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % NaCl) dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % NaCl) dextrose 50 % in water (d50w) (Dextrose 50 % in PA BvD Water) dextrose 70 % in water (d70w) (Dextrose 70 % in PA BvD Water) dextrose with sodium chloride (Dextrose 5 %-0.2 % NaCl) FREAMINE HBC 6.9 % PA BvD 78

79 FREAMINE III 10 % PA BvD gluco burst * (Dextrose) glucose gel * (Dextrose) glucose * oral tablet,chewable (Dextrose) glutose 15 * (Dextrose) HEPATAMINE 8% PA BvD HEPATASOL 8 % PA BvD insta-glucose * (Dextrose/Dextrin/ Maltose) INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % KABIVEN PA BvD LIPOSYN II PA BvD LIPOSYN III PA BvD NEPHRAMINE 5.4 % PA BvD NUTRILIPID PA BvD PERIKABIVEN PA BvD potassium chloride in lr-d5 (Potassium intravenous parenteral solution Chloride In Lr-D5) PREMASOL 10 % PA BvD PREMASOL 6 % PA BvD PROCALAMINE 3% PA BvD PROSOL 20 % PA BvD TRAVASOL 10 % PA BvD TROPHAMINE 10 % PA BvD TROPHAMINE 6% PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) 79

80 (Clonidine clonidine hcl-chlorthalidone HCl/Chlorthalidon e) clonidine transdermal patch weekly QL (4 per 28 days) (Catapres-Tts 1) 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly QL (8 per 28 days) (Catapres-Tts 1) 0.3 mg/24 hr doxazosin (Cardura) guanfacine oral tablet (Tenex) PA-HRM midodrine (Midodrine HCl) nasal decongestant (pe) * oral tablet 10 mg (Medi-Phenyl) NORTHERA PA; QL (180 per 30 days) phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) sudogest pe * (Medi-Phenyl) wal-phed pe * (Medi-Phenyl) Angiotensin Ii Receptor Antagonists BENICAR ST BENICAR HCT ST candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT) DIOVAN ST irbesartan (Avapro) irbesartan-hydrochlorothiazide (Avalide) losartan (Cozaar) losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR ST valsartan (Diovan) 80

81 valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) (Captopril/Hydroch captopril-hydrochlorothiazide lorothiazide) enalapril maleate (Vasotec) enalaprilat intravenous injectable (Enalaprilat Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) fosinopril (Fosinopril Sodium) (Fosinopril/Hydroc fosinopril-hydrochlorothiazide hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg (Cordarone) amiodarone oral (Cordarone) disopyramide phosphate oral capsule (Norpace) flecainide (Flecainide Acetate) 81

82 lidocaine (pf) intravenous syringe (Lidocaine 50 mg/5 ml (1 %) HCl/PF) lidocaine in 5 % dextrose (pf) (Lidocaine intravenous parenteral solution 8 HCl/D5w/PF) mg/ml (0.8 %) mexiletine (Mexiletine HCl) MULTAQ procainamide injection (Procainamide HCl) propafenone oral capsule,extended release 12 hr (Rythmol SR) propafenone oral tablet (Rythmol) quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) TIKOSYN Beta-Adrenergic Blocking Agents acebutolol oral (Sectral) atenolol (Tenormin) atenolol-chlorthalidone (Tenoretic 50) betaxolol oral (Kerlone) bisoprolol fumarate (Zebeta) bisoprolol-hydrochlorothiazide (Ziac) BYSTOLIC carvedilol (Coreg) esmolol intravenous (Esmolol HCl) PA BvD labetalol intravenous solution (Trandate) labetalol oral (Trandate) metoprolol succinate (Toprol XL) metoprolol ta-hydrochlorothiaz (Lopressor HCT) metoprolol tartrate intravenous (Metoprolol Tartrate) 82

83 metoprolol tartrate oral (Lopressor) nadolol (Corgard) pindolol (Pindolol) propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release 24 hr (Inderal LA) propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) (Propranolol/Hydro propranolol-hydrochlorothiazid chlorothiazid) sotalol hcl oral tablet 120 mg, 160 (Betapace) mg, 240 mg, 80 mg sotalol oral (Betapace) timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents cartia xt (Cardizem CD) diltiazem hcl intravenous (Cardizem CD) diltiazem hcl oral capsule, extended (Cardizem CD) release 180 mg, 360 mg, 420 mg diltiazem hcl oral (Cardizem CD) diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 (Cardizem CD) mg, 300 mg diltiazem hcl oral (Cardizem CD) diltiazem hcl oral (Cardizem LA) dilt-xr (Cardizem CD) matzim la (Cardizem CD) taztia xt (Cardizem CD) verapamil intravenous syringe (Verapamil HCl) verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 83

84 verapamil oral capsule,ext rel. pellets 24 hr (Verelan) verapamil oral tablet (Calan) verapamil oral tablet extended release (Calan SR) Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV adrenalin injection solution 1 mg/ml (1:1,000) (1ml) (Epinephrine) DEMSER digitek oral tablet 125 mcg (Lanoxin) digitek oral tablet 250 mcg (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; QL (30 per 30 days) digoxin injection (Digoxin) PA-HRM DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 days) digoxin oral tablet (Lanoxin) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) dobutamine in d5w intravenous (Dobutamine PA BvD parenteral solution HCl/D5W) dobutamine intravenous solution (Dobutamine HCl) PA BvD dopamine in 5 % dextrose (Dopamine PA BvD intravenous solution HCl/D5W) 84

85 dopamine intravenous solution (Dopamine HCl) PA BvD ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine 1 mg/ml ampul latex-free (Epinephrine) epinephrine injection auto-injector (Adrenaclick) epinephrine injection syringe 0.1 mg/ml (1:10,000) (Epinephrine) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin (Ethanolamine Oleate) FIRAZYR hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET MCG, 62.5 MCG milrinone (Milrinone Lactate) PA BvD milrinone in 5 % dextrose PA BvD (Milrinone intravenous piggyback 40 mg/200 Lactate/D5W) ml (200 mcg/ml) (Levophed PA BvD norepinephrine bitartrate Bitartrate) papaverine injection solution (Papaverine HCl) PA papaverine oral (Papaverine HCl) PA RANEXA Dihydropyridines amlodipine (Norvasc) amlodipine-benazepril (Lotrel) AZOR ST PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) 85

86 CLEVIPREX INTRAVENOUS EMULSION EXFORGE ST EXFORGE HCT ST felodipine (Felodipine) isradipine (Isradipine) nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release 24hr 30 mg (Adalat CC) nifedipine oral tablet extended release 24hr 60 mg, 90 mg (Procardia XL) nifedipine oral tablet extended release 30 mg, 60 mg (Adalat CC) Diuretics amiloride oral (Midamor) (Amiloride/Hydroc amiloride-hydrochlorothiazide hlorothiazide) bumetanide (Bumetanide) chlorothiazide (Chlorothiazide) chlorothiazide sodium (Sodium Diuril) chlorthalidone oral tablet 25 mg, 50 (Chlorthalidone) mg DYRENIUM furosemide injection (Furosemide) furosemide oral solution (Furosemide) furosemide oral tablet (Lasix) hydrochlorothiazide oral capsule (Microzide) (Hydrochlorothiazi hydrochlorothiazide oral tablet de) indapamide (Indapamide) methyclothiazide (Methyclothiazide) metolazone (Zaroxolyn) 86

87 torsemide oral (Demadex) triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral (Maxzide) tablet Dyslipidemics amlodipine-atorvastatin (Caduet) atorvastatin (Lipitor) cholestyramine (with sugar) oral (Questran) cholestyramine-aspartame oral (Cholestyramine/A powder 4 gram spartame) cholestyramine-aspartame oral powder in packet 4 gram (Questran) colestipol (Colestid) CRESTOR endur-acin * oral tablet extended release 500 mg (Slo-Niacin) fenofibrate micronized (Antara) fenofibrate nanocrystallized (Tricor) fenofibrate oral tablet (Lofibra) fenofibric acid (Fibricor) fenofibric acid (choline) (Trilipix) gemfibrozil oral (Lopid) lipogen * (Inositol/Choline/V it B Comp) lovastatin (Mevacor) niacin * oral capsule, extended release 500 mg (Niacin) niacin * oral tablet 100 mg, 50 mg, 500 mg (Slo-Niacin) niacin oral tablet extended release 24 hr (Niaspan) 87

88 niacin * oral tablet extended release 500 mg (Slo-Niacin) omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) pravastatin (Pravachol) simvastatin (Zocor) QL (30 per 30 days) VASCEPA WELCHOL ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) spironolactone (Aldactone) spironolacton-hydrochlorothiaz (Aldactazide) Vasodilators isosorbide dinitrate oral (Isochron) isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr (Imdur) minitran transdermal patch 24 hour QL (30 per 30 days) (Nitro-Dur) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 days) (Nitro-Dur) 0.4 mg/hr minoxidil oral (Minoxidil) NITRO-BID nitroglycerin in 5 % dextrose (Nitroglycerin/D5 intravenous solution W) nitroglycerin intravenous (Nitroglycerin) 88

89 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) (Nitro-Dur) QL (30 per 30 days) QL (60 per 30 days) NITROSTAT PROGLYCEM Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) QL (60 per 30 days) AMPYRA PA; QL (60 per 30 days) caffeine citrated intravenous (Cafcit) caffeine citrated oral (Cafcit) caffeine-sodium benzoate (Caffeine/Sodium Benzoate) clonidine hcl oral tablet extended release 12 hr (Kapvay) dexmethylphenidate oral tablet (Focalin) QL (60 per 30 days) dextroamphetamine oral capsule, QL (120 per 30 days) (Dexedrine) extended release dextroamphetamine oral tablet (Dexedrine) QL (180 per 30 days) dextroamphetamine-amphetamine QL (30 per 30 days) oral capsule,extended release 24hr (Adderall XR) 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine QL (60 per 30 days) oral capsule,extended release 24hr (Adderall XR) 20 mg, 25 mg, 30 mg flumazenil (Romazicon) guanfacine oral tablet extended release 24 hr (Intuniv) INTUNIV ER QL (30 per 30 days) lithium carbonate oral capsule (Eskalith) 89

90 lithium carbonate oral tablet (Lithobid) lithium carbonate oral tablet extended release (Lithobid) lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er QL (30 per 30 days) biphasic mg, 20 mg, 50 (Metadate Cd) mg, 60 mg methylphenidate oral capsule, er QL (60 per 30 days) (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 days) (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (60 per 30 days) (Metadate Cd) biphasic mg methylphenidate oral capsule,er QL (30 per 30 days) (Ritalin LA) biphasic mg methylphenidate oral solution (Methylin) QL (900 per 30 days) methylphenidate oral tablet (Ritalin) QL (90 per 30 days) methylphenidate oral tablet QL (90 per 30 days) (Ritalin-SR) extended release methylphenidate oral tablet QL (30 per 30 days) extended release 24hr 18 mg, 27 (Concerta) mg, 54 mg methylphenidate oral tablet QL (60 per 30 days) (Concerta) extended release 24hr 36 mg NUEDEXTA QL (60 per 30 days) QUILLIVANT XR riluzole (Rilutek) SAVELLA QL (60 per 30 days) STRATTERA XENAZINE PA; QL (112 per 28 days) 90

91 Contraceptives Contraceptives ashlyna (Seasonique) QL (91 per 84 days) deblitane (Nor-Q-D) desog-e.estradiol/e.estradiol (Mircette) desogestrel-ethinyl estradiol oral tablet 0.1/.125/ mg-mcg, (Desogen) mg drospirenone-ethinyl estradiol (Yaz) ELLA ethinyl estradiol/drospirenone (Yaz) (Ethynodiol ethynodiol d-ethinyl estradiol D-Ethinyl Estradiol) gildess 24 fe (Loestrin Fe) l norgest&e estradiol-e estrad (Seasonique) QL (91 per 84 days) levonorgestrel 1.5 mg tablet (rx) (Plan B One-Step) QL (6 per 365 days) levonorgestrel oral tablet 0.75 mg (Plan B One-Step) levonorgestrel * oral tablet 1.5 mg (Plan B One-Step) QL (6 per 365 days) levonorgestrel-ethin estradiol oral (Levonorgestrel-Et tablet mg-mcg, hin Estradiol) mg, (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral QL (91 per 84 days) (Levonorgestrel-Et tablets,dose pack,3 month hin Estradiol) mg-mcg levonorgestrel-ethinyl estrad oral (Levonorgestrel-Et tablet hin Estradiol) levonorgestrel-ethinyl estrad oral (Levonorgestrel-Et QL (91 per 84 days) tablets,dose pack,3 month hin Estradiol) l-norgest-eth estr/ethin estra (Seasonique) QL (91 per 84 days) next choice one dose 1.5 mg tb (rx) QL (6 per 365 days) (Plan B One-Step) 1.5 mg 91

92 norelgestromin/ethin.estradiol (Ortho Evra) QL (3 per 28 days) noreth-ethinyl estradiol/iron (Femcon Fe) norethindrone (Nor-Q-D) norethindrone (contraceptive) (Nor-Q-D) norethindrone ac-eth estradiol (Loestrin) norethindrone ac-eth estradiol oral tablet mg-mcg (Loestrin) norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), (Loestrin Fe) 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet mg-mcg, mg-mcg, /1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 (Modicon) mcg, 0.5/1/ mg-mcg, 1-35 mg-mcg norethindrone-mestranol (Norinyl 1+50) norgestimate-ethinyl estradiol (Ortho-Cyclen) norgestrel-ethinyl estradiol (Norgestrel-Ethinyl Estradiol) NUVARING ST; QL (1 per 28 days) opcicon one-step * (Plan B One-Step) QL (6 per 365 days) PLAN B ONE-STEP * 3 $0 QL (6 per 365 days) tarina fe (Loestrin Fe) Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) adt robitussin peak cld dm max * (G-Zyncof) adult nasal decongestant * (Pseudoephedrine HCl) 92

93 adult robitussin lingering cld * (Dextromethorphan Hbr) adult robitussin peak cold dm * (G-Zyncof) (Robitussin adult wal-tussin * Mucus-Chest Congest) adult wal-tussin dm max * (G-Zyncof) alka-seltzer plus mucus-conges * (Guaifenesin/Dextr omethorphan) alka-seltzer plus sinus-cough * (D-Methorphan/Pe/ Acetaminophen) (Dm/Phenyleph/Ch ambi 10peh-4cpm-20dm * lorpheniramine) ambi 20dm-4cpm * (Coricidin Hbp) ambi 40pse-400gfn-20dm * (Guaifenesin/Dm/P seudoephedrine) (D-Methorphan ambi 60pse-4cpm-20dm * Hb/P-Ephed HCl/Cp) benzonatate * (Tessalon Perle) 3 $0 (D-Methorphan bio-dtuss dmx * Hb/P-Epd HCl/Bpm) bionel * (Guaifenesin/Dm/P seudoephedrine) bionel pediatric * (Trispec Pse) biospec dmx * (G-Zyncof) (D-Methorphan bromphenex dm * Hb/P-Epd HCl/Bpm) (D-Methorphan brompheniramine-pseudoeph-dm * Hb/P-Epd oral liquid HCl/Bpm) 93

94 (D-Methorphan brompheniramine-pseudoeph-dm * Hb/P-Epd oral syrup HCl/Bpm) (Brompheniram/Ph brompheniram-phenylephrine-dm * 3 $0 enylephrine/dm) broncotron-s * (G-Zyncof) cardec dm (phenyleph-chlorphn) * (Accuhist Pdx) cheratussin ac * (M-Clear Wc) cheratussin dac * (Tusnel C) chest congestion relief + dm * (Allfen Dm) (Guaifenesin/Pseud chest congestion relief d * oephedrne HCl) chest congestion relief pe * (Maxiphen) (D-Methorphan child cough & sore throat * Hb/Acetaminophen ) (Robitussin child mucinex chest congestion * Mucus-Chest Congest) child mucus relief cough * (G-Zyncof) child plus cough & runny nose * child triaminic cough-congest * child wal-tussin cough relief * children's chest congestion * children's dimetapp cold &flu * (Dextromethorphn/ Acetaminoph/Cp) (Guaifenesin/Dextr omethorphan) (Dextromethorphan Hbr) (Robitussin Mucus-Chest Congest) (Dm Hb/Pe/Acetaminop hen/chlorph) 94

95 children's flu relief * (Childrens Tylenol Plus Cold) children's mucinex cough * (G-Zyncof) children's silfedrine * (Pseudoephedrine HCl) children's sudafed * (Pseudoephedrine HCl) children's sudafed pe cough * (Dextromethorphan /Phenylephrine) chlophedianol-guaifenesin * (Vanacof G) chlorpheniramine-phenyleph-dm * codituss dm * cold multi-symptom * cold multi-symptom day/night * (Dm/Phenyleph/Ch lorpheniramine) (Pyrilamine/Pe/De xtromethorphan) (Comtrex Cold and Cough) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm/Pe/Acetamino cold multi-symptom nighttime * phen/doxylamine) (Dm cold relief m/s day/night * Hb/Pe/Acetaminop hen/chlorph) cold-flu relief * oral liquid (D-Methorphan/Ac ,000 mg/30 ml etamin/doxylamn) cold-flu relief, day/night * (Vicks Dayquil-Nyquil) (Guaifenesin/Pseud congestac * oephedrne HCl) (Guaifenesin/Dextr coricidin hbp * oral capsule omethorphan) cough & cold * oral (Coricidin Hbp) 95

96 cough & runny nose * oral liquid (Dimetapp 1-5 mg/5 ml Long-Acting) coughtab * (Allfen) (Guaifenesin/Dextr creo-terpin (dm-guaifenesin) * omethorphan) DALLERGY DM * daytime cold & cough * (Triaminic) daytime cold-flu * (D-Methorphan/Pe/ Acetaminophen) day-time cough * (Dextromethorphan Hbr) daytime mucus relief dm * (G-Zyncof) daytime-nighttime * (Vicks Dayquil-Nyquil) (Dm/Pe/Acetamino daytime-nighttime cold-flu * phen/doxylamine) (Dextromethorphan daytime-nighttime cough * Hb/Doxylamine) decongestant cough * (Trispec Pse) delsym cough+chest congest dm * (G-Zyncof) despec-dm (pseudoeph-dm-guaif) * (Guaifenesin/Dm/P oral tablet mg seudoephedrine) (D-Chlorphenira/Ps dexchlorphen-pse-chlophedianol * e/chlophedian) dextromethorphan polistirex * (Delsym) (Robitussin diabetic siltussin das-na * Mucus-Chest Congest) diabetic tussin dm * (G-Zyncof) (Robitussin diabetic tussin ex * oral Mucus-Chest Congest) 96

97 dimaphen dm * Name of Drug d-methorphan hb-p-epd hcl-bpm * oral syrup mg/5 ml dm-phenyleph-chlorpheniramine * oral drops mg/ml (Brompheniram/Ph enylephrine/dm) (D-Methorphan Hb/P-Epd HCl/Bpm) (Dm/Phenyleph/Ch lorpheniramine) 3 $0 dm-phenyleph-chlorpheniramine * (Dm/Phenyleph/Ch oral liquid mg/5 ml, lorpheniramine) mg/5 ml double-tussin dm * (G-Zyncof) ed bron gp * (Despec) entre-cough * (Trispec Pse) exefen dmx * (Guaifenesin/Dm/P seudoephedrine) expectorant max strength * (Dextromethorphan /Pseudoephed) (Robitussin expectorant * oral Mucus-Chest Congest) (Dm/Pe/Acetamino flu formula daytime-nighttime * ph/diphenhydram) (Dm flu severe cold-congestion * Hb/Pseudoephed/A cetamin/cp) flu-severe cold-cough * oral (D-Methorphan/Pe/ powder in packet mg Acetaminophen) guaiatussin ac * (M-Clear Wc) guaifenesin dac * (Tusnel C) guaifenesin * oral tablet 200 mg (Allfen) guaifenesin * oral tablet extended release 12hr (Mucinex) 97

98 (Dm head congestion day-night * Hb/Pe/Acetaminop hen/chlorph) (Hydrocodone hydrocodone bit-homatrop me-br * Bit/Homatrop oral syrup mg/5 ml Me-Br) 3 $0 hydrocodone-chlorpheniramine * (Tussionex) 3 $0 (Hydrocodone hydrocodone-homatropine * oral Bit/Homatrop syrup mg/5 ml Me-Br) 3 $0 hydrocodone-homatropine * oral tablet (Tussigon) 3 $0 (Dm/Pseudoephed/ infants' non-aspirin cold * Acetaminophen) intense cough reliever * oral liquid (G-Zyncof) (Child Triaminic-D kidkare cough/cold * Mt-Sym Cold) liquibid d-r * (Maxiphen) lohist peb dm * (Ala-Hist Dm) lortuss ex * oral syrup (Tusnel C) mar-cof bp * (Bromphenira/Pseu doephed/codein) 3 $0 mar-cof cg * (M-Clear Wc) 3 $0 maximum strength flu * (Coricidin Hbp) (D-Methorphan medi-brom * Hb/P-Epd HCl/Bpm) (D-Methorphan mesehist dm * Hb/P-Ephed HCl/Cp) mucinex fast-max dm max * (G-Zyncof) mucus dm * (Mucinex Dm) 98

99 mucus dm max * (Mucinex Dm) mucus relief * oral tablet 400 mg (Allfen) (Dm multi-symptom cold night time * Hb/Pe/Acetaminop hen/chlorph) (Dm multi-symptom cold-cough * Hb/Pseudoephed/A cetamin/cp) nasal & sinus decongestant * (Sudafed 12-Hour) nasohist dm * (Accuhist Pdx) neo-tuss * (G-Zyncof) NEXAFED * night time cold-flu * oral night time cold-flu relief * oral liquid night time * oral capsule nighttime cold-flu * nighttime cough * nite time cold-flu * oral nite time-d cold-flu relief * nohist-dm * non-aspirin cold * (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/P-Ephed/Acet aminoph/doxylam) (D-Methorphan/Ac etamin/doxylamn) (Dextromethorphan Hb/Doxylamine) (D-Methorphan/Ac etamin/doxylamn) (Dm/P-Ephed/Acet aminoph/doxylam) (Dm/Phenyleph/Ch lorpheniramine) (Dm Hb/Pseudoephed/A cetamin/cp) 99

100 non-aspirin flu * oral tablet (Dm/Pseudoephed/ mg Acetaminophen) pecgen dmx * (G-Zyncof) pedia relief * pedia relief infant * pediacare multi-symptom cold * phenylhistine dh * (Child Triaminic-D Mt-Sym Cold) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) poly-tussin * (Chlorcyclizine/Co deine) POLY-TUSSIN DM * promethazine-codeine * (Promethazine HCl/Codeine) 3 $0 promethazine-dm * (D-Methorphan Hb/Prometh HCl) 3 $0 (Promethazine/Phe promethazine-phenyleph-codeine * 3 $0 nyleph/codeine) (Pseudoephedrine pseudoephedrine hcl * oral HCl) pseudoephedrine hcl * oral (Sudafed 12-Hour) (D-Methorphan q-tapp dm * Hb/P-Epd HCl/Bpm) (Robitussin q-tussin * Mucus-Chest Congest) q-tussin dm * (Guaifenesin/Dextr omethorphan) refenesen * (Allfen) 100

101 refenesen pe * (Maxiphen) relcof c * (M-Clear Wc) 3 $0 REZIRA * 3 $0 (Robitussin robafen * Mucus-Chest Congest) robafen cough * (Dextromethorphan Hbr) robafen dm * (Guaifenesin/Dextr omethorphan) robitussin cough & cold cf * (Giltuss) (Guaifenesin/Dextr robitussin cough-chest-cong dm * omethorphan) robitussin dm max * (G-Zyncof) robitussin long-acting * (Dimetapp Long-Acting) robitussin pediatric * (Dextromethorphan Hbr) rydex * (Bromphenira/Pseu doephed/codein) safe tussin dm * (G-Zyncof) scot-tussin dm * (Dimetapp Long-Acting) (Robitussin scot-tussin expectorant * Mucus-Chest Congest) siltussin dm das * (G-Zyncof) (Robitussin siltussin sa * Mucus-Chest Congest) sudogest * (Sudafed 12-Hour) 101

102 suphedrin * oral suphedrine pe day-night * Name of Drug suphedrine severe cold max str * theraflu nighttime severe cold * oral tablet mg theraflu severe cold-cough * triacting m-sym cold/cough * triaminic cold & cough (pe) * triaminic cough-nasal congesti * triaminic cough-sore throat * oral liquid mg/5 ml (Pseudoephedrine HCl) (Diphenhydram/Pe/ Dm/Acetamin/Gg) (Dm/Pseudoephed/ Acetaminophen) (Dm Hb/Pe/Acetaminop hen/chlorph) (Dm Hb/Pseudoephed/A cetamin/cp) (Child Triaminic-D Mt-Sym Cold) (Dextromethorphan /Phenylephrine) (Robitussin Pediatric) (Triaminic) tri-dex pe * (Dm/Phenyleph/Ch lorpheniramine) trigofen dm * (Accuhist Pdx) trymine cg * (M-Clear Wc) tusnel diabetic * (G-Zyncof) TUSNEL PEDIATRIC * ORAL LIQUID tussin cf cough-cold * (Giltuss) tussin cf * oral (Guaifenesin/Dm/P seudoephedrine) tussin cold-congestion * (Guaifenesin/Dm/P seudoephedrine) 102

103 tussin cough (dm only) * oral (Dextromethorphan Hbr) tussin dm cough & chest * oral liquid mg/5 ml (G-Zyncof) tussin dm * oral syrup mg/5 (Guaifenesin/Dextr ml omethorphan) tussin maximum strength cough * (Dextromethorphan Hbr) tussin pe * oral liquid (Despec) (D-Methorphan valu-tapp dm * Hb/P-Epd HCl/Bpm) vicks dayquil cough * (Dextromethorphan Hbr) vicks nature fusion cough * (Dextromethorphan Hbr) virdec dm * (Accuhist Pdx) wal-phed * oral tablet 30 mg (Sudafed 12-Hour) (Diphenhydram/Pe/ wal-phed pe day-night * Dm/Acetamin/Gg) wal-tussin cough & cold cf * (Giltuss) wal-tussin cough * oral capsule (Dextromethorphan Hbr) wal-tussin cough * oral liquid (Scot-Tussin) wal-tussin dm * (Guaifenesin/Dextr omethorphan) zephrex-d * (Sudafed 12-Hour) ZONATUSS * 3 $0 zyncof * (G-Zyncof) Dental And Oral Agents Dental And Oral Agents cevimeline (Evoxac) 103

104 chlorhexidine gluconate mucous membrane (Peridex) PHOS-FLUR * DENTAL SOLUTION pilocarpine hcl oral (Salagen) PREVIDENT 5000 SENSITIVE * 3 $0 triamcinolone acetonide dental (Triamcinolone paste 0.1 % Acetonide) Dermatological Agents Dermatological Agents, Other 8-MOP acitretin (Soriatane) acne medication * topical gel 10 % (Benzoyl Peroxide) acne medication * topical lotion (Benzoyl Peroxide) acne-clear * (Benzoyl Peroxide) acyclovir topical (Zovirax) QL (30 per 30 days) ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride (Drysol) amlactin * topical lotion (Lac-Hydrin Five) ammonium lactate * 12% cream (Ammonium fragrance free (otc) Lactate) ammonium lactate * 12% lotion (otc) (Lac-Hydrin Five) ammonium lactate topical cream 12 (Lac-Hydrin) % ammonium lactate topical lotion 12 % (Lac-Hydrin) ANACAINE benzoyl peroxide * 10% gel aqueous (otc) (Benzoyl Peroxide) 104

105 benzoyl peroxide * topical gel 10 % (Benzac Ac) 3 $0 benzoyl peroxide * topical gel 5 % (Benzoyl Peroxide) benzoyl peroxide * topical (Benzoyl Peroxide) BETADINE SPRAY * calcipotriene (Calcipotriene) calcipotriene topical cream (Dovonex) calcipotriene topical solution (Calcipotriene) calcitriol topical (Vectical) CASTELLANI PAINT MODIFIED * CONDYLOX TOPICAL GEL FLUOROPLEX fluorouracil topical cream (Carac) fluorouracil topical solution (Fluorouracil) geri-hydrolac * topical (Lac-Hydrin Five) imiquimod (Aldara) PA NSO; QL (24 per 30 days) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (Isotretinoin) LACTINOL HX * lobana bath * (Mineral Oil) mafenide acetate (Mafenide Acetate) methoxsalen rapid (Oxsoralen-Ultra) PANRETIN persa-gel * (Benzoyl Peroxide) PICATO TOPICAL GEL % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox (Condylox) podophyllum resin (Podophyllum Resin) 105

106 potassium hydroxide (Potassium Hydroxide) SANTYL silver nitrate applicators (Silver Nitrate Applicator) skin treatment * (Lac-Hydrin Five) VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM QL (15 per 30 days) Dermatological Antibacterials bacitracin * topical (Bacitracin) bacitraycin plus * topical ointment 500 unit/gram (Bacitracin) clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical lotion (Cleocin T) clindamycin phosphate topical solution (Cleocin T) clindamycin phosphate topical swab (Cleocin T) erythromycin base-ethanol (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical (Erythromycin solution Base/Ethanol) erythromycin with ethanol topical (Erythromycin swab Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical cream 0.75 % (Metrocream) metronidazole topical (Nydamax) metronidazole topical (Metrolotion) 106

107 mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide topical shampoo (Selenium Sulfide) selenium sulfide topical suspension 2.5 % (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone (Aclovate) aquanil hc * (Cortizone-10) beta-hc * (Cortizone-10) betamethasone dipropionate topical (Diprosone) cream betamethasone dipropionate topical (Betamethasone lotion Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate) betamethasone valerate topical (Betamethasone cream Valerate) betamethasone valerate topical foam (Luxiq) betamethasone valerate topical (Betamethasone lotion Valerate) betamethasone valerate topical (Betamethasone ointment Valerate) betamethasone, augmented topical cream (Diprolene AF) 107

108 betamethasone, augmented topical (Betamethasone gel Dipropionate) betamethasone, augmented topical lotion (Diprolene) betamethasone, augmented topical ointment (Diprolene) clobetasol propionate topical (Clobetasol solution 0.05 % Propionate) clobetasol topical cream (Temovate) clobetasol topical foam (Olux) clobetasol topical gel (Temovate) clobetasol topical lotion (Clobex) clobetasol topical ointment (Temovate) clobetasol topical shampoo (Clobex) clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical (Temovate) clocortolone pivalate (Cloderm) CORDRAN TOPICAL OINTMENT cortizone-10 * topical cream (Hydrocortisone) CORTIZONE-10 * TOPICAL LOTION cortizone-10 * topical ointment (Hydrocortisone) dermarest eczema (hydrocort) * (Cortizone-10) desonide topical cream (Desowen) desonide topical ointment (Tridesilon) desoximetasone (Topicort) ELIDEL fluocinonide topical cream 0.05 % (Vanos) fluocinonide topical gel (Fluocinonide) PA; (PA for Ages < 2); AGE (Min 2 Years) 108

109 fluocinonide topical ointment (Fluocinonide) fluocinonide topical solution (Fluocinonide) fluocinonide-emollient base (Vanos) fluticasone topical cream (Cutivate) fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate (Ultravate) hydro skin * topical (Cortizone-10) hydrocortisone * 1% cream maximum strength (otc) (Hydrocortisone) hydrocortisone * 1% lotion (otc) (Cortizone-10) 3 $0 hydrocortisone * 1% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera topical gel (Nuzon) hydrocortisone acetate * topical (Hydrocortisone cream 1 % Acetate) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate (Locoid) hydrocortisone butyr-emollient (Locoid) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema (Cortenema) hydrocortisone * topical cream 0.5 % (Hydrocortisone) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone * topical lotion 1 % (Rederm) 3 $0 hydrocortisone topical lotion 2 % (Rederm) hydrocortisone * topical ointment 0.5 % (Hydrocortisone) 109

110 hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone) hydrocortisone valerate topical (Hydrocortisone cream Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) neosporin anti-itch * (Hydrocortisone) prednicarbate (Dermatop) preparation h hydrocortisone * (Hydrocortisone) PROTOPIC TOPICAL OINTMENT 0.03 % PROTOPIC TOPICAL OINTMENT 0.1 % recort plus * (Hydrocortisone) tacrolimus topical (Protopic) triamcinolone acetonide topical (Triamcinolone cream Acetonide) triamcinolone acetonide topical lotion (Kenalog) triamcinolone acetonide topical ointment %, 0.05 %, 0.1 %, (Triderm) 0.5 % triderm topical cream (Triamcinolone Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Tretinoin Microspheres) PA; (0.03%; PA for Ages < 2); AGE (Min 2 Years) PA; (0.1%; PA for Ages < 15); AGE (Min 15 Years) PA 110

111 tretinoin topical (Retin-A) PA Scabicides And Pediculicides lice cream rinse * (Nix) (Piperonyl lice killing * Butoxide/Pyrethrin s) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN PEN NEEDLE NEEDLE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U-100 SYRINGE SURE COMFORT INS. SYR. U-100 Disinfectants (For Non-Dermatologic Use) Disinfectants (For Non-Dermatologic Use) iodine * (Iodine) 111

112 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA PA CIMZIA POWDER FOR PA RECONST CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS QL (30 per 30 days) lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME PA BvD VIMIZIM PA VPRIV ZAVESCA QL (90 per 30 days) ZENPEP 112

113 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) alaway * (Zaditor) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette % F) artificial tears * ophthalmic drops % (Tears Naturale) artificial tears * ophthalmic drops (Polyvinyl % Alcohol/Povidone) artificial tears * ophthalmic (Petrolat,Wht/Min ointment Oil/Sod Chl) (Glycerin/Propylen artificial tears(glycerin-peg) * e Glycol) (Genteal Mild To artificial tears(hypromellose) * Moderate) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal (Astelin) QL (30 per 25 days) azelastine ophthalmic (Optivar) (Dextran bion tears (pf) * 70/Hypromellose/P F) carteolol (Carteolol HCl) 113

114 cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate (Cyclogyl) CYSTARAN deep sea nasal * (Little Remedies) dristan long lasting * (Oxymetazoline HCl) epinastine (Elestat) eq gentle * (Genteal Mild To Moderate) GENTEAL MILD TO MODERATE * GENTEAL GEL * GENTEAL MILD * GENTEAL SEVERE * homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,non-aerosol 0.03 % (Atrovent) ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) isopto tears * (Genteal Mild To Moderate) ketotifen fumarate * (Zaditor) LACRISERT liquitears * (Polyvinyl Alcohol) lubricant dry eye relief * (Carboxymethylcel lulose Sodium) QL (30 per 28 days) QL (15 per 10 days) 114

115 lubricant eye (polyv alcohol) * (Polyvinyl Alcohol) lubricant eye (propyl glycol) * (Systane Balance) lubricant eye drops * ophthalmic (Carboxymethylcel dropperette lulose Sodium) lubricant eye drops * ophthalmic drops (Refresh Tears) lubricating drops * (Refresh Optive) lubrifresh pm * (Genteal Pm) muro 128 * (Sodium Chloride) naphazoline (Naphazoline HCl) nasal decongestant (oxymetazl) * (Afrin) natural balance * (Genteal Mild To Moderate) (Dextran natural tears (pf) * 70/Hypromellose/P F) nature's tears * (Genteal Mild To Moderate) neo-synephrine 12 h spr (oxym) * (Oxymetazoline HCl) nighttime relief eye * (Petrolat,Wht/Min Oil/Sod Chl) ocean nasal * (Little Remedies) olopatadine (Patanase) QL (30.5 per 30 days) PATADAY ST PATANOL ST phenylephrine hcl ophthalmic (Mydfrin) proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) 115

116 (Proparacaine/Fluo proparacaine-fluorescein sod rescein Sod) (Genteal Mild To pure & gentle eye * Moderate) REFRESH CLASSIC (PF) * REFRESH LACRI-LUBE * REFRESH LIQUIGEL * REFRESH OPTIVE * retaine cmc * (Carboxymethylcel lulose Sodium) saline mist * (Little Remedies) sea soft nasal mist * (Little Remedies) sochlor * ophthalmic (Sodium Chloride) sodium chloride * ophthalmic (Sodium Chloride) STERILE LUBRICANT * tears again * ophthalmic drops (Polyvinyl Alcohol) tears again * ophthalmic ointment (Lanolin/Min Oil/Petrolat, Wht) TEARS NATURALE II * tetracaine hcl (Tetcaine) ultra fresh pm * (Lanolin/Min Oil/Petrolat, Wht) vicks qlearquil(oxymetazoline) * (Oxymetazoline HCl) vicks sinex 12-hour * (Afrin) wal-zyr (ketotifen) * (Zaditor) zyrtec itchy eye drops (keto) * (Zaditor) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Vosol) bacitracin ophthalmic (Bacitracin) 116

117 (Bacitracin/Polymy bacitracin-polymyxin b ophthalmic xin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan) ciprofloxacin hcl otic (Cetraxal) COLY-MYCIN S erythromycin ophthalmic (Ilotycin) gatifloxacin (Zymaxid) gentamicin ophthalmic (Garamycin) gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) (Garamycin) levofloxacin ophthalmic (Quixin) MOXEZA NATACYN (Neomy neomy sulf-bacitrac zn-poly-hc Sulf/Bacitrac Zn/Poly/HC) (Neomy neomycin-bacitracin-poly-hc Sulf/Bacitrac Zn/Poly/HC) (Neomy neomycin-bacitracin-polymyxin Sulf/Bacitra/Polym yxin B) neomycin-polymyxin b-dexameth (Maxitrol) neomycin-polymyxin-gramicidin (Neosporin) neomycin-polymyxin-hc (Oticin HC) ofloxacin ophthalmic (Ocuflox) ofloxacin otic (Ocuflox) polymyxin b sulf-trimethoprim (Polytrim) REFRESH OPTIVE ADVANCED * 117

118 sulfacetamide sodium Name of Drug sulfacetamide sodium ophthalmic drops 10 % (Sulfacetamide Sodium) (Sulfacetamide Sodium) (Sulfacetamide/Pre sulfacetamide-prednisolone dnisolone Sp) TOBRADEX ST tobramycin (Tobrex) trifluridine (Viroptic) VIGAMOX ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate ophthalmic (Dexasol) diclofenac sodium ophthalmic (Diclofenac Sodium) DUREZOL fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) QL (16 per 30 days) ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX QL (34 per 28 days) NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate ophthalmic (Prednisol) PROLENSA 118

119 RESTASIS QL (60 per 30 days) Gastrointestinal Agents Antiflatulents anti-gas maximum strength * (Gas-X) bicarsim forte * (Simethicone) gas free extra strength * (Gas-X) gas relief 80 * (Gas-X) gas relief extra strength * oral (Gas-X) gas relief * oral (Gas-X) gas-x ultra-strength * (Gas-X) mi-acid gas relief * (Gas-X) mylanta gas * (Gas-X) mytab gas * (Gas-X) mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Gas-X) simethicone * oral (Infants' Mylicon) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) acid reducer (ranitidine) * oral tablet 150 mg (Zantac) acid relief (cimetidine) * (Tagamet Hb) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine hcl oral (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg (Tagamet) cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso-Osm/PF) (Rx Product Only) 119

120 famotidine oral tablet 20 mg, 40 mg (Pepcid) (Rx Product Only) lansoprazole * dr 15 mg capsule 2x14 day course (otc) (Prevacid 24hr) lansoprazole oral capsule,delayed (Rx Product Only) (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol (Cytotec) omeprazole magnesium * (Omeprazole Magnesium) omeprazole oral capsule,delayed release(dr/ec) (Prilosec) omeprazole * oral tablet,delayed release (dr/ec) (Omeprazole) omeprazole-sodium bicarbonate (Rx Product Only) (Zegerid) 3 $0 oral capsule mg-gram pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral (Protonix) PRILOSEC OTC * pub famotidine * 20 mg tablet max strength (otc) (Pepcid Ac) ra omepraz-bicarb 20-1,100 cap 3x14 day course (otc) (Zegerid Otc) ranitidine hcl injection solution 25 (Rx Product Only) (Zantac) mg/ml ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, (Rx Product Only) (Zantac) 300 mg ranitidine hcl * oral tablet 75 mg (Zantac) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) wal-zan 75 * (Zantac) zantac 75 * (Zantac) 120

121 Gastrointestinal Agents, Other acid gone antacid * (Gaviscon) almacone * oral suspension (Mylanta) almacone-2 * (Mylanta) aluminum hydroxide gel * oral suspension 320 mg/5 ml (Alternagel) AMITIZA QL (60 per 30 days) (Calcium antacid anti-gas * oral Carbonate/Simethi cone) antacid * oral tablet,chewable 200 mg calcium (500 mg) (Tums) antacid plus anti-gas * oral suspension (Mylanta) anti-diarrheal * (Pepto-Bismol) anti-diarrheal (loperamide) * oral capsule (Loperamide HCl) anti-diarrheal (loperamide) * oral (Imodium A-D) bismatrol * oral suspension 262 mg/15 ml (Pepto-Bismol) bismatrol * oral tablet,chewable (Pepto-Bismol) BUPHENYL ORAL TABLET calci-chew * (Tums) calcium antacid * oral tablet,chewable (Tums) calcium carbonate * oral tablet,chewable 500 mg calcium (Tums) (1,250 mg) CALCIUM CARBONATE-VITAMIN D3 * ORAL TABLET,CHEWABLE MG-UNIT 121

122 cal-gest antacid * (Tums) children's pepto * (Tums) children's soothe * (Tums) comfort gel extra strength * (Mylanta) cromolyn oral (Gastrocrom) diamode * (Imodium A-D) dicyclomine oral capsule (Bentyl) dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet (Bentyl) diphenoxylate-atropine oral liquid (Diphenoxylate HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) flanax antacid * (Mylanta) foaming antacid * (Gaviscon) gelusil antacid & anti-gas * oral suspension (Mylanta) gelusil antacid & anti-gas * oral tablet,chewable (Almacone) glycopyrrolate (Robinul) glycopyrrolate (Robinul) imodium a-d * oral liquid (Loperamide HCl) IMODIUM A-D * ORAL TABLET kaopectate (bismuth subsalicy) * (Pepto-Bismol) lactulose (Lactulose) loperamide oral (Loperamide HCl) loperamide * oral (Loperamide HCl) maalox advanced * oral suspension (Mylanta) MAGNEBIND 300 * magnesium oxide * oral capsule 500 mg (Uromag) 122

123 magnesium oxide * oral tablet 250 mg, 400 mg, 500 mg (Magox 400) masanti double strength * (Mylanta) methscopolamine oral (Pamine) metoclopramide hcl injection (Reglan) metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral (Reglan) mi-acid * oral suspension (Mylanta) (Calcium mi-acid * oral tablet,chewable Carb/Magnesium Hydrox) mintox * (Mylanta) mintox maximum strength * (Mylanta) mintox plus * (Almacone) NUTRESTORE pep-t-med * (Pepto-Bismol) phillips * (Magox 400) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) ri-gel * (Mylanta) ri-gel ii * (Mylanta) ri-mox * (Mylanta) sodium bicarbonate * oral tablet (Sodium 650 mg Bicarbonate) soothe (bismuth subsalicylate) * (Bismuth oral Subsalicylate) soothe regular strength * (Pepto-Bismol) stomach relief * oral (Bismuth Subsalicylate) ultra strength antacid * (Tums) ursodiol oral capsule (Actigall) 123

124 ursodiol oral tablet (Urso) Laxatives alophen * (Dulcolax) bisac-evac * (Dulcolax) bisacodyl * oral (Dulcolax) bisacodyl * rectal (Dulcolax) biscolax * (Dulcolax) clearlax * oral (Miralax) colace * oral capsule 100 mg (Sof-Lax) doc-q-lace * oral (Sof-Lax) docu * (Docusate Sodium) docusate calcium * (Surfak) docusate sodium * oral (Docusate Sodium) docusol * (Docusate Sodium) dok * oral capsule (Sof-Lax) dok * oral tablet (Docusate Sodium) dulcolax stool softener (dss) * (Sof-Lax) enema disposable * (Enema) enema * rectal enema * 19-7 gram/118 ml (Enema) enemeez * rectal enema 283 mg/5 ml (Docusate Sodium) enemeez * rectal enema mg/5 ml (Docusol Plus) equalactin * (Calcium Polycarbophil) fiber (calcium polycarbophil) * (Fibercon) fiber laxative * oral tablet (Citrucel) fiber smooth * (Psyllium Seed) fiber therapy (psyllium/sugar) * (Psyllium Seed (With Sugar)) 124

125 fiber therapy * oral powder 2 gram/19 gram (Citrucel) fiber-lax * (Fibercon) FLEET BISACODYL * gentlelax * (Miralax) glycolax * oral powder (Miralax) 3 $0 healthylax * (Miralax) hydrocil instant * (Psyllium Seed) konsyl (sugar) * oral (Metamucil) konsyl fiber * (Fibercon) konsyl sugar-free * oral powder in packet (Psyllium Husk) laxative peg 3350 * (Miralax) milk of magnesia * (Milk Of Magnesia) mineral oil laxative * (Mineral Oil) MOVIPREP natural fiber laxative therapy * (Psyllium Seed (With Sugar)) oral saline laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg3350 * (Miralax) peg-electrolyte soln (Nulytely with Flavor Packs) peri-colace * (Sennosides/Docus ate Sodium) phillips liqui-gels * (Sof-Lax) phosphate laxative * oral (Na Phos,M-B/Na Phos,Di-Ba) 125

126 polyethylene glycol 3350 oral (Polyethylene powder Glycol 3350) polyethylene glycol 3350 * oral powder in packet (Miralax) promolaxin * (Docusate Sodium) purelax * (Miralax) reguloid * oral powder (Psyllium Seed (With Sugar)) senexon * oral syrup (Sennosides) senexon * oral tablet (Senokot) senna lax * (Senokot) senna * oral capsule (Sennosides) senna * oral syrup 8.8 mg/5 ml (Sennosides) senna * oral tablet (Senokot) senna with docusate sodium * (Sennosides/Docus ate Sodium) senokot-s * (Sennosides/Docus ate Sodium) silace * oral liquid (Docusate Sodium) silace * oral syrup (Colace) smoothlax * oral (Miralax) sodium chloride-nahco3-kcl-peg (Nulytely with oral recon soln 420 gram Flavor Packs) the magic bullet * (Dulcolax) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet (Calcium Acetate) (Calcium calcium carbonate-mag carb-fa Carbonate/Mag Carb/Fa) calphron * (Calcium Acetate) PHOSLYRA 126

127 RENAGEL RENVELA (Sodium sodium polystyrene sulfonate oral Polystyrene powder Sulfonate) (Sodium sodium polystyrene sulfonate oral Polystyrene suspension 15 gram/60 ml Sulfonate) (Sodium sodium polystyrene sulfonate rectal Polystyrene enema 30 gram/120 ml Sulfonate) Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr (Ditropan XL) tolterodine oral capsule,extended release 24hr (Detrol LA) tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended release 24hr (Sanctura XR) trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl) Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) PA BvD DEPEN TITRATABS 127

128 EXJADE FERRIPROX sodium thiosulfate intravenous (Sodium solution 1 gram/10 ml (100 mg/ml), Thiosulfate) 12.5 gram/50 ml (250 mg/ml) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM PA; QL (30 per 30 days) ANDROGEL TRANSDERMAL PA; QL (300 per 30 days) GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL PA; QL (150 per 30 days) GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) PA; QL (300 per 30 days) ANDROGEL TRANSDERMAL PA; QL (150 per 30 days) GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral (Danazol) fluoxymesterone (Fluoxymesterone) oxandrolone (Oxandrin) (Depo-Testosteron PA testosterone cypionate e) testosterone enanthate (Delatestryl) PA; QL (5 per 28 days) testosterone transdermal gel in PA; QL (150 per 30 days) (Androgel) packet 1 % (25 mg/2.5gram) 128

129 Estrogens And Antiestrogens COMBIPATCH PA-HRM; QL (8 per 28 days) DUAVEE PA-HRM ESTRACE VAGINAL estradiol oral (Estrace) PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) estradiol transdermal patch weekly (Climara) estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) PA-HRM estradiol-norethindrone acet (Activella) PA-HRM ESTRASORB PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days) PA-HRM; QL (97.44 per 28 days) estropipate (Ogen) PA-HRM FEMRING QL (1 per 84 days) MENEST PA-HRM norethindrone ac-eth estradiol oral PA-HRM (Femhrt) tablet 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PA-HRM PREMARIN VAGINAL PREMPHASE PA-HRM PREMPRO PA-HRM raloxifene (Evista) VAGIFEM QL (18 per 28 days) VIVELLE-DOT PA-HRM; QL (8 per 28 days) Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) PA BvD cortisone (Cortisone Acetate) PA BvD 129

130 dexamethasone oral (Dexamethasone) PA BvD dexamethasone oral (Dexamethasone) PA BvD dexamethasone sodium phosphate (Dexamethasone PA BvD injection Sod Phosphate) fludrocortisone (Fludrocortisone Acetate) hydrocortisone oral (Cortef) PA BvD hydrocortisone sod succinate (Hydrocortisone PA BvD Sod Succinate) methylprednisolone (Medrol) PA BvD methylprednisolone acetate (Depo-Medrol) PA BvD methylprednisolone sodium succ PA BvD (A-Methapred) injection recon soln 125 mg, 40 mg methylprednisolone sodium succ PA BvD (A-Methapred) intravenous prednisolone sodium phosphate PA BvD (Orapred) oral solution prednisone (Prednisone) PA BvD SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 100 MG/2 ML triamcinolone acetonide injection (Triamcinolone Acetonide) Pituitary desmopressin injection (DDAVP) desmopressin nasal (Desmopressin QL (15 per 30 days) Acetate) desmopressin nasal (Desmopressin QL (15 per 30 days) Acetate) desmopressin oral (DDAVP) GENOTROPIN PA GENOTROPIN MINIQUICK PA HUMATROPE PA 130

131 INCRELEX NORDITROPIN FLEXPRO PA SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NORDITROPIN NORDIFLEX PA NUTROPIN AQ NUSPIN PA NUTROPIN AQ PA SUBCUTANEOUS NUTROPIN SUBCUTANEOUS PA RECON SOLN 10 MG octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 (Sandostatin) mcg/ml, 500 mcg/ml octreotide acetate injection solution (Octreotide 50 mcg/ml Acetate) octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE PA PREGNYL SAIZEN PA SAIZEN CLICK.EASY PA SANDOSTATIN LAR DEPOT SEROSTIM SUBCUTANEOUS PA RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT QL (1 per 28 days) SOMAVERT SUPPRELIN LA QL (1 per 360 days) TEV-TROPIN PA vasopressin (Pitressin) 131

132 Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular suspension (Depo-Provera) medroxyprogesterone (Medroxyprogester intramuscular syringe one Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized (Prometrium) Thyroid And Antithyroid Agents levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 (Tapazole) mg QL (10 per 28 days) QL (1 per 84 days) QL (1 per 84 days) propylthiouracil (Propylthiouracil) Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL PA BvD AUBAGIO PA; QL (28 per 28 days) azathioprine (Imuran) PA BvD azathioprine sodium (Azathioprine PA BvD Sodium) CARIMUNE NF PA BvD NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS PA BvD 132

133 CELLCEPT ORAL SUSPENSION PA BvD FOR RECONSTITUTION cyclosporine intravenous (Sandimmune) PA BvD cyclosporine modified (Neoral) PA BvD cyclosporine oral capsule (Sandimmune) PA BvD cyclosporine, modified (Neoral) PA BvD ENBREL PA ENBREL SURECLICK PA FLEBOGAMMA DIF PA BvD GAMASTAN S/D PA BvD GAMMAGARD LIQUID PA BvD GAMMAPLEX PA BvD GAMUNEX-C INJECTION PA BvD SOLUTION HUMIRA PA HUMIRA CROHN'S DIS START PA PCK HUMIRA PEN PA HYPERRAB S/D (PF) HYQVIA PA BvD ILARIS (PF) PA IMOGAM RABIES-HT (PF) KINERET PA; QL (18.76 per 28 days) leflunomide (Arava) mycophenolate mofetil (Cellcept) PA BvD mycophenolate sodium (Myfortic) PA BvD NULOJIX PA BvD OCTAGAM PA BvD ORENCIA PA; QL (4 per 28 days) ORENCIA (WITH MALTOSE) PA 133

134 PRIVIGEN PA BvD PROGRAF INTRAVENOUS PA BvD RAPAMUNE ORAL SOLUTION PA BvD RAPAMUNE ORAL TABLET 1 PA BvD MG, 2 MG RIDAURA sirolimus (Rapamune) PA BvD tacrolimus oral (Hecoria) PA BvD TYSABRI PA; QL (15 per 28 days) ZORTRESS PA BvD; QL (120 per 30 days) Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) PA BvD BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) PA BvD ENGERIX-B PEDIATRIC (PF) PA BvD GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) PA BvD 134

135 INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PROQUAD (PF) RABAVERT (PF) PA BvD RECOMBIVAX HB (PF) PA BvD ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED PA BvD (PF) TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML 135

136 TETANUS-DIPHTHERIA TOXOIDS-TD Name of Drug TICE BCG PA BvD TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) QL (1 per 365 days) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM ST Irrigating Solutions Irrigating Solutions acetic acid irrigation (Acetic Acid) GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation (Tis-U-Sol) sodium chloride irrigation (Sodium Chloride Irrig Solution) sorbitol irrigation (Sorbitol Solution) sorbitol-mannitol (Mannitol/Sorbitol Solution) 136

137 water for irrigation, sterile Name of Drug Metabolic Bone Disease Agents (Water For Irrigation,Sterile) Metabolic Bone Disease Agents alendronate oral solution (Alendronate QL (300 per 28 days) Sodium) alendronate oral tablet 10 mg, 40 mg, 5 mg (Fosamax) alendronate oral tablet 35 mg, 70 QL (4 per 28 days) (Fosamax) mg calcitonin (salmon) (Miacalcin) QL (3.7 per 28 days) calcitriol intravenous solution 1 PA BvD; (PA for ESRD (Calcitriol) mcg/ml Only) calcitriol oral (Rocaltrol) PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral (Hectorol) PA BvD; (PA for ESRD Only) etidronate disodium (Etidronate Disodium) FORTEO PA; QL (2.4 per 28 days) FORTICAL QL (3.7 per 28 days) ibandronate intravenous solution PA BvD; (PA for ESRD (Ibandronate Only); QL (3 per 84 Sodium) days) ibandronate oral (Boniva) QL (1 per 28 days) MIACALCIN INJECTION PA BvD; (PA for ESRD Only) paricalcitol oral (Zemplar) PA BvD; (PA for ESRD Only) PROLIA QL (1 per 180 days) 137

138 risedronate (Actonel) QL (1 per 28 days) XGEVA PA; QL (1.7 per 28 days) ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous (Zometa) (Zoledronic zoledronic acid-mannitol-water Acid/Mannitol and intravenous piggyback Water) zoledronic acid-mannitol-water QL (100 per 300 days) (Reclast) intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS PA; QL (40 per 30 days) SOLUTION ACTEMRA SUBCUTANEOUS PA; QL (3.6 per 28 days) ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Ethyol) anticoag citrate phos dextrose (Citrate Phosphate Dextros Soln) AVODART AVONEX (WITH ALBUMIN) ST AVONEX INTRAMUSCULAR ST AVONEX INTRAMUSCULAR ST BENLYSTA INTRAVENOUS PA RECON SOLN BETASERON SUBCUTANEOUS ST bethanechol chloride (Urecholine) BOTOX INJECTION RECON PA; QL (4 per 90 days) SOLN 100 UNIT 138

139 BOTOX INJECTION RECON PA; QL (1 per 90 days) SOLN 200 UNIT buspirone (Vanspar) CERDELGA PA colchicine oral tablet (Colcrys) (Colchicine/Proben colchicine-probenecid ecid) COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE douche vinegar & water extra * (Acetic Acid) droperidol injection solution (Droperidol) ELMIRON ergoloid (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS ST extra cleansing douche * (Acetic Acid) feminine care douche * (Acetic Acid) finasteride oral tablet 5 mg (Proscar) fomepizole (Fomepizole) FUSILEV GILENYA PA; QL (28 per 28 days) GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine (Guanidine HCl) hydroxyzine hcl intramuscular (Hydroxyzine HCl) PA-HRM hydroxyzine hcl oral syrup 10 mg/5 PA-HRM (Hydroxyzine HCl) ml 139

140 hydroxyzine hcl oral tablet (Hydroxyzine HCl) PA-HRM hydroxyzine pamoate (Vistaril) PA-HRM JALYN QL (30 per 30 days) LEMTRADA PA; QL (9.6 per 365 days) leucovorin calcium injection recon (Leucovorin soln 100 mg, 200 mg, 350 mg Calcium) leucovorin calcium oral (Leucovorin Calcium) levocarnitine (with sugar) (Levocarnitine (With Sugar)) levocarnitine oral (Carnitor) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) mesna (Mesnex) MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN mineral oil * (Mineral Oil) mineral oil light * (Mineral Oil) morrhuate sodium (Sodium Morrhuate) OTEZLA PA; QL (60 per 30 days) OTEZLA STARTER ORAL PA; QL (60 per 30 days) TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19) PLEGRIDY SUBCUTANEOUS ST PEN INJECTOR PLEGRIDY SUBCUTANEOUS ST SYRINGE 125 MCG/0.5 ML probenecid (Probenecid) PROCYSBI pyridostigmine bromide (Mestinon) 140

141 REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE PA SENSIPAR SIMPONI ARIA PA; QL (12 per 28 days) SIMPONI SUBCUTANEOUS PEN PA; QL (3 per 28 days) INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN PA; QL (0.5 per 28 days) INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS PA; QL (3 per 28 days) SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS PA; QL (0.5 per 28 days) SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS PA SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " summer's eve disposable douche * (Acetic Acid) vaginal solution summers eve extra cleansing * (Acetic Acid) SUSPENDOL-S * SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG PA; QL (14 per 30 days) PA; QL (60 per 30 days) 141

142 THALOMID PA NSO; QL (60 per 30 days) TYBOST QL (30 per 30 days) ULORIC ST; QL (30 per 30 days) XELJANZ PA; QL (60 per 30 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release (Diamox Sequels) acetazolamide oral tablet (Acetazolamide) acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic (Betaxolol HCl) brimonidine (Alphagan P) (drops: 0.15%, 0.20%) COMBIGAN dorzolamide (Trusopt) dorzolamide-timolol (Cosopt) latanoprost (Xalatan) levobunolol (Betagan) LUMIGAN OPHTHALMIC QL (2.5 per 25 days) DROPS 0.01 % methazolamide oral (Neptazane) metipranolol (Metipranolol) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % (Isopto Carpine) SIMBRINZA timolol maleate ophthalmic drops (Timolol Maleate) 142

143 timolol maleate ophthalmic gel (Timoptic-Xe) forming solution TRAVATAN Z QL (2.5 per 25 days) (Travoprost QL (2.5 per 25 days) travoprost (benzalkonium) (Benzalkonium)) Replacement Preparations Replacement Preparations (Ca/D3/Mag ca-d3-mag ox-zinc-cop-mang-bor * Ox/Zinc/Cop/Mang oral tablet,chewable /Bor) calcionate * (Calcium Glubionate) calcitrate * (Calcium Citrate) calcitrate-vitamin d * (Citracal-Vitamin D) calcium d (d3) * (Os-Cal 500+D3) calcium d * oral tablet 500 mg(1,250mg) -400 unit (Os-Cal 500+D3) calcium 500 with d * (Os-Cal 500+D3) calcium 600 * (Caltrate 600) (Calcium calcium d(3) * oral capsule Carbonate/Vitamin D3) calcium d(3) * oral tablet (Os-Cal 500+D3) (Calcium calcium 600 with vitamin d3 * oral Carbonate/Vitamin D3) calcium carbonate * oral (Calcium Carbonate) calcium carbonate * oral tablet 260 (Caltrate 600) mg calcium (648 mg) 143

144 (Calcium calcium carbonate-vitamin d2 * Carbonate/Vitamin D2) calcium carbonate-vitamin d3 * (Calcium oral capsule 600 mg(1,500mg) -100 Carbonate/Vitamin unit, 600 mg(1,500mg) -400 unit, D3) 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * oral tablet (Os-Cal 500+D3) calcium carbonate-vitamin d3 * oral tablet,chewable 500 (Os-Cal 500+D) mg(1,250mg) -400 unit calcium chloride intravenous (Calcium Chloride) calcium citrate-vitamin d3 * oral (Citracal-Vitamin tablet mg-unit D) calcium gluconate intravenous (Calcium Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg) Gluconate) calcium lactate * oral tablet 84 mg (648 mg), 85 mg (650 mg) (Calcium Lactate) calcium+d * oral tablet (Os-Cal 500+D3) caltrate d * (Os-Cal 500+D) CALTRATE D VIT D3 (800) * citracal + d maximum * (Citracal-Vitamin D) (Citric citric acid-sodium citrate Acid/Sodium Citrate) citrus calcium * oral tablet (Citracal-Vitamin D) coral calcium * oral tablet (Caltrate 600) PA BvD; (PA for ESRD Only) 144

145 electrolyte-48 in d5w (Electrolyte-48 Solution/D5W) enfalyte * (Pedialyte) hi-cal plus vit d * (Os-Cal 500+D3) HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KELP (IODINE) * KLOR-CON KLOR-CON 10 KLOR-CON 8 klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) KLOR-CON/EF (Calcium liquid calcium with vitamin d * Carbonate/Vitamin D3) mag 64 * (Magnesium Chloride) mag-delay * (Magnesium Chloride) mag-g * (Magonate) (Magnesium magnesium (oxide/aa chelate) * Oxide/Mag Aa Chelate) 145

146 magnesium chloride injection (Magnesium Chloride) magnesium gluconate * oral tablet (Magonate) magnesium * oral tablet 250 mg (Magnesium) magnesium sulfate in d5w (Magnesium intravenous piggyback 1 gram/100 Sulfate/D5W) ml magnesium sulfate in water (Magnesium intravenous parenteral solution 20 Sulfate in Water) gram/500 ml (4 %) magnesium sulfate in water (Magnesium intravenous piggyback 4 gram/50 Sulfate in Water) ml (8 %) magnesium sulfate injection (Magnesium Sulfate) natural calcium * (Caltrate 600) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * (Pedialyte) oysco 500/d * oral tablet (Os-Cal 500+D3) oysco d * (Os-Cal 500+D3) oysco-500 * (Caltrate 600) oyster shell calcium 500 * (Caltrate 600) oyster shell calcium-vit d3 * (Os-Cal 500+D3) oystercal-d * (Os-Cal 500+D3) pediatric electrolyte * oral solution (Pedialyte) pediatric freezer pops * (Pedialyte) PHOS-NAK * 146

147 phosphorus #1 (K-Phos Neutral) PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot Bicarb/Cit Ac) potassium bicarb-citric acid (Klor-Con-Ef) potassium bicarbonate-cit ac oral tablet, effervescent 25 meq (Klor-Con-Ef) (Potassium potassium chlorid-d5-0.45%nacl Chloride/D5-0.45n acl) potassium chloride in 0.9%nacl (Potassium intravenous parenteral solution 20 Chloride In meq/l, 40 meq/l 0.9%NaCl) potassium chloride in 5 % dex (Potassium intravenous parenteral solution 20 Chloride In D5w) meq/l, 30 meq/l, 40 meq/l potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended release (Micro-K) potassium chloride oral liquid (Kaochlor) potassium chloride oral packet (Klor-Con) potassium chloride oral tablet extended release (Klor-Con 10) potassium chloride oral tablet,er particles/crystals 10 meq (Klor-Con 10) 147

148 potassium chloride oral tablet,er (Potassium particles/crystals 20 meq Chloride) (Potassium potassium chloride-0.45 % nacl Chloride-0.45% NaCl) (Potassium potassium chloride-d5-0.2%nacl Chloride/D5-0.2% NaCl) potassium chloride-d5-0.3%nacl (Potassium intravenous parenteral solution 20 Chloride/D5-0.3% meq/l NaCl) (Potassium potassium chloride-d5-0.9%nacl Chloride/D5-0.9% NaCl) potassium citrate-citric acid oral (Potassium packet Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium solution 1, mg/5 ml Citrate/Citric Acid) (Potassium potassium phosphate dibasic Phos,M-Basic-D-B asic) ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium solution Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) 148

149 sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) (Citric sodium citrate-citric acid Acid/Sodium Citrate) sodium lactate intravenous (Sodium Lactate) (Sodium sodium phosphate Phos,M-Basic-D-B asic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS QL (60 per 30 days) ADVAIR HFA QL (12 per 28 days) BREO ELLIPTA QL (60 per 30 days) DULERA QL (13 per 28 days) FLOVENT DISKUS QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS QL (120 per 30 days) INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION QL (12 per 28 days) 149

150 FLOVENT HFA INHALATION QL (24 per 28 days) HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION QL (21.2 per 28 days) HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (17.4 per 25 days) Antileukotrienes montelukast (Singulair) zafirlukast (Accolate) Bronchodilators albuterol sulfate inhalation solution PA BvD (Albuterol Sulfate) for nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr (Vospire ER) ANORO ELLIPTA QL (60 per 30 days) ATROVENT HFA QL (25.8 per 28 days) COMBIVENT RESPIMAT QL (8 per 30 days) metaproterenol oral (Metaproterenol Sulfate) PROAIR HFA QL (17 per 25 days) SEREVENT DISKUS QL (60 per 30 days) SPIRIVA RESPIMAT QL (4 per 30 days) SPIRIVA WITH HANDIHALER QL (30 per 30 days) terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) 150

151 theophylline anhydrous oral tablet (Theophylline extended release 12 hr 100 mg, 200 Anhydrous) mg, 300 mg theophylline in dextrose 5 % (Theophylline/D5 intravenous parenteral solution W) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) theophylline oral (Theophylline Anhydrous) TUDORZA PRESSAIR QL (1 per 28 days) Respiratory Tract Agents, Other acetylcysteine (Acetadote) PA BvD acetylcysteine solution (Acetadote) PA BvD ARALAST NP cromolyn inhalation (Cromolyn PA BvD Sodium) cromolyn * nasal (Nasalcrom) DALIRESP QL (30 per 30 days) ESBRIET PA; QL (270 per 30 days) KALYDECO PA; QL (60 per 30 days) OFEV PA; QL (60 per 30 days) sodium chloride * inhalation solution for nebulization 0.9 % (Pulmosal) 3 $0 XOLAIR PA; QL (6 per 28 days) ZEMAIRA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) carisoprodol (Soma) PA-HRM; QL (120 per 30 days) 151

152 chlorzoxazone (Parafon Forte DSC) COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) PA-HRM PA-HRM PA-HRM dantrolene (Dantrium) dantrolene sodium (Dantrium) metaxalone oral tablet 800 mg (Skelaxin) PA-HRM methocarbamol oral (Robaxin) PA-HRM tizanidine (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents NUVIGIL PA ROZEREM XYREM zaleplon (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) 152

153 zolpidem oral tablet (Ambien) zolpidem oral tablet,ext release multiphase Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents phentolamine injection (Ambien CR) (Phentolamine Mesylate) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) Vasodilating Agents Vasodilating Agents ADCIRCA PA; QL (60 per 30 days) ADEMPAS PA; QL (90 per 30 days) epoprostenol (glycine) (Flolan) PA BvD LETAIRIS PA; QL (30 per 30 days) OPSUMIT PA; QL (30 per 30 days) ORENITRAM PA REMODULIN PA BvD REVATIO INTRAVENOUS PA; QL (37.5 per 1 day) PA 153

154 sildenafil (Revatio) PA; QL (90 per 30 days) TRACLEER PA; QL (60 per 30 days) TYVASO PA BvD TYVASO REFILL KIT PA BvD TYVASO STARTER KIT PA BvD VENTAVIS PA BvD Vitamins And Minerals Vitamins And Minerals (Multivitamin/Iron/ a thru z advanced formula * Folic Acid) (Multivitamin a thru z high potency * oral tablet W-Minerals/Lutein ) a thru z select 50+ formula * (Biocel) (Multivitamin a thru z select * oral tablet W-Minerals/Lutein ) a thru z select * oral tablet mcg, (Biocel) mcg (Multivits a thru z select women's * W-Fe,Other Min/Lut) abc plus * (Biocel) adult one daily gummies * (One-A-Day Vitacraves) adults 50+ daily formula * (Biocel) adults' daily formula * airshield * oral tablet, effervescent 5, unit-mg-unit (Multivitamin/Iron/ Folic Acid) (Vit A,C, and E/Dietary Supp No.12) 154

155 animal chews * (Multivitamin) animal shape vitamins * (Multivitamin) animal shapes plus iron * (Multivitamins with Iron) antioxidant * (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) antioxidant formula * W-C and E/Min) (Multivitamin with antioxidant vitamins * oral tablet Minerals) antioxidant vitamins * oral tablet (Ocuvite with 1,000 unit-200 mg-60 unit-2 mg Lutein) apatate forte * (Multivitamin with Minerals) ascorbic acid * oral tablet extended (Ascorbic Acid) release 1,500 mg ascorbic acid * oral (Ascorbic Acid) b complete * (Vitamin B Complex) b complex 1 * (Vitamin B Complex) (Vitamin B b complex-vitamin b12 * Complex) b complex-vitamin c-folic acid * (Dialyvite 800) (Vitamin B b-100 complex * oral tablet Complex) b-12 dots * (B-12) b50 balanced * b-50 complex * oral tablet (Vitamin B Complex) (Vitamin B Complex) 155

156 bal b-100 * (Vitamin B Complex) bal b-50 * (Vitamin B Complex) balance b-100 * (Vitamin B Complex) balance b-50 * (Vitamin B Complex) (Vitamin B balanced b-100 * oral Complex) (Vit B Complex balanced b-100 * oral tablet Cmb mg #3/Herbs) balanced b-150 * (Vitamin B Complex) balanced b-50 * oral tablet (Vitamin B Complex) (Vitamin B b-complex * oral tablet Complex) b-complex with vitamin c * oral (B Complex with capsule Vitamin C) b-complex with vitamin c * oral tablet (Vita-Bee with C) bee-zee * (Multivitamin with Minerals) biosupp * (Multivitamin with Minerals) biotin * oral tablet 300 mcg (Biotin) biovol * (Multivitamin with Minerals) c complex * (Ascorbic Acid) calcidol * (Drisdol) 156

157 (Multivits centamin * W-Min/Ferrous Gluc) central vite with lutein * (Biocel) central-vite for seniors * (Multivitamin W/Iron, Minerals) central-vite * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) (Multivitamin central-vite select * oral tablet W-Minerals/Lutein ) central-vite senior * (Biocel) (Multivits centram-care * W-Min/Ferrous Gluc) centravites 50 plus * (Multivitamin W/Iron, Minerals) centrum complete * (Multivitamin/Iron/ Folic Acid) (Multivits centrum * oral liquid W-Min/Ferrous Gluc) centrum silver * oral tablet (Biocel) (Multivitamin/Iron/ centrum ultra women's * Folic Acid) century adults 50+ * (Biocel) (Multivits century advanced formula * W-Fe,Other Min/Lut) (Multivitamin century mature * oral tablet W-Minerals/Lutein ) 157

158 century mature * oral tablet mg-mcg-mcg, (Biocel) mcg century * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) century ultimate women's * oral (Multivitamin/Iron/ tablet mg-mcg Folic Acid) (Multivits cerovite * W-Min/Ferrous Gluc) (Multivitamin/Iron/ cerovite advanced formula * Folic Acid) (Multivitamin cerovite jr * W/Iron, Minerals) (Multivitamin cerovite senior * W-Minerals/Lutein ) certavite senior-antioxidant * (Biocel) (Multivits certavite-antioxid (iron gluc) * oral W-Min/Ferrous liquid 9 mg iron/15 ml Gluc) (Multivitamin/Iron/ certavite-antioxidant * Folic Acid) chewable multi vitamin * (Multivitamin) chewable-vite * (Multivitamin) (Multivitamins chewable-vite with iron * with Iron) (Pedi Mv child complete multivitamin * No.58/Ferrous Fumarate) child vitamin with minerals * (Multivitamin W/Iron, Minerals) children's chewable * (Multivitamin) 158

159 children's chewable complete * oral (Multivitamin) tablet,chewable children's chewable vitamin * (Multivitamin) children's chewable w/minerals * (Multivitamin W/Iron, Minerals) (Pedi Mv children's complete vitamin * No.67/Ferrous Fumarate) children's multivit w/extra c * (Multivitamin) (Multivitamins children's vitamin with iron * with Iron) childs chew vite * (Multivitamin) (Multivitamins child's chewable vitamins/iron * with Iron) (Multivitamins child's vitamin with iron * with Iron) child's vitamin with vitamin c * (Multivitamin) childs/iron * (Multivitamins with Iron) compete * (Multivitamin W/Iron, Minerals) complete 50+ * (Biocel) complete multi 50+ * (Biocel) complete multivitamin * oral tablet (Multivits,Th W-Fe,Other Min) complete multivitamin * oral tablet mg-mcg-mcg (Biocel) complete multivitamin-mineral * (Multivitamin/Iron/ oral tablet Folic Acid) complete senior * oral tablet (Multivitamin W/Iron, Minerals) 159

160 complete senior * oral tablet mg-mcg-mcg (Biocel) cyanocobalamin (vitamin b-12) * (Cyanocobalamin injection (Vitamin B-12)) 3 $0 cyanocobalamin (vitamin b-12) * (Cyanocobalamin oral drops 1,000 mcg/ml (Vitamin B-12)) cyanocobalamin (vitamin b-12) * oral tablet 1,000 mcg, 100 mcg, 250 (B-12) mcg, 500 mcg daily gummies * (One-A-Day Vitacraves) daily multiple * oral tablet (Multivitamin) daily multiple * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) daily multi-vitamin * (Multivitamin) (Multivitamin/Iron/ daily multivitamin with iron * Folic Acid) (Multivitamin with daily multivitamin-minerals * Minerals) daily multi-vitamins/iron * (Multivitamins with Iron) (Multivitamin/Iron/ daily teen multi-vitamin * Folic Acid) daily value * (Multivitamin) daily vitamin * (Multivitamin) daily vitamin formula * (Multivitamin) daily vitamin formula + iron * daily vitamin formula-minerals * daily vitamin with iron * (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals) (Multivitamins with Iron) 160

161 (Multivitamins daily vites/iron * with Iron) daily-vite * (Multivitamin) dino-life * (Multivitamin) dino-life with extra c * (Multivitamin) dino-life with iron-zinc * (Multivitamin W/Iron, Minerals) ECEE PLUS * eldertonic * (Multivitamin with Minerals) ellis tonic * (Multivitamin with Minerals) ergocalciferol (vitamin d2) * oral capsule (Drisdol) 3 $0 ergocalciferol (vitamin d2) * oral drops (Drisdol) essentia * (Multivitamin/Iron/ Folic Acid) (Multivits essential balance with lutein * W-Fe,Other Min/Lut) essential daily * (Tab A Vite) essential one daily * (Multivitamin) (Fe fe fumarate-doss-fa-bcomp and c * Fumarate/Doss/Fa/ 3 $0 Bcomp and C) fe fumarate-vit c-b12-if-fa * oral (Fe Fumarate/Vit capsule mg C/B12-If/Fa) 3 $0 ferate * oral tablet (Fergon) ferotrinsic * (Fe Fumarate/Vit C/B12-If/Fa) 3 $0 ferretts * oral tablet (Ferrous Fumarate) 161

162 ferrex 150 * (Pic 200) ferrex 150 plus * (Iron Aspgly and Ps Cmplx/C/Sucac) ferrocite * (Ferrous Fumarate) ferrous fumarate * oral tablet 324 mg (106 mg iron) (Ferrous Fumarate) ferrous gluconate * oral tablet (Fergon) ferrous sulfate * oral (Fer-In-Sol) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral (Ferrous Sulfate) ferrous sulfate * oral tablet 325 mg (65 mg iron) (Ferrous Sulfate) ferrous sulfate * oral tablet,delayed release (dr/ec) 324 mg (65 mg iron) (Ferrous Sulfate) flintstones complete (iron) * oral (Multivitamin tablet,chewable W/Iron, Minerals) flintstones multivitamin * oral tablet,chewable (Multivitamin) (Pedi Mv flintstones with iron * No.79/Ferrous Fumarate) flintstones/extra c * oral tablet,chewable (Multivitamin) folic acid * 1 mg tablet (rx) (Folic Acid) 3 $0 FOLIC ACID * ORAL CAPSULE folic acid * oral tablet 1 mg, 400 mcg, 800 mcg (Folic Acid) fosfree * (Calcium/Multivita mins W-Iron) fruity chews * (Multivitamin) geravim * (Pediavit) geriaton * (Pediavit) 162

163 (Vit A,C, and germ defense * E/Dietary Supp No.12) gummi bear multivitamin * (Multivitamin) gummy swirls * (Multivitamin) hair vitamins * (Multivitamins with Iron) hair,skin & nails * oral tablet (Multivitamin with Minerals) hair,skin & nails * oral tablet 1 mg (Mv,Ca,Min/Iron iron-66.7 mcg-1,000 mcg Gluc/Fa/Biotin) healthy eyes * (Ocuvite with Lutein) hemocyte * (Ferrous Fumarate) (Vitamin B hi-b complex * Complex) (Multivitamin high potency multivit-multimin * W-Minerals/Lutein ) honey bears * (Multivitamin) honey bears with iron-zinc * (Multivitamin W/Iron, Minerals) icaps plus * (Multivitamin with Minerals) iferex 150 * (Pic 200) iron high potency * (Fergon) i-vite * (Ocuvite with Lutein) kid's vitamins + extra c * (Multivitamin) kids vitamins + iron * (Ped Multivit #17/Iron Fumarate) 163

164 kid's vitamins + iron * kid's vitamins * oral tablet,chewable Name of Drug (Multivitamins with Iron) (Multivitamin) life-pack women's * (Multivitamin W/Iron, Minerals) LIQUI-E * little animals * (Multivitamin) (Multivitamins little animals/iron * with Iron) lysiplex plus * oral liquid (Pediavit) (Beta-Carotene(A) macuvite * oral tablet W-C and E/Min) macuvite * oral tablet 5, (A/C/E/Zinc/Sod unit-mg-unit Selenite/Copper) maximum daily multivitamin * (Tab A Vite) mega multiple/chelated mineral * (Multivitamin with Minerals) mega multivitamin with mineral * (Multivitamin with oral tablet Minerals) men's multi-vitamin * (Multivitamin) men's one daily * oral tablet (Multivitamin with Minerals) MEPHYTON * 3 $0 (Multivitamin milltrium senior * W-Minerals/Lutein ) multi complete with iron * (Multivitamin/Iron/ Folic Acid) multi-day with iron * (Multivitamin/Iron/ Folic Acid) multi-delyn * (Multivitamin) 164

165 (Multivitamin/Ferr multi-delyn with iron * ous Gluconate) (Multivitamin multilex * W/Iron, Minerals) multilex-t&m * (Multivits,Th W-Fe,Other Min) multiple vitamin-minerals * (Multivitamin with Minerals) multiple vitamins * (Multivitamin) multiple vitamins with iron * multivital platinum * oral tablet multivital platinum * oral tablet mcg (Multivitamins with Iron) (Multivitamin W-Minerals/Lutein ) (Biocel) (Multivitamins,The multi-vitamin hp/minerals * r W-Minerals) multivitamin * oral tablet (Multivitamin) multivitamin with iron * multivitamin with minerals * oral liquid multivitamin with minerals * oral tablet multivitamins with min no.7-fa * oral capsule 1 mg multi-vite * multi-vite 50 & over * (Multivitamins with Iron) (Multivits W-Min/Ferrous Gluc) (Multivitamin with Minerals) (Multivitamins with Min No.7/Fa) (Multivitamin/Iron/ Folic Acid) (Multivitamin W-Minerals/Lutein ) 3 $0 165

166 my favorite multiple * (Multivitamin) my-vitalife * (Multivitamin with Minerals) NASCOBAL * 3 $0 (Vitamin B natural b-100 * Complex) (Vit B Complex natural b-100 complex * 100 Cmb #2/Herbs) nephro-vite * (Dialyvite 800) niacinamide * oral tablet 500 mg (Niacinamide) niacinamide * oral tablet extended release (Niacinamide) nu-iron * (Pic 200) ocutabs * (Beta-Carotene(A) W-C and E/Min) once daily * (Multivitamin) oncovite * (Multivitamins,The rapeutic) one daily 50 plus * (Multivitamin with Minerals) one daily complete * oral tablet (Multivitamin with Minerals) one daily energy * oral tablet (Multivitamin with Minerals) one daily essential * oral tablet (Multivitamin) one daily maximum (with ca) * (Tab A Vite) one daily men's 50+ * oral tablet (Multivitamin with Minerals) (Multivitamins one daily multi-vit w-mineral * with Iron) one daily multivitamin * oral tablet (Multivitamin) 166

167 one daily multivitamin * oral tablet 400 mcg (Quintabs) (Multivitamin/Iron/ one daily multivitamin-iron * Folic Acid) one daily * oral tablet (Multivitamin) (Multivitamins one daily plus iron * oral tablet with Iron) one daily plus iron * oral tablet (Multivitamin/Iron/ mg-mcg Folic Acid) one daily plus minerals * (Multivitamin with Minerals) (Multivitamins one daily with iron * with Iron) one-a-day essential * (Multivitamin) one-a-day maximum formula * (Multivitamin with Minerals) one-a-day teen advantage * oral (Multivitamin/Iron/ tablet mg-mcg Folic Acid) one-a-day teen advantage * oral (Multivits,Ca,Mine tablet 9 mg iron-400 mcg rals/iron/fa) (Beta-Carotene(A) opti-vitamins * oral tablet W-C and E/Min) opti-vitamins * oral tablet 1,000 (Ocuvite with unit-200 mg-60 unit-2 mg Lutein) pedi m.vit no.17 with fluoride oral (Pedi Mvi No.82 drops 0.25 mg/ml with Fluoride) pediatric multivitamin * (Multivitamin) pharmacist favorite multi-vit * (Multivitamin) phytonadione * oral tablet 100 mcg (Phytonadione) poly-iron * (Pic 200) poly-vita * (Pediatric Multivit Comb No.20) 167

168 poly-vita (iron) * (Ped Multivit #46/Iron Sulfate) poly-vitamin * (Pediatric Multivit Comb No.20) poly-vitamin with iron * oral drops (Ped Multivit 1,500 unit-400 unit-10 mg/ml #46/Iron Sulfate) polyvitamin/iron * (Multivitamin W/Iron, Minerals) poly-vitamins * (Multivitamin) prenatal formula * oral tablet mg (Classic Prenatal) prenatal * oral tablet mg (Classic Prenatal) (Prenatal prenatal vit#96-ferrous fum-fa * Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) prenatal vitamins with iron (Pnv with Ca,No.72/Iron/Fa) prenatal vitamins with iron (Pnv119/Iron Fumarate/Fa/Dss) prenatal vit-iron fumarate-fa * (Classic Prenatal) prosight * oral tablet 5, (A/C/E/Zinc/Sod unit-mg-unit Selenate/Copper) pyridoxine * injection (Pyridoxine HCl) 3 $0 ra central-vite select * tab p/f (Multivitamin W/Iron, Minerals) scooby-doo one a day * (Multivitamin W/Iron, Minerals) (Multivitamin/Iron/ sentry * oral tablet mg-mcg Folic Acid) sentry senior * (Biocel) 168

169 (Pedi Mvi No.82 sodium fluoride oral tablet with Fluoride) sodium fluoride * oral tablet,chewable 0.25 mg fluorid (Sodium Fluoride) 3 $0 (0.55 mg) spectravite adult 50+ * oral tablet (Biocel) spectravite advanced formula * oral (Multivitamin/Iron/ tablet Folic Acid) spectravite * oral liquid (Pediavit) spectravite * oral tablet,chewable spectravite senior * oral tablet spectravite senior w-lycopene * spectravite ultra women * stress 500 plus zinc * stress b with zinc * stress b-biotin * stress formula * stress formula plus iron * stress formula with iron * stress formula with zinc * (Multivitamins with Iron) (Multivitamin W/Iron, Minerals) (Multivitamin W-Minerals/Lutein ) (Multivitamin/Iron/ Folic Acid) (Multivits,Stress Formula/Zinc) (Multivits,Stress Formula/Zinc) (Vitamin B Complex) (Multivits,Stress Formula) (Iron/Multivits,Stre ss Formula) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivits,Stress Formula/Zinc) 169

170 stuart prenatal * (Classic Prenatal) (Mv-Min/Iron sunvite * Fum/Fa/Lyco/Lutn/ K) super b complex-vitamin c * (Vita-Bee with C) super b/c * (B Complex with Vitamin C) super b-50 complex * (Vitamin B Complex) (Vitamin B super b-50 complex plus * Complex) (Multivitamin super multiple * oral tablet W/Iron, Minerals) super multivitamin * (Multivitamin) super quints b-50 * (Vitamin B Complex) super thera vite m * (Multivitamins,The r W-Minerals) superior 35 * (Multivitamin W/Iron, Minerals) superplex-t * (Vita-Bee with C) support * (Multivitamin with Minerals) support-500 * (B Complex with Vitamin C) 3 $0 tab-a-vite * (Multivitamin) tab-a-vite/iron * tab-a-vite-minerals * thera m plus (ferrous fumarat) * (Multivitamins with Iron) (Multivitamin with Minerals) (Multivits,Ca,Mine rals/iron/fa) 170

171 (Multivitamins,The thera vitamin * rapeutic) (Multivit,Ther theradex m * Iron,Ca,Fa and Min) (Multivits,Th thera-m * oral tablet W-Fe,Other Min) (Multivit,Ther thera-m * oral tablet mg Iron,Ca,Fa and Min) thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine mcg rals/iron/fa) (Multivitamin with theramill forte * oral capsule Minerals) therapeutic liquid * (Multivitamins,The rapeutic) therapeutic m + beta-carotene * (Tab A Vite) therapeutic vitamins/minerals * therapeutic-m * oral tablet 9 mg iron-400 mcg therapeutic-m vitamin/minerals * oral tablet mg thera-tabs * theratrum complete 50 plus * theratrum complete 50 plus/lut * therems * (Multivitamins with Min No.7/Fa) (Multivits,Ca,Mine rals/iron/fa) (Multivit,Ther Iron,Ca,Fa and Min) (Multivitamins,The rapeutic) (Multivitamin W/Iron, Minerals) (Multivitamin W-Minerals/Lutein ) (Multivitamins,The rapeutic) 3 $0 171

172 therems-h * (Multivits,Th W-Fe,Other Min) therems-m * (Multivits,Th W-Fe,Other Min) thiamine hcl * injection (Thiamine HCl) 3 $0 thiamine hcl * oral tablet 500 mg (Thiamine HCl) total b/c * (Vita-Bee with C) totalday multiple * (Multivitamin with Minerals) (Vit A tri-vi-sol * Palmitate/Vit C/Vit D3) (Pedi Multivits tri-vita * A,C, and D3 No.21) (Pedi Multivits tri-vitamin * A,C, and D3 No.21) ultra b-100 complex * oral tablet unicomplex-m * vision * vision formula * vision formula (with lutein) * vision plus lutein * vit b cmplx 3-fa-vit c-biotin * oral tablet mg-mg-mcg (Vitamin B Complex) (Multivitamin W/Iron, Minerals) (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) W-C and E/Min) (Ocuvite with Lutein) (Multivitamin W-Minerals/Lutein ) (Vit B Cmplx 3/Fa/Vit C/Biotin) 3 $0 172

173 (Vit B Cmplx vit b cmplx no3-fa-c-biot-zinc * No3/Fa/C/Biot/Zin 3 $0 c) vitabee/c * (Vita-Bee with C) vitalets * oral tablet,chewable vitamin a * oral capsule 10,000 unit, 25,000 unit (Multivitamins with Iron) (Vitamin A) (Vitamin B vitamin b complex * Complex) (B Complex with vitamin b complex with c * Vitamin C) vitamin b-1 * oral tablet (Thiamine HCl) vitamin b-100 complex * (Vitamin B Complex) (Cyanocobalamin/ vitamin b12-folic acid * oral Folic Acid) vitamin b-6 * oral tablet 100 mg, 25 (Pyridoxine HCl) mg, 250 mg, 50 mg vitamin c * oral capsule, extended release (Ascorbic Acid) vitamin c * oral syrup (Ascorbic Acid) vitamin c * oral tablet 1,000 mg, 250 mg, 500 mg (Ascorbic Acid) vitamin c * oral tablet extended release (Ascorbic Acid) vitamin c * oral tablet,chewable 250 mg, 500 mg (Ascorbic Acid) vitamins & minerals * vitamins b complex * oral capsule (Multivitamins,The r W-Minerals) (Vitamin B Complex) 173

174 (Vitamin B vitamins b complex * oral tablet Complex) (Vit B vitamins b complex * oral tablet Comp/C/Fa/Iron/Vi 500 mg-400 mcg- 18 mg iron t E) vitamins for hair * oral tablet (Multivitamin) (Multivitamin vitrum senior * oral tablet W-Minerals/Lutein ) vitrum senior * oral tablet mcg (Biocel) women's daily multivitamin * (Tab A Vite) yelets * (Multivitamin/Iron/ Folic Acid) zoo chews * (Multivitamin) 174

175 手 册 第 11 页 及 第 12 页 亦 载 有 此 表 所 列 符 号 及 缩 略 词 的 含 义 175 ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 生 效 日 期 :2015 年 5 月 1 日 处 方 集 ID: ; 版 本 :9

176 索 引 3 day vaginal pse-150gfn-15dm MOP a thru z advanced formula a thru z high potency a thru z select a thru z select 50+ formula a thru z select women's abacavir abacavir-lamivudine-zidovudine abc plus ABELCET ABILIFY ABILIFY DISCMELT... 65, 66 ABILIFY MAINTENA ABRAXANE ABREVA acamprosate acarbose acebutolol acephen acetaminophen acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid , 136 acetylcysteine acid gone antacid acid reducer (famotidine) acid reducer (ranitidine) acid relief (cimetidine) acitretin acne medication acne-clear ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir... 71, 104 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCETRIS ADCIRCA adefovir ADEMPAS ADRENALIN adrenalin adt robitussin peak cld dm max adult nasal decongestant adult one daily gummies adult robitussin lingering cld adult robitussin peak cold dm adult wal-tussin adult wal-tussin dm max adults 50+ daily formula adults' daily formula ADVAIR DISKUS ADVAIR HFA advil af AFINITOR AFINITOR DISPERZ AGGRENOX airshield AKTEN (PF) alavert d-12 allergy-sinus alaway ALBENZA ALBUKED ALBUKED ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % albuterol sulfate alclometasone ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE ALDURAZYME alendronate alfuzosin ALIMTA ALINIA alka-seltzer plus mucus-conges alka-seltzer plus sinus-cough aller-chlor allerclear d-12hr allerclear d-24hr allergy (chlorpheniramine) allergy relief (cetirizine) allergy relief (loratadine) allerhist aller-tec d allopurinol almacone almacone aloe vesta alophen ALPHAGAN P alprazolam ALREX altacaine altamist aluminum chloride aluminum hydroxide gel amantadine hcl ambi 10peh-4cpm-20dm ambi 20dm-4cpm ambi 40pse-400gfn-20dm ambi 60pse-4cpm ambi 60pse-4cpm-20dm AMBISOME ambizine amifostine crystalline amiloride amiloride-hydrochlorothiazide AMINO ACIDS 15 % ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-1 生 效 日 期 :2015 年 5 月 1 日

177 aminocaproic acid AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amiodarone hcl AMITIZA amitriptyline amlactin amlodipine amlodipine-atorvastatin amlodipine-benazepril ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphetamine salt combo amphotericin b ampicillin ampicillin sodium... 33, 34 ampicillin-sulbactam AMPYRA ANACAINE anagrelide anastrozole ANDRODERM ANDROGEL animal chews animal shape vitamins animal shapes plus iron ANORO ELLIPTA antacid antacid anti-gas antacid plus anti-gas anticoag citrate phos dextrose anti-diarrheal anti-diarrheal (loperamide) antifungal antifungal (tolnaftate) anti-gas maximum strength antioxidant antioxidant formula antioxidant vitamins apatate forte APOKYN apraclonidine APRISO aprodine APTIOM APTIVUS aquanil hc ARALAST NP ARCALYST ARRANON artificial tears artificial tears (petro/min) artificial tears (pf) artificial tears(glycerin-peg) artificial tears(hypromellose) ARZERRA ASACOL HD ascorbic acid ashlyna aspirin aspirin, buffered aspir-low ASSURE ID INSULIN SAFETY ASTAGRAF XL atenolol atenolol-chlorthalidone athlete's foot (clotrimazole) atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 44, 45, 113 ATROVENT HFA AUBAGIO AVASTIN AVC VAGINAL AVODART AVONEX AVONEX (WITH ALBUMIN) ayr saline azacitidine azathioprine azathioprine sodium azelastine AZILECT azithromycin AZOPT AZOR aztreonam b complete b complex b complex-vitamin b b complex-vitamin c-folic acid b-100 complex b-12 dots b50 balanced b-50 complex bacitracin... 28, 106, 116 bacitracin-polymyxin b bacitraycin plus baclofen bal b bal b balance b balance b balanced b balanced b balanced b ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-2 生 效 日 期 :2015 年 5 月 1 日

178 balsalazide banophen banophen allergy BANZEL BARACLUDE baza antifungal BCG VACCINE, LIVE (PF) b-complex b-complex with vitamin c BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE bee-zee BELEODAQ benadryl allergy benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide , 105 benztropine BETADINE SPRAY beta-hc betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented , 108 BETASERON betaxolol... 82, 142 bethanechol chloride BETHKIS bicalutamide bicarsim forte BICILLIN C-R BICILLIN L-A BILTRICIDE bio-dtuss dmx bion tears (pf) bionel bionel pediatric biospec dmx biosupp biotin biovol bisac-evac bisacodyl biscolax bismatrol bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin BLINCYTO BOOSTRIX TDAP BOSULIF BOTOX , 139 BREO ELLIPTA BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine bromphenex dm brompheniramine-pseudoeph-dm... 93, 94 brompheniram-phenylephrine-dm broncotron-s budesonide bufferin bumetanide BUMINATE 25 % BUMINATE 5 % BUPHENYL buprenorphine hcl... 14, 23 buprenorphine-naloxone bupropion hcl... 23, 48 buspirone butalb-acetaminophen-caffeine butalbital-acetaminop-caf-cod butalbital-acetaminophen butalbital-acetaminophen-caff butalbital-aspirin-caffeine butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC c complex cabergoline ca-d3-mag ox-zinc-cop-mang-bor caffeine citrated caffeine-sodium benzoate calci-chew calcidol calcionate calcipotriene calcitonin (salmon) calcitrate calcitrate-vitamin d calcitriol , 137 calcium d calcium d (d3) calcium 500 with d calcium calcium d(3) calcium 600 with vitamin d calcium acetate calcium antacid calcium carbonate , 143 calcium carbonate-mag carb-fa calcium carbonate-vitamin d CALCIUM CARBONATE-VITAMIN D calcium carbonate-vitamin d calcium chloride calcium citrate-vitamin d calcium gluconate calcium lactate calcium+d CALDOLOR cal-gest antacid calphron caltrate d ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-3 生 效 日 期 :2015 年 5 月 1 日

179 CALTRATE D VIT D3 (800) CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin cardec dm (phenyleph-chlorphn) CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol CASTELLANI PAINT MODIFIED CAYSTON cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os) cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefotaxime cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftibuten ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) CELEBREX celecoxib CELLCEPT CELLCEPT INTRAVENOUS CELONTIN centamin central vite with lutein central-vite central-vite for seniors central-vite select , 168 central-vite senior centram-care centravites 50 plus centrum centrum complete centrum silver centrum ultra women's century century adults century advanced formula century mature , 158 century ultimate women's cephalexin CEPROTIN (BLUE BAR) CERDELGA CEREZYME cerovite cerovite advanced formula cerovite jr cerovite senior certavite senior-antioxidant certavite-antioxid (iron gluc) certavite-antioxidant CERVARIX VACCINE (PF) cetirizine cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX cheratussin ac cheratussin dac chest congestion relief + dm chest congestion relief d chest congestion relief pe chewable multi vitamin chewable-vite chewable-vite with iron child complete multivitamin child cough & sore throat child mucinex chest congestion child mucus relief cough child plus cough & runny nose child triaminic cold & allergy child triaminic cough-congest child vitamin with minerals child wal-tap cold-allergy child wal-tussin cough relief children's advil children's aller-tec children's cetirizine children's chest congestion children's chewable children's chewable complete children's chewable vitamin children's chewable w/minerals CHILDREN'S CLARITIN children's complete vitamin children's dimetapp cold &flu children's flu relief children's mapap children's mucinex cough children's multivit w/extra c children's non-aspirin children's pain & fever relief... 14, 15 children's pain reliever children's pepto children's silapap children's silfedrine ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-4 生 效 日 期 :2015 年 5 月 1 日

180 children's soothe children's sudafed children's sudafed pe cough children's vitamin with iron children's wal-dryl allergy children's wal-zyr CHILDREN'S ZYRTEC ALLERGY childs chew vite child's chewable vitamins/iron child's vitamin with iron child's vitamin with vitamin c childs/iron chlophedianol-guaifenesin chloramphenicol sod succinate chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpheniramine-phenyleph-dm chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar) cholestyramine-aspartame choline,magnesium salicylate ciclopirox ciclopirox-ure-camph-menth-euc cilostazol cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX ciprofloxacin ciprofloxacin hcl... 35, 117 ciprofloxacin in 5 % dextrose ciprofloxacin lactate cisplatin citalopram citracal + d maximum citric acid-sodium citrate citrus calcium clarithromycin CLARITIN CLARITIN LIQUI-GEL CLARITIN REDITABS CLARITIN-D 12 HOUR CLARITIN-D 24 HOUR clearlax clemastine CLEVIPREX clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate... 29, 61, 106 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol propionate clobetasol-emollient clocortolone pivalate clomipramine clonazepam clonidine clonidine hcl... 79, 89 clonidine hcl-chlorthalidone clopidogrel clorazepate dipotassium... 24, 25 clotrimazole... 54, 55 clotrimazole 3 day clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate codeine-butalbital-asa-caffein codituss dm colace colchicine colchicine-probenecid COLCRYS cold & cough cold multi-symptom cold multi-symptom day/night cold multi-symptom nighttime cold relief m/s day/night cold-flu relief cold-flu relief, day/night colestipol colistin (colistimethate na) COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ comfort gel extra strength ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-5 生 效 日 期 :2015 年 5 月 1 日

181 COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN COMFORT PAC-TIZANIDINE compete COMPLERA complete complete multi complete multivitamin complete multivitamin-mineral complete senior , 160 compoz COMVAX (PF) CONDYLOX congestac COPAXONE coral calcium CORDRAN coricidin hbp cortisone cortizone CORTIZONE cough & cold cough & runny nose coughtab CREON creo-terpin (dm-guaifenesin) CRESTOR critic-aid clear af CRIXIVAN cromolyn , 122, 151 CUBICIN CURITY GAUZE cyanocobalamin (vitamin b-12) cyclobenzaprine CYCLOGYL cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyclosporine, modified cyproheptadine CYRAMZA CYSTADANE CYSTARAN cysteine (l-cysteine) cytarabine cytarabine (pf) d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine dactinomycin daily gummies daily multiple daily multi-vitamin daily multivitamin with iron daily multivitamin-minerals daily multi-vitamins/iron daily teen multi-vitamin daily value daily vitamin daily vitamin formula daily vitamin formula + iron daily vitamin formula-minerals daily vitamin with iron daily vites/iron dailyhist daily-vite DALIRESP DALLERGY DM danazol dantrolene dantrolene sodium dapsone DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM dayhist allergy daytime cold & cough daytime cold-flu day-time cough daytime mucus relief dm daytime-nighttime daytime-nighttime cold-flu daytime-nighttime cough deblitane decitabine decongestant cough deep sea nasal deferoxamine delsym cough+chest congest dm DELZICOL DEMSER DEPEN TITRATABS DEPO-PROVERA dermafungal dermarest eczema (hydrocort) desenex desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone despec-dm (pseudoeph-dm-guaif) dex4 glucose dexamethasone dexamethasone sodium phosphate , 130 dexchlorphen-pse-chlophedianol dexmethylphenidate dextroamphetamine dextroamphetamine-amphetamine dextromethorphan polistirex ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-6 生 效 日 期 :2015 年 5 月 1 日

182 dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride diabetic siltussin das-na diabetic tussin dm diabetic tussin ex diamode DIASTAT ACUDIAL diazepam diazepam intensol diclofenac potassium diclofenac sodium... 20, 118 diclofenac-misoprostol dicloxacillin dicyclomine didanosine DIFICID diflunisal digitek digoxin DIGOXIN dihydroergotamine... 61, 62 DILANTIN diltiazem hcl dilt-xr dimaphen (pe) dimaphen dm dimenhydrinate dimetapp cold-congestion dino-life dino-life with extra c dino-life with iron-zinc DIOVAN DIPENTUM diphenhist diphenhydramine hcl diphenoxylate-atropine disopyramide phosphate disulfiram divalproex d-methorphan hb-p-epd hcl-bpm dm-phenyleph-chlorpheniramine dobutamine dobutamine in d5w doc-q-lace docu docusate calcium docusate sodium docusol dok donepezil... 47, 48 dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol double-tussin dm douche vinegar & water extra doxazosin doxepin doxercalciferol doxorubicin hcl doxorubicin hcl peg-liposomal doxorubicin, peg-liposomal doxycycline hyclate... 35, 36 doxycycline monohydrate dramamine driminate dristan long lasting dronabinol droperidol drospirenone-ethinyl estradiol DROXIA DUAVEE dulcolax stool softener (dss) DULERA duloxetine DURAMORPH (PF) DUREZOL DYRENIUM e.c. prin ECEE PLUS econazole ed bron gp ed chlorped jr EDURANT EFFIENT ELAPRASE eldertonic electrolyte-48 in d5w ELIDEL ELIGARD ELIQUIS ELITEK ELLA ellis tonic ELMIRON elon dual defense EMCYT EMEND EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endur-acin enema enema disposable enemeez enfalyte ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 72, 73 entacapone entecavir entre-cough ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-7 生 效 日 期 :2015 年 5 月 1 日

183 ephedrine sulfate epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin EPIVIR EPIVIR HBV eplerenone EPOGEN epoprostenol (glycine) EPZICOM eq gentle equalactin ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE ERYTHROCIN erythromycin... 33, 117 erythromycin base ERYTHROMYCIN BASE erythromycin base-ethanol erythromycin ethylsuccinate erythromycin stearate erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole sodium essentia essential balance with lutein essential daily essential one daily estazolam ESTRACE estradiol estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet ESTRASORB estropipate ethambutol ethamolin ethinyl estradiol/drospirenone ethosuximide ethynodiol d-ethinyl estradiol etidronate disodium etodolac ETOPOPHOS etoposide exefen dmx EXELON exemestane EXFORGE EXFORGE HCT EXJADE expectorant expectorant max strength EXTAVIA extra cleansing douche FABRAZYME famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON FASLODEX FAZACLO fe fumarate-doss-fa-bcomp and c fe fumarate-vit c-b12-if-fa felbamate felodipine feminine care douche FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate ferate ferotrinsic ferretts ferrex ferrex 150 plus FERRIPROX ferrocite ferrous fumarate ferrous gluconate ferrous sulfate FETZIMA feverall fiber (calcium polycarbophil) fiber laxative fiber smooth fiber therapy fiber therapy (psyllium/sugar) fiber-lax finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flanax antacid FLEBOGAMMA DIF flecainide FLECTOR FLEET BISACODYL FLEXBUMIN 25 % FLEXBUMIN 5 % flintstones complete (iron) flintstones multivitamin flintstones with iron flintstones/extra c FLOVENT DISKUS FLOVENT HFA , 150 floxuridine flu formula daytime-nighttime flu severe cold-congestion fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) flucytosine fludarabine fludrocortisone flumazenil fluocinonide , 109 fluocinonide-emollient base fluorometholone ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-8 生 效 日 期 :2015 年 5 月 1 日

184 FLUOROPLEX fluorouracil... 39, 105 fluoxetine FLUOXETINE fluoxymesterone fluphenazine decanoate fluphenazine hcl flurazepam flurbiprofen flurbiprofen sodium flu-severe cold-cough flutamide fluticasone , 118 fluvoxamine foaming antacid folic acid FOLIC ACID fomepizole fondaparinux FORTEO FORTICAL foscarnet fosfree fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % fruity chews fungi cure FUNGI-NAIL fungoid-d furosemide FUSILEV FUZEON FYCOMPA gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gas free extra strength gas relief gas relief gas relief extra strength gas-x ultra-strength gatifloxacin GAZYVA gelusil antacid & anti-gas gemcitabine gemfibrozil GENOTROPIN GENOTROPIN MINIQUICK gentamicin... 28, 106, 117 gentamicin in nacl (iso-osm) gentamicin sulfate gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) GENTEAL MILD TO MODERATE GENTEAL GEL GENTEAL MILD GENTEAL SEVERE gentlelax GEODON geravim geriaton geri-hydrolac germ defense gildess 24 fe GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) gluco burst glucose glucose gel glutose glyburide glyburide micronized glyburide-metformin GLYCINE glycolax glycopyrrolate glydo granisetron (pf) granisetron hcl GRANIX griseofulvin microsize guaiatussin ac guaifenesin guaifenesin dac guanfacine... 80, 89 guanidine gummi bear multivitamin gummy swirls hair vitamins hair,skin & nails HALAVEN halobetasol propionate haloperidol haloperidol decanoate... 66, 67 haloperidol lactate HARVONI HAVRIX (PF) head congestion day-night healthy eyes healthylax hemocyte heparin (porcine) heparin (porcine) in 5 % dex... 73, 74 heparin (porcine) in nacl (pf) heparin(porcine) in 0.45% nacl heparin, porcine (pf) HEPATAMINE 8% HEPATASOL 8 % HERCEPTIN HEXALEN hi-b complex hi-cal plus vit d high potency multivit-multimin ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-9 生 效 日 期 :2015 年 5 月 1 日

185 homatropine hbr honey bears honey bears with iron-zinc HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N PEN HUMULIN R HUMULIN R U-500 "CONCENTRATED" hydralazine hydro skin hydrochlorothiazide hydrocil instant hydrocodone bit-homatrop me-br hydrocodone-acetaminophen hydrocodone-chlorpheniramine hydrocodone-homatropine hydrocodone-ibuprofen hydrocortisone , 110, 130 hydrocortisone acet-aloe vera hydrocortisone acetate hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone sod succinate hydrocortisone valerate hydromorphone hydromorphone (pf)... 15, 16 hydroxychloroquine hydroxyurea hydroxyzine hcl , 140 hydroxyzine pamoate HYPERLYTE CR HYPERRAB S/D (PF) HYQVIA ibandronate ibuprofen ibuprofen jr strength icaps plus ICLUSIG iferex ifosfamide ifosfamide-mesna ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod imodium a-d IMODIUM A-D IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX indapamide indomethacin indomethacin sodium INFANRIX (DTAP) (PF) infant acetaminophen infantaire infant's ibuprofen INFANT'S MOTRIN infants' non-aspirin cold infant's pain reliever INLYTA... 39, 40 insta-glucose INSULIN PEN NEEDLE INSULIN SYRINGE INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE-NEEDLE U INTELENCE intense cough reliever INTRALIPID INTRON A INTUNIV ER INVANZ INVEGA INVEGA SUSTENNA INVIRASE INVOKAMET INVOKANA inzo antifungal iodine IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide IPRIVASK irbesartan irbesartan-hydrochlorothiazide iron high potency ISENTRESS ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isopto tears isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX itraconazole ivermectin i-vite IXEMPRA ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-10 生 效 日 期 :2015 年 5 月 1 日

186 IXIARO (PF) JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA jr. acetaminophen junior mapap KABIVEN KADCYLA KALETRA KALYDECO kaopectate (bismuth subsalicy) KEDBUMIN KELP (IODINE) ketoconazole... 55, 56 ketoprofen ketorolac... 21, 118 ketotifen fumarate KEYTRUDA KHEDEZLA kidkare cough/cold kid's vitamins kid's vitamins + extra c kids vitamins + iron kid's vitamins + iron KINERET KINRIX (PF) KLOR-CON KLOR-CON KLOR-CON klor-con m klor-con m KLOR-CON/EF konsyl (sugar) konsyl fiber konsyl sugar-free KORLYM KRYSTEXXA KUVAN KYPROLIS l norgest&e estradiol-e estrad labetalol LACRISERT LACTATED RINGERS LACTINOL HX lactulose LAMICTAL LAMISIL (AEROSOL) lamisil af LAMISIL AT lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR latanoprost LATUDA laxative peg LAZANDA leflunomide LEMTRADA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 35, 117 levofloxacin in d5w levonorgestrel levonorgestrel-ethin estradiol levonorgestrel-ethinyl estrad levorphanol tartrate levothyroxine LEXIVA lice cream rinse lice killing lice treatment lidocaine lidocaine (pf)... 22, 82 lidocaine hcl lidocaine in 5 % dextrose (pf) lidocaine-prilocaine LIDODERM life-pack women's linezolid LINZESS liothyronine lipase-protease-amylase lipogen LIPOSYN II LIPOSYN III liquibid d-r liquid calcium with vitamin d LIQUI-E liquitears lisinopril lisinopril-hydrochlorothiazide lithium carbonate... 89, 90 lithium citrate little animals little animals/iron l-norgest-eth estr/ethin estra lobana bath lohist peb dm lomustine loperamide loradamed loratadine loratadine-d lorazepam lortuss ex losartan losartan-hydrochlorothiazide LOTEMAX LOTRIMIN ULTRA LOTRONEX lovastatin loxapine succinate lubricant dry eye relief lubricant eye (polyv alcohol) lubricant eye (propyl glycol) ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-11 生 效 日 期 :2015 年 5 月 1 日

187 lubricant eye drops lubricating drops lubrifresh pm LUMIGAN LUMINAL LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) LYNPARZA LYRICA lysiplex plus LYSODREN maalox advanced macuvite mafenide acetate mag mag-delay mag-g MAGNEBIND magnesium magnesium (oxide/aa chelate) magnesium chloride magnesium gluconate magnesium oxide , 123 magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion mapap (acetaminophen) mapap arthritis pain mapap extra strength maprotiline mar-cof bp mar-cof cg MARPLAN MARQIBO masanti double strength MATULANE matzim la maximum daily multivitamin maximum strength flu meclizine medi-brom medroxyprogesterone mefenamic acid mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) mega multiple/chelated mineral mega multivitamin with mineral MEGACE ES megestrol MEKINIST meloxicam melphalan hcl intravenous MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) men's multi-vitamin men's one daily MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON mercaptopurine meropenem mesehist dm mesna MESNEX MESTINON MESTINON TIMESPAN metaproterenol metaxalone metformin methadone methadone hcl methazolamide methenamine hippurate methenamine mandelate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate... 82, 83 metronidazole... 61, 64, 106 metronidazole in nacl (iso-os) mexiletine MIACALCIN mi-acid mi-acid gas relief micatin miconazole miconazole nitrate midazolam midazolam (pf) midodrine milk of magnesia milltrium senior milrinone milrinone in 5 % dextrose mineral oil mineral oil laxative mineral oil light minitran minocycline minoxidil mintox mintox maximum strength mintox plus ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-12 生 效 日 期 :2015 年 5 月 1 日

188 MIRCERA mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide mometasone MONISTAT monistat montelukast morphine MORPHINE morphine concentrate morrhuate sodium motion sickness MOVIPREP MOXEZA moxifloxacin MOZOBIL mucinex fast-max dm max mucus dm mucus dm max mucus relief MULTAQ multi complete with iron multi-day with iron multi-delyn multi-delyn with iron multilex multilex-t&m multiple vitamin-minerals multiple vitamins multiple vitamins with iron multi-symptom cold night time multi-symptom cold-cough multivital platinum multivitamin multi-vitamin hp/minerals multivitamin with iron multivitamin with minerals multivitamins with min no.7-fa multi-vite multi-vite 50 & over mupirocin mupirocin calcium muro MUSTARGEN my favorite multiple myco nail a mycophenolate mofetil mycophenolate sodium mylanta gas MYOZYME mytab gas mytab gas maximum strength my-vitalife nabumetone nadolol nafcillin nafcillin in dextrose iso-osm NAGLAZYME naloxone naltrexone naltrexone hcl NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline naproxen naproxen sodium naratriptan nasal & sinus decongestant nasal decongestant (oxymetazl) nasal decongestant (pe) NASCOBAL nasohist dm NASONEX NATACYN nateglinide natural b natural b-100 complex natural balance natural calcium natural fiber laxative therapy natural tears (pf) nature's tears NEBUPENT nefazodone neomy sulf-bacitrac zn-poly-hc neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc neosporin anti-itch neo-synephrine 12 h spr (oxym) neo-tuss NEPHRAMINE 5.4 % nephro-vite NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAFED NEXAVAR niacin... 87, 88 niacinamide nicardipine NICODERM CQ nicorelief nicorette nicotine nicotine (polacrilex) NICOTROL nifedipine night time night time cold-flu night time cold-flu relief nighttime cold-flu nighttime cough nighttime relief eye ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-13 生 效 日 期 :2015 年 5 月 1 日

189 NILANDRON nite time cold-flu nite time-d cold-flu relief NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin... 88, 89 nitroglycerin in 5 % dextrose NITROSTAT nohist-dm non-aspirin cold non-aspirin extra strength non-aspirin flu non-aspirin jr strength NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX norelgestromin/ethin.estradiol norepinephrine bitartrate noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 92, 129 norethindrone-e.estradiol-iron norethindrone-ethinyl estrad norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH nortemp NORTHERA nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOXAFIL NUCYNTA NUCYNTA ER NUEDEXTA nu-iron NULOJIX NUTRESTORE NUTRILIPID NUTRILYTE NUTRILYTE II NUTROPIN NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVIGIL nystatin NYSTATIN (BULK) nystatin-triamcinolone ocean nasal OCTAGAM octreotide acetate ocutabs OFEV ofloxacin... 35, 117 olanzapine... 67, 68 olanzapine-fluoxetine olopatadine OLYSIO omega-3 acid ethyl esters omeprazole omeprazole magnesium omeprazole-sodium bicarbonate OMNITROPE ONCASPAR once daily oncovite ondansetron ondansetron hcl ondansetron hcl (pf) one daily one daily 50 plus one daily complete one daily energy one daily essential one daily maximum (with ca) one daily men's one daily multi-vit w-mineral one daily multivitamin , 167 one daily multivitamin-iron one daily plus iron one daily plus minerals one daily with iron one-a-day essential one-a-day maximum formula one-a-day teen advantage ONFI opcicon one-step OPDIVO OPSUMIT opti-vitamins oral saline laxative oralyte ORAP ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone oxycodone hcl-acetaminophen... 17, 18 oxycodone hcl-aspirin oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone oysco 500/d oysco d ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-14 生 效 日 期 :2015 年 5 月 1 日

190 oysco oyster shell calcium oyster shell calcium-vit d oystercal-d paclitaxel pain relief pain relief adult pain reliever pain reliever jr strength PANRETIN pantoprazole papaverine paricalcitol paromomycin paroxetine hcl... 49, 50 PASER PATADAY PATANOL PAXIL pecgen dmx pedi m.vit no.17 with fluoride pedia relief pedia relief infant pediacare multi-symptom cold PEDIARIX (PF) pediatric electrolyte pediatric freezer pops pediatric multivitamin PEDVAX HIB (PF) peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl peg PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline pep-t-med peri-colace PERIKABIVEN perindopril erbumine PERJETA permethrin perphenazine perphenazine-amitriptyline persa-gel pharbetol pharmacist favorite multi-vit phenelzine phenobarbital phenobarbital sodium phentolamine phenylephrine hcl... 80, 115 phenylephrine-chlorpheniramine phenylhistine dh phenytoin phenytoin sodium phenytoin sodium extended phillips phillips liqui-gels PHOS-FLUR PHOSLYRA PHOS-NAK phosphate laxative PHOSPHOLINE IODIDE phosphorus # phytonadione PICATO pilocarpine hcl , 142 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam piroxicam PLAN B ONE-STEP PLASBUMIN 25 % PLASBUMIN 5 % PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podactin podofilox podophyllum resin polyethylene glycol poly-iron polymyxin b sulf-trimethoprim poly-tussin POLY-TUSSIN DM poly-vita poly-vita (iron) poly-vitamin poly-vitamin with iron polyvitamin/iron poly-vitamins POMALYST potassium acetate potassium bicarb and chloride potassium bicarb-citric acid potassium bicarbonate-cit ac potassium chlorid-d5-0.45%nacl potassium chloride , 148 potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-15 生 效 日 期 :2015 年 5 月 1 日

191 potassium chloride-d5-0.9%nacl potassium citrate-citric acid potassium hydroxide potassium phosphate dibasic POTIGA PRADAXA pramipexole PRANDIMET pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate , 130 prednisone PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal prenatal formula prenatal vit#96-ferrous fum-fa prenatal vitamin with minerals prenatal vitamins prenatal vit-iron fumarate-fa preparation h hydrocortisone PREVIDENT 5000 SENSITIVE PREZISTA PRIFTIN PRILOSEC OTC PRIMAQUINE primidone PRISTIQ PRIVIGEN PROAIR HFA probenecid procainamide PROCALAMINE 3% prochlorperazine edisylate prochlorperazine maleate... 63, 64 PROCRIT PROCYSBI progesterone progesterone micronized PROGLYCEM PROGRAF PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 60, 64 promethazine hcl promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promolaxin propafenone propantheline proparacaine proparacaine hcl proparacaine-fluorescein sod propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) prosight PROSOL 20 % protamine PROTOPIC protriptyline pseudoephedrine hcl PULMOZYME pure & gentle eye purelax PURIXAN pyrazinamide pyridostigmine bromide pyridoxine q-dryl q-pap q-pap extra strength q-tapp q-tapp dm q-tussin q-tussin dm QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECOMBIVAX HB (PF) recort plus refenesen refenesen pe REFRESH CLASSIC (PF) REFRESH LACRI-LUBE REFRESH LIQUIGEL REFRESH OPTIVE REFRESH OPTIVE ADVANCED reguloid relcof c RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENVELA repaglinide RESCRIPTOR RESTASIS retaine cmc RETROVIR REVATIO ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-16 生 效 日 期 :2015 年 5 月 1 日

192 REVLIMID REYATAZ REZIRA ribavirin RIDAURA rifabutin rifampin RIFATER ri-gel ri-gel ii riluzole rimantadine ri-mox ringers , 148 risedronate RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate rizatriptan robafen robafen cough robafen dm robitussin cough & cold cf robitussin cough-chest-cong dm robitussin dm max robitussin long-acting robitussin pediatric ropinirole ROTARIX ROTATEQ VACCINE ROZEREM rydex SABRIL safe tussin dm SAIZEN SAIZEN CLICK.EASY saline mist salsalate SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SAVELLA scooby-doo one a day scot-tussin dm scot-tussin expectorant sea soft nasal mist selegiline hcl selenium sulfide SELZENTRY senexon senna senna lax senna with docusate sodium senokot-s SENSIPAR sentry sentry senior SEREVENT DISKUS SEROQUEL XR SEROSTIM sertraline silace siladryl sa silapap sildenafil SILENOR siltussin dm das siltussin sa silver nitrate silver nitrate applicators silver sulfadiazine SIMBRINZA simethicone simply sleep SIMPONI SIMPONI ARIA simvastatin sinus & allergy (pseudoephed) sirolimus SIRTURO skin treatment sleep aid (diphenhydramine) sleep-tabs smoothlax sochlor sodium acetate sodium bicarbonate , 148 sodium chloride , 136, 149, 151 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium chloride-nahco3-kcl-peg sodium citrate-citric acid sodium fluoride sodium lactate sodium phosphate sodium polystyrene sulfonate sodium thiosulfate sod-pot-k cit-sod cit-cit acid SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe (bismuth subsalicylate) soothe regular strength sorbitol sorbitol-mannitol sotalol sotalol hcl SOVALDI spectravite spectravite adult spectravite advanced formula spectravite senior spectravite senior w-lycopene spectravite ultra women SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRYCEL st joseph aspirin st. joseph aspirin stavudine ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-17 生 效 日 期 :2015 年 5 月 1 日

193 STELARA STERILE LUBRICANT STERILE PADS STIVARGA stomach relief STRATTERA streptomycin stress 500 plus zinc stress b with zinc stress b-biotin stress formula stress formula plus iron stress formula with iron stress formula with zinc STRIBILD STROMECTOL stuart prenatal sucralfate sudogest sudogest cold & allergy sudogest pe sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulfatrim sulfazine sulfazine ec sulindac sumatriptan sumatriptan succinate summer's eve disposable douche summers eve extra cleansing sunvite super b complex-vitamin c super b/c super b-50 complex super b-50 complex plus super multiple super multivitamin super quints b super thera vite m superior superplex-t suphedrin suphedrine pe day-night suphedrine severe cold max str support support SUPPRELIN LA SUPRAX SURE COMFORT INS. SYR. U SURMONTIL SUSPENDOL-S SUSTIVA SUTENT SYLATRON SYLATRON 4-PACK SYLVANT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYPRINE tab-a-vite tab-a-vite/iron tab-a-vite-minerals TABLOID tacrolimus , 134 tactinal tactinal extra strength TAFINLAR TAMIFLU tamoxifen tamsulosin TARCEVA TARGRETIN... 42, 43 tarina fe TASIGNA TAZORAC taztia xt tears again TEARS NATURALE II TECFIDERA TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam TEMODAR TENIVAC (PF) terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracaine hcl tetracycline TEV-TROPIN THALOMID the magic bullet theophylline theophylline anhydrous theophylline in dextrose 5 % thera m plus (ferrous fumarat) thera vitamin theradex m theraflu nighttime severe cold theraflu severe cold-cough thera-m theramill forte therapeutic liquid therapeutic m + beta-carotene therapeutic vitamins/minerals therapeutic-m therapeutic-m vitamin/minerals ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-18 生 效 日 期 :2015 年 5 月 1 日

194 thera-tabs theratrum complete 50 plus theratrum complete 50 plus/lut therems therems-h therems-m thiamine hcl thioridazine thiothixene tiagabine TICE BCG TIKOSYN timolol maleate... 83, 142, 143 TIVICAY tizanidine TOBI PODHALER TOBRADEX ST tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl tobramycin sulfate tolazamide tolbutamide tolmetin tolnaftate tolterodine topiramate toposar intravenous topotecan TORISEL torsemide total b/c totalday multiple TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travel sickness (meclizine) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triacting m-sym cold/cough triamcinolone acetonide , 110, 130 triaminic cold & cough (pe) triaminic cold & cough nt (pe) triaminic cough-nasal congesti triaminic cough-sore throat triamterene-hydrochlorothiazid triazolam... 27, 28 TRIBENZOR tri-buffered aspirin triderm tri-dex pe trifluoperazine trifluridine trigofen dm trihexyphenidyl TRILEPTAL trimethoprim triple paste af TRIUMEQ tri-vi-sol tri-vita tri-vitamin TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA trymine cg TUDORZA PRESSAIR tusnel diabetic TUSNEL PEDIATRIC tussin cf tussin cf cough-cold tussin cold-congestion tussin cough (dm only) tussin dm tussin dm cough & chest tussin maximum strength cough tussin pe TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO TYVASO REFILL KIT TYVASO STARTER KIT TYZEKA ULORIC ultra b-100 complex ultra fresh pm ultra sleep (doxylamine succ) ultra strength antacid unicomplex-m unisom sleepgels ursodiol , 124 VAGIFEM valacyclovir VALCHLOR VALCYTE valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALSTAR valu-tapp dm vancomycin... 29, 30 vancomycin in d5w ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-19 生 效 日 期 :2015 年 5 月 1 日

195 VAQTA (PF) VARIVAX (PF) VASCEPA vasopressin VECTIBIX VELCADE venlafaxine VENTAVIS verapamil... 83, 84 VERSACLOZ vicks dayquil cough vicks nature fusion cough vicks qlearquil(oxymetazoline) vicks sinex 12-hour VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAMOX VIIBRYD VIMIZIM VIMPAT vinblastine vincristine vincristine sulfate vinorelbine VIRACEPT VIRAMUNE XR VIRAZOLE virdec dm VIREAD vision vision formula vision formula (with lutein) vision plus lutein vit b cmplx 3-fa-vit c-biotin vit b cmplx no3-fa-c-biot-zinc vitabee/c vitalets vitamin a vitamin b complex vitamin b complex with c vitamin b vitamin b-100 complex vitamin b12-folic acid vitamin b vitamin c vitamins & minerals vitamins b complex , 174 vitamins for hair VITEKTA vitrum senior VIVELLE-DOT VOLTAREN voriconazole VOTRIENT VPRIV wal-act d cold & allergy wal-dram wal-dryl allergy wal-finate wal-finate-d wal-itin wal-itin d wal-itin d 12 hour wal-phed... 61, 103 wal-phed pe wal-phed pe day-night wal-phed pe sinus & allergy wal-profen wal-sleep z wal-som wal-tap wal-tussin cough wal-tussin cough & cold cf wal-tussin dm wal-zan wal-zyr (cetirizine) wal-zyr (ketotifen) wal-zyr d warfarin water for irrigation, sterile WELCHOL women's daily multivitamin XALKORI XARELTO XELJANZ XENAZINE XGEVA XIFAXAN XOLAIR XTANDI xylon XYREM yelets YERVOY YF-VAX (PF) zafirlukast zaleplon ZALTRAP zantac ZAVESCA ZELBORAF ZEMAIRA ZEMPLAR ZENPEP zephrex-d ZETIA ZIAGEN zidovudine zinc oxide ziprasidone hcl ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem ZOMETA ZONATUSS zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) ZOVIRAX z-sleep ZUBSOLV ZYDELIG ZYKADIA ZYLET zyncof ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-20 生 效 日 期 :2015 年 5 月 1 日

196 ZYPREXA RELPREVV ZYRTEC zyrtec itchy eye drops (keto) ZYTIGA ZYVOX ICS 社 区 护 理 增 值 计 划 2015 FIDA-MMP 处 方 集 处 方 集 ID: ; 版 本 :9 I-1 生 效 日 期 :2015 年 5 月 1 日

197 此 处 方 集 更 新 时 间 为 2015 年 5 月 1 日 如 有 问 题, 请 在 周 一 至 周 五 上 午 8 点 至 晚 上 8 点 致 电 ICS Community Care Plus FIDA-MMP 计 划, 电 话 号 码 为 ICS.2525 此 为 免 费 电 话 更 多 详