Plan Year 2022 CCHP Senior Select Program (HMO D-SNP) 東華智選 (HMO D-SNP) 計劃 2022 Formulary (List of Covered Drugs) 藥物表 ( 保障藥物一覽表 ) 請閱讀 : 本文件包含有關我們在本計劃中涵

Transcription

1 Plan Year 2022 CCHP Senior Select Program (HMO D-SNP) 東華智選 (HMO D-SNP) 計劃 2022 Formulary (List of Covered Drugs) 藥物表 ( 保障藥物一覽表 ) 請閱讀 : 本文件包含有關我們在本計劃中涵蓋的藥物信息 HPMS Approved Formulary File Submission ID , Version Number 4 本藥物表是 202 年 8 月 9 日修定本 如欲了解最新詳情或有疑問, 請致電 與華人保健計劃會員服務中心聯絡 ( 聽力殘障人仕請電 TTY ), 每週 7 天, 上午 8 時至晚上 8 時, 或瀏覽網址 H057_2022_56CH_FINAL C

2 會員請注意 : 此藥物表已經修改, 請查閱您服食的藥物是否仍受承保 在此藥物㆒覽表 ( 藥物表 ), 我們 或 我們的 表 CCHP 東華智選 (HMO D-SNP) 計劃 本計劃 或 我們的計劃 表東華智選 (HMO D-SNP) 計劃 此藥物表列出我們承保藥物的最新版本, 生效 期是 : 202 年 8 9 如欲索取最新的處方藥物表, 請與我們聯繫 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 您通常須前往聯網藥房, 以獲享配購處方藥物的保障 保障 藥物表 聯網藥房 費及 / 或 付費 / 共同保險額, 或於 2022 年 起 更新 甚麼是東華智選 (HMO D-SNP) 計劃藥物表? 東華智選 (HMO D-SNP) 計劃與㆒組医療保健提供者商議之, 選擇了㆒批最能確保優質治療方案的處方藥物, 並在此列出這份藥物表 只要您配購的藥物是基於治療所需 在東華智選 (HMO D-SNP) 計劃屬 的聯網藥房購買, 以及附合其他條款, 則受承保 欲了解如何配取處方藥物, 請參閱保障說明書 如需㆒份完整的東華智選 (HMO D-SNP) 計劃所涵蓋的處方藥物表, 請致電與我們聯絡或到我們 的網站查詢 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 藥物㆒覽表 ( 藥物表 ) 會 更改嗎? 大部分藥物保障範圍的更改會在 作出, 但藥物表也 可能會在年 添加或刪除藥物, 如將某藥物移到另㆒個 付費等級, 或加入新限制 我們必須遵守聯邦保健 (Medicare) 的規定進行更改 列更改是會影響到您今年的藥物保障 : 新非商標藥物, 如果我們同時以相同或更少限制及相同或較低分擔費用等級的新非商標藥替 藥物表 的商標藥 ; 我們可能會立即在我們的藥物表 刪除商標藥 此外, 在添加新非商標藥時, 我們可能會決定將商標藥物保留在我們的藥物表, 但會立即將其移 不同的分擔費用等級或添加新的限制 如果您正在服用該商標藥物, 我們可能未我們可能未提前通知您 關的更改, 但仍會在更改後通知您 o 如我們作出更改, 您或處方医生可要求本計劃對藥物進行例外處理及要求繼續承保該商標藥物 了解如何提出例外處理, 請參閱本冊 如何要求東華智選 (HMO D-SNP) 計劃對藥物作出例外處理? 部分 I

3 藥物在市場 被移除回收 如果藥物表內 藥物經聯邦藥物及食品管理局認為不安全或藥廠從市場 收回的藥物, 我們會立刻將該藥物從藥物表內刪除, 並通知服食該藥物的會員 其他更改 我們的更改可能影響到會員正在服用的藥物 例如 : 我們可能增加㆒種並不是新的非商標藥以取 在藥物表 的商標藥, 或會更改商標藥的分擔費用等級或添加新的限制, 亦 可能亦 可能根據新的臨床医療指南進行更改或增加事前批准條例, 數量限制或階段治療限制, 亦可能將藥物分擔費用等級提高 我們在更改前最少 30 內通知會員或在會員提出加配藥物要求時我們會提供 30 的藥量 o 如我們作出更改, 您或處方医生可要求本計劃對藥物進行例外處理及要求繼續承保該商標藥物 了解如何提出例外處理, 請參閱本冊 如何要求東華智選 (HMO D-SNP) 計劃對藥物作出例外處理? 部分 大部分更改是不會影響到您現正服用的藥物的保障 : ㆒般來說, 除非是 列情況, 如果您正在服用我們的 2022 年年初藥物表 的藥物, 我們在 2022 年保障期內不會停止或減少對此藥物的保障 這意味著會員服用的這些藥物在保障期內會繼續得到保障, 並在無額外限制 以同樣的 付費配購藥物 此藥物表為 202 年 8 9 起更新 欲索取最新的藥物表, 請與我們聯絡 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 如果藥物表在年 任何更改, 我們會寄發糾正通知, 您亦可瀏覽 查閱變更 II

4 如何使用此藥物表? 以 列出兩種方法查閱藥物表內的藥物 : 按疾病狀況 藥物表從第 3 頁開始, 並以疾病情況來分類 例如, 用來治療心臟病的藥物歸屬於 心血管藥物 - 其它 ㆒欄 如果您知道您的藥物用來作何種用途的話, 請查閱分類目錄從第 3 頁開始, 然後按該目錄的分類找出您要配購的藥物 按藥物 稱的英文字母排列 如果您不確定藥物屬於那㆒項分類, 您可以查閱藥物表第 I- 頁開始的藥物 稱的英文字母索引 英文字母索引列出藥物表所 的藥物, 包括商標及非商標藥物 請查閱索引, 找出您要配購的藥物 在藥物 稱的同㆒欄, 找出 關該藥物保障 料的頁數, 然後到該頁內查閱藥物的 料 甚麼是非商標藥物? 東華智選 (HMO D-SNP) 計劃承保商標藥物及非商標藥物 非商標藥物與商標藥物通常是採用同樣的成份製成 非商標藥物是經過聯邦藥物及食品管理局 (FDA) 認可而價格比商標藥物較廉宜 保障的藥物 其它的限制嗎? 某些保障藥物可能 附加的限制或規定, 這些限制或規定可能包括以 幾點 : 需取得事先批准 : 東華智選 (HMO D-SNP) 計劃要求某些藥物需事先取得批准方能購買 這就是說, 您 ( 或您的医生 ) 必須取得東華智選 (HMO D-SNP) 計劃的批准, 方能配購這些處方藥物 否則, 東華智選 (HMO D-SNP) 計劃是不會承保該藥物的保障 數量限制 : 東華智選 (HMO D-SNP) 計劃對某些藥物的保障設 數量的限制 ㆒般而言, 藥物通常配㆒個 或㆔個 的藥量, 但某些藥物是 限制的, 如 SAVELLA, 每張處方只可配 60 tablets 階段治療 : 在某些情況, 東華智選 (HMO D-SNP) 計劃可能要求您在治療疾病時, 先嘗試建議的藥物, 然後再考慮是否承保另㆒類的藥物 例如 A 類藥物與 B 類藥物皆可以治療您的疾病, 東華智選 (HMO D-SNP) 計劃可能讓您先使用 A 類藥物, 若沒 成效才保障 B 類藥物的費用 III

5 您可從第 3 頁開始, 找到您欲配購的處方藥物是否 附加規定或限制 查詢更多 關藥物的限制及附加規定, 請瀏覽我們的網址 我們的網址 載了關於事前批准及階段治療的條款限制的文件 您亦可以聯絡我們索取㆒分影印本 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 您可以要求東華智選 (HMO D-SNP) 計劃對這些附加規定或限制作出例外處理, 或提供治療同㆒種症狀的其他承保藥物 稱 了解如何提出例外處理, 請參閱本冊 如何要求東華智選 (HMO D-SNP) 計劃對藥物作出例外處理? 部分, 第 IV 頁 什麼是非處方藥物 (OTC)? 配購非處方藥物無須医生處方, 通常不受聯邦健保處方藥物計劃的保障 東華智選 (HMO D-SNP) 計劃會保障某些非處方藥物 FREESTYLE LITE METER FREESTYLE FREEDOM LITE METER FREESTYLE LITE TEST STRIPS FREESTYLE INSULINX METER FREESTYLE INSULINX TEST STRIPS FREESTYLE CONTROL SOLUTION PRECISION XTRA METER PRECISION XTRA TEST STRIPS MEDISENSE CONTROL SOLUTION LANCETS LANCET DEVICES LANCET KIT KETOTIFEN FUMARATE OPHTHALMIC LORATADINE CETIRIZINE FEXOFENADINE LEVOCETIRIZINE OLOPATADINE 東華智選 (HMO D-SNP) 計劃免費提供以 非處方藥物 這些藥物的費用將不計算入您的 D 部份藥物費用總額 ( 即非處方藥物費用不計算入承保間斷期藥物費用額 ) 如果我的藥物不包括在藥物表內該怎麼辦? 如果您的藥物並不包括在藥物表 ( 藥物㆒覽表 ) 內, 您應該首先與會員服務 心聯絡, 求證該藥物是否受保障 如需更多 料, 請與我們聯絡 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 如果您的藥物不受保障, 您 以 兩種選擇 : 您可以向會員服務 心索取㆒份受東華智選 (HMO D-SNP) 計劃保障的同類型藥物表 然 IV

6 後出示給您的医生, 要求医生處方受保障的藥物 您也可以向東華智選 (HMO D-SNP) 計劃要求對您所需的藥物作出例外保障處理 請參閱以, 了解如何提出例外處理 如何要求東華智選 (HMO D-SNP) 計劃對藥物作出例外處理? 您可以要求東華智選 (HMO D-SNP) 計劃對藥物保障作出例外處理 以 是兩種可以提出例外處理的例子 您可以要求本計劃承保沒 列在藥物表之內的藥物 若計劃批准您的要求, 您的藥物將會 ㆒個 定的分攤費用, 而您將不能再申請降低該藥物的分攤費 除了 殊藥物外, 您可以要求本計劃以較低的分攤費等級承保您的藥物 如果獲得批准, 可減低您需要支付的藥物費用 您也可以要求我們取消對您所需藥物的限制或規定 例如東華智選 (HMO D-SNP) 計劃對某些藥物 數量的限制, 您可以要求我們取消此限制或增加承保的數量 ㆒般來說, 如果其它在藥物表 的藥物對您的病情無效或引起不良的副作用, 東華智選 (HMO D-SNP) 計劃才會批准您的要求作例外情況處理 您可以聯絡我們要求對您的申請作㆒個初級的審定附加條件限制例外處理 當在申請對藥物表或附加條件限制等例外處理時, 您必須附加㆒份医生或處方藥劑師的證明作為支持申請的理據 ㆒般來說, 我們會在收到 關医生的證明文件後 72 小時內對您的申請作出答覆 如果您或您的医生認為在等候的 72 小時內會危害到您的健康情況, 您可以要求加快例外處理 如果您的加快申請獲得批准, 我們會在收到 關医生或處方藥劑師的證明文件後的 24 小時內作出決定 在與医生商量改藥或申請例外處理之前, 我該怎麼辦? 無論是新會員或現任會員, 您正在服食的藥物可能不包括在藥物表內, 又或藥物在藥物表內但 限制 例如, 您需預先取得我們的批准方能配購藥物 您應與医生商量您是否可轉用另㆒種保障之內的藥物, 或提出例外處理的申請以使您的藥物受到保障 在某情況, 您與医生商量的期間內, 我們可以在您成為會員的首 90 之內承保您所需的藥物 如果您的藥物不在藥物表內或取不到藥物的情況, 您必須在聯網藥房配購藥物, 我們會為每㆒種藥物提供 30 的臨時保障 ( 如果您的藥物處方是少於 30, 我們會允許續配最 V

7 多 30 藥量 ) 但在 30 之後, 即使您是加入不到 90 的新會員, 我們也不再保障 關所需的藥物 如果您住在長期療養院內, 您需要的藥物不在藥物表內, 又或 困難取到藥物, 但您又超過了 90 的新會員期, 在申請藥物例外處理的過程, 我們會提供 3 的緊急藥物補給量 欲了解 關詳情 欲了解更多 關東華智選 (HMO D-SNP) 計劃處方藥物保障, 請參閱保障說明書及計劃的其它說明 料 如對東華智選 (HMO D-SNP) 計劃 任何疑問, 請與我們聯絡 我們的聯絡 料連同最近更新藥物表的 期會列在本冊的封面及封底 如您對聯邦保健藥物保障 任何疑問, 可於每週 7, 每 24 小時, 致電聯邦保健 -800-MEDICARE ( ), 聽力殘障 士請致電 TTY , 或瀏覽 : 東華智選 (HMO D-SNP) 計劃處方藥物表 頁的藥物目錄表提供了東華智選 (HMO D-SNP) 計劃承保的部份處方藥物 料 如您對查閱藥物 任何疑問, 請查閱索引目錄第 I- 頁 藥物表內第㆒欄是藥物的 稱, 商標藥物以大写字母列出, 如 (VYVANSE ), 而非商標藥物則以斜體小写字母列出, 如 (alendronate) 在 殊要求該欄, 說明了東華智選 (HMO D-SNP) 計劃對您所需的藥物是否 別的規定及限制 LD 標誌的藥物表示該藥物受聯邦藥物及食品管理局 (FDA) 的限制, 並只能在指定藥房購買 詳情請查閱医生 錄, 医療服務及藥房手冊或請每週㈦, 午 8 時 晚 8 時致電 與會員服務 心聯絡 聽力殘障 士請致電 TTY NM 標誌的藥物表示該非郵寄服務藥物在零售及郵寄藥房都只供應 30 的藥量 PA 標誌的藥物表示該藥物需要預先取得批准 這就是說, 在配購藥物前, 您 ( 或您的医生 ) 必須取得東華智選 (HMO D-SNP) 計劃的批准, 方能配購這些處方藥物 否則, 東華智選 (HMO D-SNP) 計劃是不會承保該藥物的保障 VI

8 PA BvD 標誌的藥物表示, 該藥物同時在聯邦保健 D 部分或 B 部分藥物承保 您 ( 或您的医生 ) 需要東華智選 (HMO D-SNP) 計劃事前批准來確定該藥物被哪㆒個藥物保障部分承保, 你才能配藥 若沒 事前批准, 東華智選 (HMO D-SNP) 計劃可能不承保該藥物 PA NSO 標誌的藥物表示, 如會員從未配購該藥物, 您 ( 或您的医生 ) 需要取得東華智選 (HMO D-SNP) 計劃事前批准才能配藥 若沒 事前批准, 東華智選 (HMO SNP) 計劃可能不承保該藥物 QL 標誌的藥物表示該藥物 數量的限制 東華智選 (HMO D-SNP) 計劃設 具體的限制包括 : 每 的數量限制, 每 的數量限制或每年的數量限制 ST 標誌的藥物表示該藥物在某些情況, 東華智選 (HMO D-SNP) 計劃可能要求您在治療疾病時, 先嘗試建議的藥物, 然後再考慮是否承保另㆒類的藥物 例如 A 類藥物與 B 類藥物皆可以治療您的疾病, 東華智選 (HMO D-SNP) 計劃可能讓您先使用 A 類藥物, 若沒 成效才保障 B 類藥物的費用 VII

9 目錄 Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials... Anticancer Agents... 8 Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents... 7 Central Nervous System Agents Contraceptives Dental And Oral Agents... 92

10 Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying... 0 Immunological Agents... 6 Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution QL ( /5 ml acetaminophen-codeine oral tablet QL ( , acetaminophen-codeine oral tablet QL ( ascomp with codeine oral capsule QL (80 buprenorphine hcl injection solution (Buprenex) 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch (Butrans) QL (4 per 28 days) weekly 0 mcg/hour, 5 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital-acetaminop-caf-cod oral (Fioricet with Codeine) QL (80 capsule butalbital-acetaminop-caf-cod oral QL (80 capsule butalbital-acetaminophen oral tablet (Tencon) QL ( butalbital-acetaminophen-caff oral (Zebutal) QL (80 capsule butalbital-acetaminophen-caff oral (Esgic) QL (80 tablet butalbital-aspirin-caffeine oral QL (80 capsule butalbital-aspirin-caffeine oral tablet QL ( butorphanol nasal spray,non-aerosol QL (5 per 28 days) 0 /ml codeine sulfate oral tablet 30, 60 QL (80 codeine-butalbital-asa-caff oral (Ascomp with Codeine) QL (80 capsule endocet oral tablet QL (80 endocet oral tablet , 5- QL ( endocet oral tablet QL (240 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 3 3

12 fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet 0-325, , hydrocodone-acetaminophen oral tablet , 5-300, hydrocodone-ibuprofen oral tablet 0-200, 5-200, hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml (Actiq) PA; NM; NDS; QL (20 (Actiq) PA; QL (20 per 30 days) QL (0 QL (2700 (Vicodin HP) QL (80 QL (80 QL (240 QL (50 hydromorphone oral liquid /ml (Dilaudid) QL (200 hydromorphone oral tablet 2, 4 (Dilaudid) QL (80, 8 LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY PA; NM; NDS; QL (30 methadone injection solution 0 QL (20 /ml methadone oral solution 0 /5 ml QL (600 methadone oral solution 5 /5 ml QL (200 methadone oral tablet 0 QL (20 methadone oral tablet 5 QL (80 methadose oral tablet,soluble 40 QL (30 morphine concentrate oral solution 00 /5 ml (20 /ml) PA; QL (80 per 30 days) morphine oral solution 0 /5 ml QL (700 morphine oral solution 20 /5 ml (4 QL (300 /ml) MORPHINE ORAL TABLET 5 QL (80 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 4 4

13 MORPHINE ORAL TABLET 30 QL (20 morphine oral tablet extended (MS Contin) QL (60 release 00, 200, 60 morphine oral tablet extended (MS Contin) QL (90 release 5, 30 oxycodone oral capsule 5 QL (80 oxycodone oral concentrate 20 /ml PA; QL (20 per 30 days) oxycodone oral solution 5 /5 ml QL (300 oxycodone oral tablet 0 QL (80 oxycodone oral tablet 5, 30 (Roxicodone) QL (20 oxycodone oral tablet 20 QL (20 oxycodone oral tablet 5 (Roxicodone) QL (80 oxycodone oral tablet,oral only,ext.rel.2 hr 0, 5, 20, 30, 40, 60, 80 (OxyContin) QL (60 oxycodone-acetaminophen oral tablet (Endocet) QL ( oxycodone-acetaminophen oral tablet (Endocet) QL ( , oxycodone-acetaminophen oral tablet (Endocet) QL ( oxycodone-aspirin oral tablet QL ( OXYCONTIN ORAL QL (60 TABLET,ORAL ONLY,EXT.REL.2 HR 0, 5, 20, 30, 40, 60, 80 oxymorphone oral tablet 0 QL (20 oxymorphone oral tablet 5 QL (80 oxymorphone oral tablet extended QL (60 release 2 hr 0, 5, 20, 30, 40, 5, 7.5 tencon oral tablet QL (80 tramadol oral tablet 50 (Ultram) QL (240 tramadol-acetaminophen oral tablet (Ultracet) QL ( vicodin hp oral tablet QL (80 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 5 5

14 XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT CRUSH) 3.5, 8, 9 XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT CRUSH) 27 XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT QL (60 QL (20 QL (240 CRUSH) 36 zebutal oral capsule QL (80 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 00, 200, 400, 50 (Celebrex) QL (60 diclofenac epolamine transdermal (Flector) PA; QL (60 patch 2 hour.3 % diclofenac potassium oral tablet 50 (Cataflam) QL (20 diclofenac sodium oral tablet QL (60 extended release 24 hr 00 diclofenac sodium oral tablet,delayed QL (50 release (dr/ec) 25 diclofenac sodium oral tablet,delayed QL (20 release (dr/ec) 50 diclofenac sodium oral tablet,delayed QL (60 release (dr/ec) 75 diclofenac sodium topical drops.5 QL (300 % diclofenac sodium topical gel % (Arthritis Pain QL (000 (diclofenac)) diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 28 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg (Arthrotec 50) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg (Arthrotec 75) diflunisal oral tablet 500 DUEXIS ORAL TABLET PA; NM; NDS; QL (90 etodolac oral capsule 200, 300 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 6 6

15 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 fenoprofen oral tablet 600 (Nalfon) flurbiprofen oral tablet 00 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 (Children's Advil) ml ibuprofen oral tablet 400, 600, 800 (IBU) indomethacin oral capsule 25 QL (240 indomethacin oral capsule 50 QL (20 indomethacin oral capsule, extended QL (60 release 75 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 24 hr 200 ketorolac injection cartridge 5 QL (40 /ml ketorolac injection cartridge 30 QL (20 /ml ketorolac injection solution 5 /ml QL (40 ketorolac injection solution 30 /ml QL (20 ( ml) ketorolac injection syringe 5 /ml QL (40 ketorolac injection syringe 30 /ml QL (20 ketorolac intramuscular cartridge 60 QL (20 /2 ml ketorolac intramuscular solution 60 QL (20 /2 ml ketorolac intramuscular syringe 60 QL (20 /2 ml ketorolac oral tablet 0 QL (20 mefenamic acid oral capsule 250 meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 (Relafen) naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 375, 500 (EC-Naprosyn) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 7 7

16 naproxen-esomeprazole oral tablet,ir,delayed rel,biphasic PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 /GRAM /ACTUATION(2 %) (Vimovo) PA; NM; NDS; QL (60 PA; NM; NDS; QL (224 per 28 days) piroxicam oral capsule 0, 20 (Feldene) sulindac oral tablet 50, 200 tolmetin oral capsule 400 tolmetin oral tablet 200, 600 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % QL (30 lidocaine (pf) injection solution 5 (Xylocaine-MPF) /ml (.5 %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl % 20 /2 ml vl latexfree, (Xylocaine-MPF) sdv, p/f 0 /ml ( %) lidocaine hcl injection solution 0 /ml ( %), 20 /ml (2 %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly QL (30 2 % lidocaine hcl mucous membrane PA solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % PA; QL (30 ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED.8 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents PA; QL (90 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 8 8

17 acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet 2 QL (90, 8 buprenorphine-naloxone sublingual (Suboxone) QL (60 film 2-3, 8-2 buprenorphine-naloxone sublingual (Suboxone) QL (30 film 2-0.5, 4- buprenorphine-naloxone sublingual QL (90 tablet 2-0.5, 8-2 bupropion hcl (smoking deter) oral tablet extended release 2 hr 50 CHANTIX CONTINUING MONTH QL (336 per 365 days) BOX ORAL TABLET CHANTIX ORAL TABLET 0.5, QL (336 per 365 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 ()- (42) disulfiram oral tablet 250, 500 KLOXXADO NASAL QL (4 SPRAY,NON-AEROSOL 8 /ACTUATION LUCEMYRA ORAL TABLET 0.8 NM; NDS; QL (228 per 4 days) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 AEROSOL 4 /ACTUATION NICOTROL INHALATION QL (008 per 90 days) CARTRIDGE 0 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 /0.5 ML NM; NDS; QL (0.5 per 30 days) SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 300 /.5 ML Antianxiety Agents Benzodiazepines NM; NDS; QL (.5 per 30 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 9 9

18 alprazolam oral tablet 0.25, 0.5 (Xanax) QL (20, alprazolam oral tablet 2 (Xanax) QL (50 alprazolam oral tablet extended (Xanax XR) QL (20 release 24 hr 0.5,, 2 alprazolam oral tablet extended (Xanax XR) QL (90 release 24 hr 3 chlordiazepoxide hcl oral capsule 0 QL (20, 25, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 clonazepam oral tablet 2 (Klonopin) QL (300 clonazepam oral tablet,disintegrating QL ( , 0.25, 0.5, clonazepam oral tablet,disintegrating QL (300 2 clorazepate dipotassium oral tablet QL (80 5, 3.75 clorazepate dipotassium oral tablet (Tranxene T-Tab) QL ( diazepam injection solution 5 /ml QL (0 per 28 days) diazepam injection syringe 5 /ml QL (0 per 28 days) diazepam oral concentrate 5 /ml (Diazepam Intensol) QL (200 diazepam oral solution 5 /5 ml ( QL (200 /ml) diazepam oral tablet 0, 2, 5 (Valium) QL (20 estazolam oral tablet QL (60 estazolam oral tablet 2 QL (30 flurazepam oral capsule 5 QL (60 flurazepam oral capsule 30 QL (30 lorazepam 2 /ml oral concent 2 (Lorazepam Intensol) QL (50 /ml lorazepam injection solution 2 (Ativan) QL (2 /ml, 4 /ml lorazepam injection syringe 2 /ml, QL (2 4 /ml lorazepam intensol oral concentrate QL (50 2 /ml lorazepam oral tablet 0.5, (Ativan) QL (90 lorazepam oral tablet 2 (Ativan) QL (50 midazolam oral syrup 2 /ml QL (0 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 0 0

19 oxazepam oral capsule 0, 5, QL (20 30 temazepam oral capsule 5, 30 (Restoril) QL (30 triazolam oral tablet 0.25 QL (20 triazolam oral tablet 0.25 (Halcion) QL (60 Antibacterials Aminoglycosides gentamicin injection solution 20 /2 ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 20 /2 ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 streptomycin intramuscular recon NM; NDS soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION NM; NDS; QL (224 per 28 days) DEVICE 28 tobramycin in % nacl (Tobi) PA BvD; NM; NDS inhalation solution for nebulization 300 /5 ml tobramycin inhalation solution for (Bethkis) PA BvD; NM; NDS nebulization 300 /4 ml tobramycin sulfate injection solution 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, (Cleocin HCl) 300, 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊

20 clindamycin phosphate injection (Cleocin) solution 50 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection (Coly-Mycin M PA BvD; NM; NDS recon soln 50 Parenteral) daptomycin intravenous recon soln (Cubicin) NM; NDS 500 FIRVANQ ORAL RECON SOLN 25 /ML linezolid 600 /300 ml-0.9% nacl 600 /300 ml linezolid in dextrose 5% intravenous (Zyvox) piggyback 600 /300 ml linezolid oral suspension for (Zyvox) NM; NDS reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /00 ml metronidazole oral tablet 250, 500 nitrofurantoin macrocrystal oral (Macrodantin) QL (20 capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 capsule 00 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS NM; NDS RECON SOLN 500 trimethoprim oral tablet 00 vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 25 (Vancocin) QL (56 per 4 days) vancomycin oral capsule 250 (Vancocin) QL (2 per 4 days) XIFAXAN ORAL TABLET 200 PA; NM; NDS; QL (9 XIFAXAN ORAL TABLET 550 PA; NM; NDS; QL (90 Cephalosporins 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 2 2

21 cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefaclor oral tablet extended release 2 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefepime injection recon soln gram, 2 gram cefixime oral capsule 400 (Suprax) cefixime oral suspension for (Suprax) reconstitution 00 /5 ml, 200 /5 ml cefotaxime injection recon soln gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln gram, 2 gram (Fortaz) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 3 3

22 ceftazidime injection recon soln 6 (Tazicef) gram ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 TEFLARO INTRAVENOUS NM; NDS RECON SOLN 400, 600 Macrolides azithromycin intravenous recon soln (Zithromax) 500 azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack), 600 azithromycin oral tablet 250, 500 (Zithromax) clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 /ML ST; NM; NDS; QL (36 per 0 days) DIFICID ORAL TABLET 200 ST; NM; NDS; QL (20 per 0 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 4 4

23 erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral suspension for reconstitution 400 /5 ml erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 /ML ertapenem injection recon soln gram imipenem-cilastatin intravenous recon soln 250 imipenem-cilastatin intravenous recon soln 500 meropenem intravenous recon soln gram meropenem intravenous recon soln 500 meropenem-0.9% nacl 500 / /50 ml Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml (E.E.S. Granules) (EryPed 400) (Azactam) PA; NM; LA; NDS (Invanz) (Primaxin IV) (Augmentin) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 5 5

24 amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral (Augmentin) tablet , amoxicillin-pot clavulanate oral (Augmentin XR) tablet extended release 2 hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin sodium injection recon soln gram, 0 gram, 25, 2 gram, 250, 500 ampicillin-sulbactam injection recon (Unasyn) soln.5 gram, 5 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin gm/ 50 ml inj gram/50 ml nafcillin 2 gm/ 00 ml inj 2 gram/00 ml nafcillin injection recon soln gram, 2 gram nafcillin injection recon soln 0 gram NM; NDS penicillin g potassium injection recon (Pfizerpen-G) soln 20 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 6 6

25 pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 PA; NM; NDS; QL (28 per 4 days) ciprofloxacin hcl oral tablet 00 ciprofloxacin hcl oral tablet 250, (Cipro) 500 ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml, 400 /200 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250, 500, 750 moxifloxacin oral tablet 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet Tetracyclines demeclocycline oral tablet 50, 300 doxy-00 intravenous recon soln 00 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 7 7

26 doxycycline hyclate intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 20 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50, 75 doxycycline hyclate oral tablet,delayed release (dr/ec) 200, 50 doxycycline monohydrate oral capsule 00 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 00 doxycycline monohydrate oral tablet 50 doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 mondoxyne nl oral capsule 00, 75 tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 ADCETRIS INTRAVENOUS RECON SOLN 50 (Doxy-00) (Morgidox) (Doryx) (Mondoxyne NL) QL (60 (Monodox) QL (60 (Vibramycin) (Avidoxy) QL (60 QL (60 QL (60 (Tygacil) NM; NDS PA BvD; NM; NDS PA NSO; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 8 8

27 adriamycin intravenous solution 0 /5 ml, 2 /ml, 20 /0 ml, 50 /25 ml adrucil intravenous solution 2.5 gram/50 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2, 3, 5 PA BvD PA BvD PA NSO; NM; NDS; QL (2 per 28 days) AFINITOR ORAL TABLET 0 PA NSO; NM; NDS; QL (56 per 28 days) ALECENSA ORAL CAPSULE 50 PA NSO; NM; NDS; QL (240 ALIMTA INTRAVENOUS RECON NM; NDS SOLN 00, 500 ALIQOPA INTRAVENOUS RECON SOLN 60 PA NSO; NM; NDS; QL (3 per 28 days) ALUNBRIG ORAL TABLET 80, 90 PA NSO; NM; NDS; QL (30 ALUNBRIG ORAL TABLET 30 PA NSO; NM; NDS; QL (20 ALUNBRIG ORAL TABLETS,DOSE PACK 90 (7)- 80 (23) PA NSO; NM; NDS anastrozole oral tablet (Arimidex) arsenic trioxide intravenous solution NM; NDS /ml arsenic trioxide intravenous solution (Trisenox) NM; NDS 2 /ml ASPARLAS INTRAVENOUS PA NSO; NM; NDS SOLUTION 750 UNIT/ML AVASTIN INTRAVENOUS PA NSO; NM; NDS SOLUTION 25 /ML AYVAKIT ORAL TABLET 00, 200, 25, 300, 50 PA NSO; NM; NDS; QL (30 azacitidine injection recon soln 00 (Vidaza) NM; NDS BALVERSA ORAL TABLET 3 PA NSO; NM; NDS; QL (84 per 28 days) BALVERSA ORAL TABLET 4 PA NSO; NM; NDS; QL (56 per 28 days) BALVERSA ORAL TABLET 5 PA NSO; NM; NDS; QL (28 per 28 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 9 9

28 BAVENCIO INTRAVENOUS PA NSO; NM; NDS SOLUTION 20 /ML BELEODAQ INTRAVENOUS PA NSO; NM; NDS RECON SOLN 500 BENDEKA INTRAVENOUS PA NSO; NM; NDS SOLUTION 25 /ML BESPONSA INTRAVENOUS PA NSO; NM; NDS RECON SOLN 0.9 (0.25 /ML INITIAL) bexarotene oral capsule 75 (Targretin) PA NSO; NM; NDS bicalutamide oral tablet 50 (Casodex) BLENREP INTRAVENOUS PA NSO; NM; NDS RECON SOLN 00 bleomycin injection recon soln 5 unit, 30 unit BLINCYTO INTRAVENOUS KIT PA NSO; NM; NDS 35 MCG BORTEZOMIB INTRAVENOUS PA NSO; NM; NDS RECON SOLN 3.5 BOSULIF ORAL TABLET 00 PA NSO; NM; NDS; QL (90 BOSULIF ORAL TABLET 400, 500 PA NSO; NM; NDS; QL (30 BRAFTOVI ORAL CAPSULE 75 PA NSO; NM; NDS; QL (80 BRUKINSA ORAL CAPSULE 80 PA NSO; NM; NDS; QL (20 CABOMETYX ORAL TABLET 20, 60 PA NSO; NM; NDS; QL (30 CABOMETYX ORAL TABLET 40 PA NSO; NM; NDS; QL (60 CALQUENCE ORAL CAPSULE 00 PA NSO; NM; NDS; QL (60 CAPRELSA ORAL TABLET 00 PA NSO; NM; NDS; QL (60 CAPRELSA ORAL TABLET 300 PA NSO; NM; NDS; QL (30 carboplatin intravenous solution 0 (Paraplatin) /ml cladribine intravenous solution 0 PA BvD /0 ml clofarabine intravenous solution 20 /20 ml (Clolar) NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 20 20

29 COMETRIQ ORAL CAPSULE 00 /DAY(80 X-20 X), 40 /DAY(80 X-20 X3), 60 /DAY (20 X 3/DAY) COPIKTRA ORAL CAPSULE 5, 25 PA NSO; NM; NDS; QL (2 per 28 days) PA NSO; NM; NDS; QL (56 per 28 days) COTELLIC ORAL TABLET 20 PA NSO; NM; LA; NDS; QL (63 per 28 days) cyclophosphamide intravenous recon PA BvD; NM; NDS soln gram, 2 gram, 500 cyclophosphamide intravenous PA BvD; NM; NDS solution 200 /ml CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25, 50 cyclophosphamide oral tablet 25, PA BvD; ST 50 CYRAMZA INTRAVENOUS PA NSO; NM; NDS SOLUTION 0 /ML DANYELZA INTRAVENOUS PA NSO; NM; NDS; QL SOLUTION 4 /ML DARZALEX FASPRO SUBCUTANEOUS SOLUTION,800-30,000 UNIT/5 ML DARZALEX INTRAVENOUS SOLUTION 20 /ML DAURISMO ORAL TABLET 00 DAURISMO ORAL TABLET 25 decitabine intravenous recon soln 50 docetaxel intravenous solution 20 /2 ml (0 /ml), 80 /4 ml (20 /ml) docetaxel intravenous solution 80 /8 ml (0 /ml) doxorubicin intravenous solution 0 /5 ml, 2 /ml, 20 /0 ml, 50 /25 ml doxorubicin, peg-liposomal intravenous suspension 2 /ml (20 per 28 days) PA NSO; NM; NDS PA NSO; NM; LA; NDS PA NSO; NM; NDS; QL (30 PA NSO; NM; NDS; QL (60 (Dacogen) NM; NDS NM; NDS (Adriamycin) PA BvD (Doxil) PA BvD; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 2 2

30 ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 ELIGARD SUBCUTANEOUS SYRINGE 7.5 ( MONTH) EMCYT ORAL CAPSULE 40 NM; NDS EMPLICITI INTRAVENOUS PA NSO; NM; NDS RECON SOLN 300, 400 ENHERTU INTRAVENOUS PA NSO; NM; NDS RECON SOLN 00 ERBITUX INTRAVENOUS PA NSO; NM; NDS SOLUTION 00 /50 ML, 200 /00 ML ERIVEDGE ORAL CAPSULE 50 PA NSO; NM; NDS; QL (30 ERLEADA ORAL TABLET 60 PA NSO; NM; NDS; QL (20 erlotinib oral tablet 00, 25 (Tarceva) PA NSO; NM; NDS; QL (60 erlotinib oral tablet 50 (Tarceva) PA NSO; NM; NDS; QL (90 ETOPOPHOS INTRAVENOUS RECON SOLN 00 etoposide intravenous solution 20 (Toposar) /ml everolimus (antineoplastic) oral tablet 2.5, 5, 7.5 (Afinitor) PA NSO; NM; NDS; QL (28 per 28 days) exemestane oral tablet 25 (Aromasin) FARYDAK ORAL CAPSULE 0 PA NSO; NM; NDS, 5, 20 floxuridine injection recon soln 0.5 PA BvD gram fluorouracil intravenous solution PA BvD gram/20 ml, 5 gram/00 ml, 500 /0 ml flutamide oral capsule 25 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 22 22

31 FOTIVDA ORAL CAPSULE 0.89,.34 PA NSO; NM; NDS; QL (2 per 28 days) fulvestrant intramuscular syringe 250 (Faslodex) NM; NDS /5 ml GAVRETO ORAL CAPSULE 00 PA NSO; NM; NDS; QL (20 GAZYVA INTRAVENOUS PA NSO; NM; NDS SOLUTION,000 /40 ML gemcitabine intravenous recon soln PA BvD gram, 200 gemcitabine intravenous recon soln 2 PA BvD; NM; NDS gram gemcitabine intravenous solution PA BvD; NM; NDS gram/26.3 ml (38 /ml), 200 /5.26 ml (38 /ml) gemcitabine intravenous solution 2 PA BvD gram/52.6 ml (38 /ml) GILOTRIF ORAL TABLET 20, 30, 40 PA NSO; NM; NDS; QL (30 HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 PA NSO; NM; NDS; QL (5 per 2 days) -0,000 UNIT/5 ML HERCEPTIN INTRAVENOUS PA NSO; NM; NDS RECON SOLN 50 HERZUMA INTRAVENOUS RECON SOLN 50, 420 PA NSO; NM; NDS hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00, 25, 75 PA NSO; NM; NDS; QL (2 per 28 days) IBRANCE ORAL TABLET 00, 25, 75 PA NSO; NM; NDS; QL (2 per 28 days) ICLUSIG ORAL TABLET 0, 5, 30, 45 PA NSO; NM; NDS; QL (30 IDHIFA ORAL TABLET 00, 50 PA NSO; NM; NDS; QL (30 ifosfamide intravenous recon soln (Ifex) gram ifosfamide intravenous solution gram/20 ml, 3 gram/60 ml imatinib oral tablet 00 (Gleevec) PA NSO; QL (80 per 30 days) imatinib oral tablet 400 (Gleevec) PA NSO; QL (60 per 30 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 23 23

32 IMBRUVICA ORAL CAPSULE 40 PA NSO; NM; NDS; QL (20 IMBRUVICA ORAL CAPSULE 70 PA NSO; NM; NDS; QL (28 per 28 days) IMBRUVICA ORAL TABLET 40, 280, 420, 560 PA NSO; NM; NDS; QL (28 per 28 days) IMFINZI INTRAVENOUS PA NSO; NM; NDS SOLUTION 50 /ML IMLYGIC INJECTION SUSPENSION 0EXP6 ( PA NSO; QL (4 per 365 days) MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 0EXP8 (00 PA NSO; NM; NDS; QL (8 per 28 days) MILLION) PFU/ML INFUGEM INTRAVENOUS PA BvD; NM; NDS PIGGYBACK,200 /20 ML (0 /ML),,300 /30 ML (0 /ML),,400 /40 ML (0 /ML),,500 /50 ML (0 /ML),,600 /60 ML (0 /ML),,700 /70 ML (0 /ML),,800 /80 ML (0 /ML),,900 /90 ML (0 /ML), 2,000 /200 ML (0 /ML), 2,200 /220 ML (0 /ML) INLYTA ORAL TABLET PA NSO; NM; NDS; QL (80 INLYTA ORAL TABLET 5 PA NSO; NM; NDS; QL (20 INQOVI ORAL TABLET PA NSO; NM; NDS; QL (5 per 28 days) INREBIC ORAL CAPSULE 00 PA NSO; NM; NDS; QL (20 IRESSA ORAL TABLET 250 PA NSO; NM; NDS; QL (60 irinotecan intravenous solution 00 (Camptosar) /5 ml, 300 /5 ml, 40 /2 ml irinotecan intravenous solution 500 /25 ml IXEMPRA INTRAVENOUS RECON SOLN 5, 45 NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 24 24

33 JAKAFI ORAL TABLET 0, 5, 20, 25, 5 PA NSO; NM; NDS; QL (60 JEMPERLI INTRAVENOUS PA NSO; NM; NDS SOLUTION 50 /ML KANJINTI INTRAVENOUS PA NSO; NM; NDS RECON SOLN 50, 420 KEYTRUDA INTRAVENOUS SOLUTION 25 /ML PA NSO; NM; NDS; QL (8 per 2 days) KISQALI FEMARA CO-PACK ORAL TABLET 200 /DAY(200 PA NSO; NM; NDS; QL (49 per 28 days) X )-2.5 KISQALI FEMARA CO-PACK ORAL TABLET 400 /DAY(200 PA NSO; NM; NDS; QL (70 per 28 days) X 2)-2.5 KISQALI FEMARA CO-PACK ORAL TABLET 600 /DAY(200 PA NSO; NM; NDS; QL (9 per 28 days) X 3)-2.5 KISQALI ORAL TABLET 200 /DAY (200 X ) PA NSO; NM; NDS; QL (2 per 28 days) KISQALI ORAL TABLET 400 /DAY (200 X 2) PA NSO; NM; NDS; QL (42 per 28 days) KISQALI ORAL TABLET 600 /DAY (200 X 3) PA NSO; NM; NDS; QL (63 per 28 days) KOSELUGO ORAL CAPSULE 0 PA NSO; NM; NDS; QL (300 KOSELUGO ORAL CAPSULE 25 PA NSO; NM; NDS; QL (20 KYPROLIS INTRAVENOUS PA NSO; NM; NDS RECON SOLN 0, 30, 60 lapatinib oral tablet 250 (Tykerb) PA NSO; NM; NDS LENVIMA ORAL CAPSULE 0 PA NSO; NM; NDS /DAY (0 X ), 2 /DAY (4 X 3), 4 /DAY(0 X -4 X ), 8 /DAY (0 X -4 X2), 20 /DAY (0 X 2), 24 /DAY(0 X 2-4 X ), 4, 8 /DAY (4 X 2) letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 NM; NDS leuprolide subcutaneous kit /0.2 ml NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 25 25

34 LIBTAYO INTRAVENOUS SOLUTION 50 /ML PA NSO; NM; NDS; QL (7 per 2 days) LONSURF ORAL TABLET PA NSO; NM; NDS; QL (00 per 28 days) LONSURF ORAL TABLET PA NSO; NM; NDS; QL (80 per 28 days) LORBRENA ORAL TABLET 00 PA NSO; NM; NDS; QL (30 LORBRENA ORAL TABLET 25 PA NSO; NM; NDS; QL (90 LUMAKRAS ORAL TABLET 20 PA NSO; NM; NDS; QL (240 LUMOXITI INTRAVENOUS PA NSO; NM; NDS RECON SOLN LUPRON DEPOT (3 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 22.5 LUPRON DEPOT (4 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 30 LUPRON DEPOT (6 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 45 LYNPARZA ORAL TABLET 00, 50 PA NSO; NM; NDS; QL (20 LYSODREN ORAL TABLET 500 NM; NDS MARQIBO INTRAVENOUS KIT 5 PA NSO; NM; NDS /3 ML(0.6 /ML) FINAL MATULANE ORAL CAPSULE 50 NM; NDS megestrol oral tablet 20, 40 MEKINIST ORAL TABLET 0.5 PA NSO; NM; NDS; QL (90 MEKINIST ORAL TABLET 2 PA NSO; NM; NDS; QL (30 MEKTOVI ORAL TABLET 5 PA NSO; NM; NDS; QL (80 melphalan hcl intravenous recon soln (Alkeran (as HCl)) NM; NDS 50 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram PA BvD 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 26 26

35 methotrexate sodium (pf) injection PA BvD solution 25 /ml methotrexate sodium injection PA BvD solution 25 /ml methotrexate sodium oral tablet 2.5 PA BvD; ST mitoxantrone intravenous concentrate 2 /ml MONJUVI INTRAVENOUS PA NSO; NM; NDS RECON SOLN 200 MVASI INTRAVENOUS PA NSO; NM; NDS SOLUTION 25 /ML MYLOTARG INTRAVENOUS PA NSO; NM; NDS RECON SOLN 4.5 ( /ML INITIAL CONC) NERLYNX ORAL TABLET 40 PA NSO; NM; NDS; QL (80 NEXAVAR ORAL TABLET 200 PA NSO; NM; NDS; QL (20 nilutamide oral tablet 50 (Nilandron) NM; NDS NINLARO ORAL CAPSULE 2.3, 3, 4 PA NSO; NM; NDS; QL (3 per 28 days) NUBEQA ORAL TABLET 300 PA NSO; NM; NDS; QL (20 ODOMZO ORAL CAPSULE 200 PA NSO; NM; LA; NDS OGIVRI INTRAVENOUS RECON PA NSO; NM; NDS SOLN 50, 420 ONCASPAR INJECTION PA NSO; NM; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS NM; NDS DISPERSION 4.3 /ML ONTRUZANT INTRAVENOUS PA NSO; NM; NDS RECON SOLN 50, 420 ONUREG ORAL TABLET 200, 300 PA NSO; NM; NDS; QL (4 per 28 days) OPDIVO INTRAVENOUS PA NSO; NM; NDS SOLUTION 00 /0 ML, 240 /24 ML, 40 /4 ML oxaliplatin intravenous recon soln 00, 50 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 27 27

36 oxaliplatin intravenous solution 00 /20 ml, 200 /40 ml, 50 /0 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PADCEV INTRAVENOUS RECON SOLN 20, 30 PEMAZYRE ORAL TABLET 3.5, 4.5, 9 PEPAXTO INTRAVENOUS RECON SOLN 20 PERJETA INTRAVENOUS SOLUTION 420 /4 ML (30 /ML) PHESGO SUBCUTANEOUS SOLUTION, UNIT/5ML PHESGO SUBCUTANEOUS SOLUTION UNIT/0ML PIQRAY ORAL TABLET 200 /DAY (200 X ) PIQRAY ORAL TABLET 250 /DAY (200 X-50 X), 300 /DAY (50 X 2) POLIVY INTRAVENOUS RECON SOLN 40, 30 POMALYST ORAL CAPSULE, 2, 3, 4 PORTRAZZA INTRAVENOUS SOLUTION 800 /50 ML (6 /ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 /ML PA BvD PA NSO; NM; NDS PA NSO; NM; NDS; QL (4 per 2 days) PA NSO; NM; NDS; QL (2 per 28 days) PA NSO; NM; NDS PA NSO; NM; NDS; QL (5 per 2 days) PA NSO; NM; NDS; QL (0 per 2 days) PA NSO; NM; NDS; QL (28 per 28 days) PA NSO; NM; NDS; QL (56 per 28 days) PA NSO; NM; NDS PA NSO; NM; NDS; QL (2 per 28 days) PA NSO; NM; NDS; QL (00 per 2 days) NM; NDS NM; NDS QINLOCK ORAL TABLET 50 PA NSO; NM; NDS; QL (90 RETEVMO ORAL CAPSULE 40 PA NSO; NM; NDS; QL (80 RETEVMO ORAL CAPSULE 80 PA NSO; NM; NDS; QL (20 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 28 28

37 REVLIMID ORAL CAPSULE 0, 5, 2.5, 20, 25, 5 RIABNI INTRAVENOUS SOLUTION 0 /ML RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 /.7 ML (20 /ML), 600 /3.4 ML (20 /ML) RITUXAN INTRAVENOUS CONCENTRATE 0 /ML ROZLYTREK ORAL CAPSULE 00 ROZLYTREK ORAL CAPSULE 200 RUBRACA ORAL TABLET 200, 250, 300 RUXIENCE INTRAVENOUS SOLUTION 0 /ML RYBREVANT INTRAVENOUS SOLUTION 50 /ML PA NSO; NM; LA; NDS; QL (28 per 28 days) PA NSO; NM; NDS PA NSO; NM; NDS PA NSO; NM; NDS PA NSO; NM; NDS; QL (80 PA NSO; NM; NDS; QL (90 PA NSO; NM; NDS; QL (20 PA NSO; NM; NDS PA NSO; NM; NDS RYDAPT ORAL CAPSULE 25 PA NSO; NM; NDS; QL (224 per 28 days) SARCLISA INTRAVENOUS PA NSO; NM; NDS SOLUTION 20 /ML SOLTAMOX ORAL SOLUTION 20 NM; NDS /0 ML SPRYCEL ORAL TABLET 00, 40, 50, 70, 80 PA NSO; NM; NDS; QL (30 SPRYCEL ORAL TABLET 20 PA NSO; NM; NDS; QL (90 STIVARGA ORAL TABLET 40 PA NSO; NM; NDS; QL (84 per 28 days) SUTENT ORAL CAPSULE 2.5, 25, 37.5, 50 PA NSO; NM; NDS; QL (30 SYLVANT INTRAVENOUS PA NSO; NM; NDS RECON SOLN 00, 400 SYNRIBO SUBCUTANEOUS PA NSO; NM; NDS RECON SOLN 3.5 TABLOID ORAL TABLET 40 TABRECTA ORAL TABLET 50, 200 PA NSO; NM; NDS; QL (20 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 29 29

38 TAFINLAR ORAL CAPSULE 50, 75 PA NSO; NM; NDS; QL (20 TAGRISSO ORAL TABLET 40, 80 PA NSO; NM; LA; NDS; QL (30 per 30 days) TALZENNA ORAL CAPSULE 0.25 PA NSO; NM; NDS; QL (90 TALZENNA ORAL CAPSULE PA NSO; NM; NDS; QL (30 tamoxifen oral tablet 0, 20 TARGRETIN TOPICAL GEL % PA NSO; NM; NDS TASIGNA ORAL CAPSULE 50, 200 PA NSO; NM; NDS; QL (2 per 28 days) TASIGNA ORAL CAPSULE 50 PA NSO; NM; NDS; QL (20 TAZVERIK ORAL TABLET 200 PA NSO; NM; NDS; QL (240 TECENTRIQ INTRAVENOUS PA NSO; NM; NDS SOLUTION,200 /20 ML (60 /ML), 840 /4 ML (60 /ML) TEMODAR INTRAVENOUS PA NSO; NM; NDS RECON SOLN 00 temsirolimus intravenous recon soln 30 /3 ml (0 /ml) (first) (Torisel) PA BvD; NM; NDS; QL (4 per 28 days) TEPMETKO ORAL TABLET 225 PA NSO; NM; NDS; QL (60 thiotepa injection recon soln 00, (Tepadina) NM; NDS 5 TIBSOVO ORAL TABLET 250 PA NSO; NM; NDS; QL (60 TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 toposar intravenous solution 20 /ml topotecan intravenous recon soln 4 (Hycamtin) NM; NDS topotecan intravenous solution 4 NM; NDS /4 ml ( /ml) toremifene oral tablet 60 (Fareston) NM; NDS TRAZIMERA INTRAVENOUS RECON SOLN 50, 420 PA NSO; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 30 30

39 TREANDA INTRAVENOUS PA NSO; NM; NDS RECON SOLN 00, 25 TRELSTAR INTRAMUSCULAR SUSPENSION FOR NM; NDS; QL ( per 84 days) RECONSTITUTION.25 TRELSTAR INTRAMUSCULAR SUSPENSION FOR NM; NDS; QL ( per 68 days) RECONSTITUTION 22.5 TRELSTAR INTRAMUSCULAR QL ( per 28 days) SUSPENSION FOR RECONSTITUTION 3.75 tretinoin (antineoplastic) oral NM; NDS capsule 0 TRODELVY INTRAVENOUS PA NSO; NM; NDS RECON SOLN 80 TRUSELTIQ ORAL CAPSULE 00 PA NSO; NM; NDS /DAY (00 X ), 25 /DAY(00 X-25 X), 50 /DAY (25 X 2), 75 /DAY (25 X 3) TRUXIMA INTRAVENOUS PA NSO; NM; NDS SOLUTION 0 /ML TUKYSA ORAL TABLET 50 PA NSO; NM; NDS; QL (20 TUKYSA ORAL TABLET 50 PA NSO; NM; NDS; QL (300 TURALIO ORAL CAPSULE 200 PA NSO; NM; NDS; QL (20 UKONIQ ORAL TABLET 200 PA NSO; NM; NDS; QL (20 UNITUXIN INTRAVENOUS PA NSO; NM; NDS SOLUTION 3.5 /ML valrubicin intravesical solution 40 (Valstar) NM; NDS /ml VECTIBIX INTRAVENOUS PA NSO; NM; NDS SOLUTION 00 /5 ML (20 /ML), 400 /20 ML (20 /ML) VELCADE INJECTION RECON PA NSO; NM; NDS SOLN 3.5 VENCLEXTA ORAL TABLET 0 PA NSO; LA; QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 3 3

40 VENCLEXTA ORAL TABLET 00 PA NSO; NM; LA; NDS; QL (80 per 30 days) PA NSO; LA; QL (30 PA NSO; NM; LA; NDS VENCLEXTA ORAL TABLET 50 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK VERZENIO ORAL TABLET 00 PA NSO; NM; NDS; QL, 50, 200, 50 (56 per 28 days) vinblastine intravenous solution PA BvD /ml vincasar pfs intravenous solution PA BvD /ml, 2 /2 ml vincristine intravenous solution (Vincasar PFS) PA BvD /ml, 2 /2 ml vinorelbine intravenous solution 0 (Navelbine) /ml, 50 /5 ml VITRAKVI ORAL CAPSULE 00 PA NSO; NM; NDS; QL (60 VITRAKVI ORAL CAPSULE 25 PA NSO; NM; NDS; QL (80 VITRAKVI ORAL SOLUTION 20 PA NSO; NM; NDS; QL /ML (300 VIZIMPRO ORAL TABLET 5 PA NSO; NM; NDS; QL, 30, 45 (30 VOTRIENT ORAL TABLET 200 PA NSO; NM; NDS; QL (20 VYXEOS INTRAVENOUS RECON PA BvD; NM; NDS SOLN XALKORI ORAL CAPSULE 200 PA NSO; NM; NDS; QL, 250 (20 XATMEP ORAL SOLUTION 2.5 PA BvD; ST /ML XOSPATA ORAL TABLET 40 PA NSO; NM; NDS; QL (90 XPOVIO ORAL TABLET 00 PA NSO; NM; NDS; QL /WEEK (20 X 5) (20 per 28 days) XPOVIO ORAL TABLET 00 PA NSO; NM; NDS; QL /WEEK (50 X 2), 40 (8 per 28 days) /WEEK (20 X 2), 40 TWICE WEEK (40 X 2), 80 /WEEK (40 X 2) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 32 32

41 XPOVIO ORAL TABLET 40 /WEEK (40 X ), 60 /WEEK (60 X ) XPOVIO ORAL TABLET 40 TWICE WEEK (80 /WEEK), 80 /WEEK (20 X 4) XPOVIO ORAL TABLET 60 /WEEK (20 X 3) XPOVIO ORAL TABLET 60 TWICE WEEK (20 /WEEK) XPOVIO ORAL TABLET 80 PA NSO; NM; NDS; QL (4 per 28 days) PA NSO; NM; NDS; QL (6 per 28 days) PA NSO; NM; NDS; QL (2 per 28 days) PA NSO; NM; NDS; QL (24 per 28 days) PA NSO; NM; NDS; QL (32 per 28 days) TWICE WEEK (60 /WEEK) XTANDI ORAL CAPSULE 40 PA NSO; NM; NDS; QL (20 XTANDI ORAL TABLET 40 PA NSO; NM; NDS; QL (20 XTANDI ORAL TABLET 80 PA NSO; NM; NDS; QL (60 YERVOY INTRAVENOUS PA NSO; NM; NDS SOLUTION 200 /40 ML (5 /ML), 50 /0 ML (5 /ML) YONDELIS INTRAVENOUS PA NSO; NM; NDS RECON SOLN YONSA ORAL TABLET 25 PA NSO; NM; NDS; QL ZALTRAP INTRAVENOUS SOLUTION 00 /4 ML (25 /ML), 200 /8 ML (25 /ML) (20 PA NSO; NM; NDS ZEJULA ORAL CAPSULE 00 PA NSO; NM; NDS; QL (90 ZELBORAF ORAL TABLET 240 PA NSO; NM; NDS; QL (240 ZEPZELCA INTRAVENOUS PA NSO; NM; NDS RECON SOLN 4 ZIRABEV INTRAVENOUS PA NSO; NM; NDS SOLUTION 25 /ML ZOLADEX SUBCUTANEOUS QL ( per 84 days) IMPLANT 0.8 ZOLADEX SUBCUTANEOUS QL ( per 28 days) IMPLANT 3.6 ZOLINZA ORAL CAPSULE 00 NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 33 33

42 ZYDELIG ORAL TABLET 00, 50 ZYKADIA ORAL TABLET 50 ZYNLONTA INTRAVENOUS RECON SOLN 0 ZYTIGA ORAL TABLET 250, 500 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200, 400 APTIOM ORAL TABLET 600, 800 BRIVIACT INTRAVENOUS SOLUTION 50 /5 ML BRIVIACT ORAL SOLUTION 0 /ML BRIVIACT ORAL TABLET 0, 00, 25, 50, 75 carbamazepine oral capsule, er multiphase 2 hr 00, 200, 300 carbamazepine oral suspension 00 /5 ml (Carbatrol) (Tegretol) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 PA NSO; NM; NDS; QL (60 PA NSO; NM; NDS; QL (84 per 28 days) PA NSO; NM; NDS PA NSO; NM; NDS; QL (20 NM; NDS; QL (30 per 30 days) NM; NDS; QL (60 per 30 days) QL (80 QL (600 QL (60 carbamazepine oral tablet 200 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 clobazam oral suspension 2.5 /ml (Onfi) PA NSO; QL (480 per 30 days) clobazam oral tablet 0, 20 (Onfi) PA NSO; QL (60 per 30 days) DIACOMIT ORAL CAPSULE 250 PA NSO; NM; NDS; QL (360 DIACOMIT ORAL CAPSULE 500 PA NSO; NM; NDS; QL (80 DIACOMIT ORAL POWDER IN PACKET 250 PA NSO; NM; NDS; QL (360

43 DIACOMIT ORAL POWDER IN PACKET 500 PA NSO; NM; NDS; QL (80 diazepam rectal kit (Diastat AcuDial), diazepam rectal kit 2.5 (Diastat) DILANTIN ORAL CAPSULE 30 divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 25 divalproex oral tablet extended (Depakote ER) release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 25, 250, 500 (Depakote) EPIDIOLEX ORAL SOLUTION PA NSO; NM; NDS 00 /ML epitol oral tablet 200 ethosuximide oral capsule 250 (Zarontin) ethosuximide oral solution 250 /5 (Zarontin) ml felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) FINTEPLA ORAL SOLUTION 2.2 /ML PA NSO; NM; NDS fosphenytoin injection solution 00 pe/2 ml, 500 pe/0 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 /ML NM; NDS; QL (720 per 30 days) FYCOMPA ORAL TABLET 0, 2, 8 NM; NDS; QL (30 per 30 days) FYCOMPA ORAL TABLET 2 QL (30 FYCOMPA ORAL TABLET 4, 6 NM; NDS; QL (60 per 30 days) gabapentin oral capsule 00, 300 (Neurontin) QL (360 gabapentin oral capsule 400 (Neurontin) QL (270 gabapentin oral solution 250 /5 ml (Neurontin) QL (260 gabapentin oral tablet 600 (Neurontin) QL (80 gabapentin oral tablet 800 (Neurontin) QL (20 lamotrigine oral tablet 00, 50, 200, 25 (Subvenite) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 35 35

44 lamotrigine oral tablet disintegrating, dose pk 25 (2) - 50 (7) lamotrigine oral tablet disintegrating, dose pk 25 (4)-50 (4)-00 (7) lamotrigine oral tablet disintegrating, dose pk 50 (42) - 00 (4) lamotrigine oral tablet extended release 24hr 00, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 lamotrigine oral tablet,disintegrating 00, 200, 25, 50 levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml levetiracetam oral tablet,000, 250, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 NAYZILAM NASAL SPRAY,NON- AEROSOL 5 /SPRAY (0. ML) oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 50, 300 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 phenobarbital oral elixir 20 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 phenytoin oral suspension 25 /5 ml (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Keppra) (Keppra) (Keppra) (Keppra XR) (Trileptal) (Trileptal) (Dilantin-25) QL (0 NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 36 36

45 phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral (Dilantin Extended) capsule 00 phenytoin sodium extended oral (Phenytek) capsule 200, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml pregabalin oral capsule 00, 50 (Lyrica) QL (90, 200, 25, 50, 75 pregabalin oral capsule 225, 300 (Lyrica) QL (60 pregabalin oral solution 20 /ml (Lyrica) QL (900 primidone oral tablet 250, 50 (Mysoline) rufinamide oral suspension 40 /ml (Banzel) NM; NDS rufinamide oral tablet 200, 400 (Banzel) NM; NDS SPRITAM ORAL TABLET FOR ST; QL (60 SUSPENSION,000 SPRITAM ORAL TABLET FOR SUSPENSION 250, 500, ST; QL (20 per 30 days) 750 subvenite oral tablet 00, 50, 200, 25 SYMPAZAN ORAL FILM 0, 20 PA NSO; NM; NDS; QL (60 SYMPAZAN ORAL FILM 5 PA NSO; QL (60 per 30 days) tiagabine oral tablet 2, 6, 2 (Gabitril), 4 topiramate oral capsule, sprinkle 5 (Topamax), 25 topiramate oral tablet 00, 200 (Topamax), 25, 50 valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 250 /5 ml valproic acid oral capsule 250 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 37 37

46 VALTOCO NASAL SPRAY,NON- AEROSOL 0 /SPRAY (0. ML), 5 /2 SPRAY (7.5/0.ML X 2), 20 /2 SPRAY (0/0.ML X2), 5 /SPRAY (0. ML) vigabatrin oral powder in packet 500 (Vigadrone) PA NSO; NM; NDS; QL (80 vigabatrin oral tablet 500 (Sabril) PA NSO; NM; NDS; QL (80 vigadrone oral powder in packet 500 PA NSO; NM; NDS; QL (80 VIMPAT INTRAVENOUS QL (200 per 5 days) SOLUTION 200 /20 ML VIMPAT ORAL SOLUTION 0 QL (200 /ML VIMPAT ORAL TABLET 00, QL (60 50, 200, 50 XCOPRI MAINTENANCE PACK QL (56 per 28 days) ORAL TABLET 250 /DAY (200 X-50 X), 250/DAY(50 X-00 X), 350 /DAY (200 X- 50 X) XCOPRI ORAL TABLET 00, QL (30 50 XCOPRI ORAL TABLET 50, QL ( XCOPRI TITRATION PACK ORAL TABLETS,DOSE PACK 2.5 (4)- 25 (4), 50 (4)- 200 (4), 50 (4)- 00 (4) zonisamide oral capsule 00, 25 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 23, 5 (Aricept) QL (30 donepezil oral tablet,disintegrating QL (30 0, 5 ergoloid oral tablet 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 38 38

47 galantamine oral capsule,ext rel. (Razadyne ER) QL (30 pellets 24 hr 6, 24, 8 galantamine oral solution 4 /ml QL (200 galantamine oral tablet 2, 4, QL (60 8 memantine oral capsule,sprinkle,er (Namenda XR) ST; QL (30 24hr 4, 2, 28, 7 memantine oral solution 2 /ml QL (300 memantine oral tablet 0, 5 (Namenda) QL (60 NAMZARIC ORAL ST CAP,SPRINKLE,ER 24HR DOSE PACK 7/4/2/28-0 NAMZARIC ORAL ST; QL (30 CAPSULE,SPRINKLE,ER 24HR 4-0, 2-0, 28-0, 7-0 rivastigmine tartrate oral capsule.5 QL (60, 3, 4.5, 6 rivastigmine transdermal patch 24 (Exelon Patch) QL (30 hour 3.3 /24 hour, 4.6 /24 hour, 9.5 /24 hour Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 25, 50, 75 amitriptyline-chlordiazepoxide oral tablet 2.5-5, 25-0 amoxapine oral tablet 00, 50, 25, 50 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended (Wellbutrin XL) release 24 hr 50, 300 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) 2 hr 00, 50, 200 citalopram oral solution 0 /5 ml QL (600 citalopram oral tablet 0, 20, (Celexa) QL (30 40 clomipramine oral capsule 25, 50, 75 (Anafranil) desipramine oral tablet 0, 25 (Norpramin) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 39 39

48 desipramine oral tablet 00, 50, 50, 75 desvenlafaxine succinate oral tablet (Pristiq) QL (30 extended release 24 hr 00, 25, 50 doxepin oral capsule 0, 00, 50, 25, 50, 75 doxepin oral concentrate 0 /ml DRIZALMA SPRINKLE ORAL ST; QL (60 CAPSULE, DELAYED REL SPRINKLE 20, 30, 60 DRIZALMA SPRINKLE ORAL ST; QL (30 CAPSULE, DELAYED REL SPRINKLE 40 duloxetine oral capsule,delayed (Cymbalta) QL (60 release(dr/ec) 20, 30, 60 duloxetine oral capsule,delayed QL (30 release(dr/ec) 40 EMSAM TRANSDERMAL PATCH 24 HOUR 2 /24 HR, 6 /24 ST; NM; NDS; QL (30 HR, 9 /24 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0 (Lexapro), 20, 5 FETZIMA ORAL CAPSULE,EXT ST REL 24HR DOSE PACK 20 (2)- 40 (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20, 20, 40, 80 ST; QL (30 fluoxetine oral capsule 0, 20, (Prozac) 40 fluoxetine oral solution 20 /5 ml (4 /ml) fluvoxamine oral tablet 00, 25, 50 imipramine hcl oral tablet 0, 25, 50 imipramine pamoate oral capsule 00, 25, 50, 75 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 40 40

49 maprotiline oral tablet 25, 50, 75 MARPLAN ORAL TABLET 0 mirtazapine oral tablet 5, 30 (Remeron) mirtazapine oral tablet 45, 7.5 mirtazapine oral tablet,disintegrating (Remeron SolTab) 5, 30, 45 nefazodone oral tablet 00, 50, 200, 250, 50 nortriptyline oral capsule 0, 25 (Pamelor), 50, 75 nortriptyline oral solution 0 /5 ml paroxetine hcl oral tablet 0, 20 (Paxil), 30, 40 paroxetine hcl oral tablet extended (Paxil CR) release 24 hr 2.5, 25, 37.5 PAXIL ORAL SUSPENSION 0 /5 ML perphenazine-amitriptyline oral tablet 2-0, 2-25, 4-0, 4-25, 4-50 phenelzine oral tablet 5 (Nardil) protriptyline oral tablet 0, 5 sertraline oral concentrate 20 /ml (Zoloft) sertraline oral tablet 00, 25, 50 (Zoloft) SPRAVATO NASAL SPRAY,NON- PA NSO AEROSOL 28 SPRAVATO NASAL SPRAY,NON- AEROSOL 56 (28 X 2), 84 (28 X 3) PA NSO; NM; NDS tranylcypromine oral tablet 0 (Parnate) trazodone oral tablet 00, 50, 300, 50 trimipramine oral capsule 00, 25, 50 TRINTELLIX ORAL TABLET 0 QL (30, 20, 5 venlafaxine oral capsule,extended release 24hr 50 (Effexor XR) QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 4 4

50 venlafaxine oral capsule,extended release 24hr 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 venlafaxine oral tablet extended release 24hr 50, 37.5 venlafaxine oral tablet extended release 24hr 75 VIIBRYD ORAL TABLET 0, 20, 40 VIIBRYD ORAL TABLETS,DOSE PACK 0 (7)- 20 (23) ZULRESSO INTRAVENOUS SOLUTION 5 /ML Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00, 25, 50 FARXIGA ORAL TABLET 0, 5 JARDIANCE ORAL TABLET 0, 25 JENTADUETO ORAL TABLET 2.5-,000, , (Effexor XR) QL (90 QL (30 QL (90 QL (30 NM; NDS (Precose) QL (90 QL (30 QL (30 QL (60 JENTADUETO XR ORAL QL (60 TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 JENTADUETO XR ORAL QL (30 TABLET, IR - ER, BIPHASIC 24HR 5-,000 KORLYM ORAL TABLET 300 PA; NM; NDS; QL (2 per 28 days) metformin oral solution 500 /5 ml (Riomet) QL (765 metformin oral tablet,000 QL (75 metformin oral tablet 500 QL (50 metformin oral tablet 850 QL (90 metformin oral tablet extended QL (20 release 24 hr 500 metformin oral tablet extended release 24 hr 750 QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 42 42

51 miglitol oral tablet 00, 25, QL (90 50 nateglinide oral tablet 20, 60 QL (90 OZEMPIC SUBCUTANEOUS PEN QL (.5 per 28 days) INJECTOR 0.25 OR 0.5 (2 /.5 ML) OZEMPIC SUBCUTANEOUS PEN QL (3 per 28 days) INJECTOR /DOSE (2 /.5 ML), /DOSE (4 /3 ML) pioglitazone oral tablet 5, 30 (Actos) QL (30, 45 repaglinide oral tablet 0.5, QL (20 repaglinide oral tablet 2 QL (240 repaglinide-metformin oral tablet - QL (50 500, RYBELSUS ORAL TABLET 4 QL (30, 3, 7 SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML PA; NM; NDS; QL (0.8 per 28 days) SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET 2.5-,000, , 5-,000, SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 0-,000, 25-,000 SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000, 5-,000 TRADJENTA ORAL TABLET 5 TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 /0.5 ML,.5 /0.5 ML, 3 /0.5 ML, 4.5 /0.5 ML VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 /0. ML (8 /3 ML) PA; NM; NDS; QL (0.8 per 28 days) QL (60 QL (30 QL (60 QL (30 QL (2 per 28 days) QL (9 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 43 43

52 XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 0-,000, XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000, 5-,000, Insulins FIASP FLEXTOUCH U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) FIASP PENFILL U-00 INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML (3 ML) FIASP U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) LANTUS SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN FLEXPEN U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) NOVOLIN N NPH U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML QL (30 QL (60 QL (30 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (24 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (30 per 28 days) QL (40 per 28 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 44 44

53 NOVOLIN R FLEXPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) NOVOLIN R REGULAR U-00 QL (40 per 28 days) INSULN INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN U-00 QL (30 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) NOVOLOG MIX U-00 QL (40 per 28 days) INSULN SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN QL (30 per 28 days) U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG PENFILL U-00 QL (30 per 28 days) INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG U-00 INSULIN QL (40 per 28 days) ASPART SUBCUTANEOUS SOLUTION 00 UNIT/ML SOLIQUA 00/33 QL (30 SUBCUTANEOUS INSULIN PEN 00 UNIT-33 MCG/ML TOUJEO MAX U-300 SOLOSTAR QL (8 per 28 days) SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 QL (3.5 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) XULTOPHY 00/3.6 QL (5 per 28 days) SUBCUTANEOUS INSULIN PEN 00 UNIT-3.6 /ML (3 ML) Sulfonylureas glimepiride oral tablet, 2 (Amaryl) QL (30 glimepiride oral tablet 4 (Amaryl) QL (60 glipizide oral tablet 0 (Glucotrol) QL (20 glipizide oral tablet 5 QL (60 glipizide oral tablet extended release 24hr 0 (Glucotrol XL) QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 45 45

54 glipizide oral tablet extended release (Glucotrol XL) QL (30 24hr 2.5, 5 glipizide-metformin oral tablet 2.5- QL ( glipizide-metformin oral tablet 2.5- QL (20 500, glyburide micronized oral tablet.5 (Glynase), 3, 6 glyburide oral tablet.25, 2.5, 5 glyburide-metformin oral tablet , , Antifungals Antifungals ABELCET INTRAVENOUS PA BvD SUSPENSION 5 /ML AMBISOME INTRAVENOUS PA BvD; NM; NDS SUSPENSION FOR RECONSTITUTION 50 amphotericin b injection recon soln PA BvD 50 caspofungin intravenous recon soln (Cancidas) NM; NDS 50 caspofungin intravenous recon soln (Cancidas) 70 ciclopirox topical cream 0.77 % (Ciclodan) QL (80 ciclopirox topical gel 0.77 % QL (300 ciclopirox topical shampoo % (Loprox) ciclopirox topical solution 8 % (Ciclodan) QL (9.8 ciclopirox topical suspension 0.77 % (Loprox (as olamine)) QL (80 clotrimazole mucous membrane troche 0 clotrimazole topical cream % (Antifungal (clotrimazole)) clotrimazole topical solution % clotrimazole-betamethasone topical QL (90 cream % clotrimazole-betamethasone topical QL (90 lotion % econazole topical cream % QL (70 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 46 46

55 fluconazole in nacl (iso-osm) intravenous piggyback 00 /50 ml, 200 /00 ml, 400 /200 ml PA BvD fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50 (Diflucan), 200, 50 flucytosine oral capsule 250, 500 (Ancobon) NM; NDS griseofulvin microsize oral suspension 25 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 25, 250 itraconazole oral capsule 00 (Sporanox) itraconazole oral solution 0 /ml (Sporanox) PA ketoconazole oral tablet 200 ketoconazole topical cream 2 % QL (80 ketoconazole topical shampoo 2 % QL (360 miconazole-3 vaginal suppository 200 NOXAFIL INTRAVENOUS NM; NDS SOLUTION 300 /6.7 ML NOXAFIL ORAL SUSPENSION PA; NM; NDS 200 /5 ML (40 /ML) nyamyc topical powder 00,000 QL (60 unit/gram nystatin oral suspension 00,000 QL (900 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 QL (60 unit/gram nystatin topical ointment 00,000 QL (60 unit/gram nystatin topical powder 00,000 (Nyamyc) QL (60 unit/gram nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 47 47

56 nystop topical powder 00,000 QL (60 unit/gram posaconazole oral tablet,delayed (Noxafil) PA; NM; NDS release (dr/ec) 00 terbinafine hcl oral tablet 250 voriconazole intravenous recon soln (Vfend IV) PA BvD; NM; NDS 200 voriconazole oral suspension for (Vfend) PA; NM; NDS reconstitution 200 /5 ml (40 /ml) voriconazole oral tablet 200, 50 (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 00 (Zyloprim) allopurinol oral tablet 300 colchicine oral tablet 0.6 (Colcrys) PA; QL (20 per 30 days) febuxostat oral tablet 40, 80 (Uloric) ST; QL (30 MITIGARE ORAL CAPSULE 0.6 QL (60 probenecid oral tablet 500 probenecid-colchicine oral tablet Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 clemastine oral tablet 2.68 cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet 4 diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml diphenhydramine hcl oral elixir 2.5 (Diphen) /5 ml hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 48 48

57 hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 25, 50 levocetirizine oral solution 2.5 /5 (Xyzal) ml levocetirizine oral tablet 5 (24HR Allergy Relief) promethazine oral syrup 6.25 /5 ml Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) clindamycin phosphate vaginal (Cleocin) cream 2 % metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents dihydroergotamine injection solution /ml dihydroergotamine nasal spray,nonaerosol 0.5 /pump act. (4 /ml) EALITY PEN SUBCUTANEOUS PEN INJECTOR 20 /ML EALITY SYRINGE SUBCUTANEOUS SYRINGE 20 /ML (D.H.E.45) QL (24 per 28 days) (Migranal) NM; NDS; QL (8 per 28 days) PA; QL (2 PA; QL (2 EALITY SYRINGE PA; QL (3 SUBCUTANEOUS SYRINGE 300 /3 ML (00 /ML X 3) naratriptan oral tablet, 2.5 (Amerge) QL (9 rizatriptan oral tablet 0 (Maxalt) QL (2 rizatriptan oral tablet 5 QL (2 rizatriptan oral tablet,disintegrating (Maxalt-MLT) QL (2 0 rizatriptan oral tablet,disintegrating 5 QL (2 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 49 49

58 sumatriptan nasal spray,non-aerosol (Imitrex) QL (2 20 /actuation sumatriptan nasal spray,non-aerosol (Imitrex) QL (8 5 /actuation sumatriptan succinate oral tablet 00 (Imitrex) QL (9 sumatriptan succinate oral tablet 25 (Imitrex) QL (8, 50 sumatriptan succinate subcutaneous (Imitrex STATdose QL (4 per 28 days) cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous (Imitrex STATdose Pen) QL (4 per 28 days) pen injector 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 days) solution 6 /0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 days) syringe 6 /0.5 ml UBRELVY ORAL TABLET 00 PA; QL (6, 50 zolmitriptan oral tablet 2.5, 5 (Zomig) QL (6 zolmitriptan oral QL (6 tablet,disintegrating 2.5, 5 Antimycobacterials Antimycobacterials dapsone oral tablet 00, 25 ethambutol oral tablet 00 ethambutol oral tablet 400 (Myambutol) isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 PRETOMANID ORAL TABLET QL ( PRIFTIN ORAL TABLET 50 pyrazinamide oral tablet 500 rifabutin oral capsule 50 (Mycobutin) rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 50, 300 SIRTURO ORAL TABLET 00 PA; NM; NDS, 20 TRECATOR ORAL TABLET 250 Antinausea Agents 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 50 50

59 Antinausea Agents AKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN AKYNZEO (FOSNETUPITANT) INTRAVENOUS SOLUTION /20 ML AKYNZEO (NETUPITANT) ORAL PA BvD CAPSULE aprepitant oral capsule 25 PA BvD; QL (2 per 28 days) aprepitant oral capsule 40 PA BvD; QL ( per 28 days) aprepitant oral capsule 80 (Emend) PA BvD; QL (4 per 28 days) aprepitant oral capsule,dose pack 25 ()- 80 (2) (Emend) PA BvD; QL (6 per 28 days) compro rectal suppository 25 dimenhydrinate injection solution 50 /ml dronabinol oral capsule 0, 2.5 (Marinol) PA; QL (60, 5 droperidol injection solution 2.5 /ml EMEND ORAL SUSPENSION FOR RECONSTITUTION 25 (25 / ML FINAL CONC.) PA BvD; QL (6 per 28 days) fosaprepitant intravenous recon soln (Emend (fosaprepitant)) QL (2 per 28 days) 50 granisetron (pf) intravenous solution /ml ( ml), 00 mcg/ml granisetron hcl intravenous solution /ml granisetron hcl oral tablet PA BvD meclizine oral tablet 2.5 meclizine oral tablet 25 (Dramamine Less Drowsy) ondansetron hcl (pf) injection solution 4 /2 ml ondansetron hcl (pf) injection syringe 4 /2 ml ondansetron hcl intravenous solution 2 /ml 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 5 5

60 ondansetron hcl oral solution 4 /5 PA BvD ml ondansetron hcl oral tablet 24, 8 PA BvD ondansetron hcl oral tablet 4 (Zofran) PA BvD ondansetron oral PA BvD tablet,disintegrating 4, 8 prochlorperazine edisylate injection solution 0 /2 ml (5 /ml), 5 /ml prochlorperazine maleate oral tablet (Compazine) 0, 5 prochlorperazine rectal suppository (Compro) 25 promethazine injection solution 25 (Phenergan) /ml, 50 /ml promethazine oral tablet 2.5, 25, 50 promethazine rectal suppository 2.5 (Promethegan), 25, 50 promethegan rectal suppository 2.5, 25, 50 scopolamine base transdermal patch (Transderm-Scop) QL (0 3 day over 3 days SYNDROS ORAL SOLUTION 5 /ML PA; NM; NDS; QL (20 Antiparasite Agents Antiparasite Agents albendazole oral tablet 200 (Albenza) NM; NDS atovaquone oral suspension 750 (Mepron) /5 ml atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) chloroquine phosphate oral tablet QL ( chloroquine phosphate oral tablet QL ( COARTEM ORAL TABLET 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 52 52

61 hydroxychloroquine oral tablet 200 (Plaquenil) QL (90 IMPAVIDO ORAL CAPSULE 50 PA; NM; NDS; QL (84 per 28 days) ivermectin oral tablet 3 (Stromectol) KRINTAFEL ORAL TABLET 50 mefloquine oral tablet 250 nitazoxanide oral tablet 500 (Alinia) NM; NDS paromomycin oral capsule 250 (Humatin) pentamidine inhalation recon soln (Nebupent) PA BvD 300 pentamidine injection recon soln 300 (Pentam) PRIMAQUINE ORAL TABLET 26.3 pyrimethamine oral tablet 25 (Daraprim) PA; NM; NDS quinine sulfate oral capsule 324 (Qualaquin) PA; QL (42 per 7 days) tinidazole oral tablet 250, 500 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 APOKYN SUBCUTANEOUS CARTRIDGE 0 /ML PA; NM; NDS; QL (60 benztropine injection solution (Cogentin) /ml benztropine oral tablet 0.5,, 2 bromocriptine oral capsule 5 (Parlodel) bromocriptine oral tablet 2.5 (Parlodel) cabergoline oral tablet 0.5 carbidopa oral tablet 25 (Lodosyn) carbidopa-levodopa oral tablet 0-00, carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release 25-00, (Sinemet) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 53 53

62 carbidopa-levodopa oral tablet,disintegrating 0-00, 25-00, carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 75) tablet carbidopa-levodopa-entacapone oral (Stalevo 00) tablet carbidopa-levodopa-entacapone oral (Stalevo 25) tablet carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 200) tablet entacapone oral tablet 200 (Comtan) INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 KYNMOBI SUBLINGUAL FILM 0, 5, 20, 25, 30 KYNMOBI SUBLINGUAL FILM NEUPRO TRANSDERMAL PATCH 24 HOUR /24 HOUR, 2 /24 HOUR, 3 /24 HOUR, 4 /24 HOUR, 6 /24 HOUR, 8 /24 HOUR ONGENTYS ORAL CAPSULE 25, 50 OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 29, 93, 258 OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 322 /DAY(29 X-93 X) pramipexole oral tablet 0.25, 0.25, 0.5, 0.75,,.5 (Mirapex) rasagiline oral tablet 0.5, (Azilect) ropinirole oral tablet 0.25, 0.5,, 2, 3, 4, 5 PA; NM; NDS; QL (300 PA; NM; NDS; QL (50 PA; NM; NDS QL (30 PA; QL (30 ST; QL (30 ST; QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 54 54

63 ropinirole oral tablet extended release 24 hr 2, 2, 4, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet 2, 5 XADAGO ORAL TABLET 00 PA; QL (30 XADAGO ORAL TABLET 50 PA; NM; NDS; QL (30 Antipsychotic Agents Antipsychotic Agents aripiprazole oral solution /ml QL (900 aripiprazole oral tablet 0, 5 (Abilify) QL (30, 20, 30, 5 aripiprazole oral tablet 2 (Abilify) QL (60 aripiprazole oral ST; QL (90 tablet,disintegrating 0 aripiprazole oral tablet,disintegrating 5 ST; NM; NDS; QL (60 ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 /2.4 ML NM; NDS; QL (4.8 per 365 days) ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING,064 /3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 44 /.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 /2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 /3.2 ML asenapine maleate sublingual tablet 0, 2.5, 5 CAPLYTA ORAL CAPSULE 42 chlorpromazine injection solution 25 /ml 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 NM; NDS; QL (3.9 per 56 days) NM; NDS; QL (.6 per 28 days) NM; NDS; QL (2.4 per 28 days) NM; NDS; QL (3.2 per 28 days) (Saphris) ST; QL (60 ST; NM; NDS; QL (30

64 chlorpromazine oral tablet 0, 00, 200, 25, 50 clozapine oral tablet 00 (Clozaril) QL (270 clozapine oral tablet 200 (Clozaril) QL (35 clozapine oral tablet 25, 50 (Clozaril) QL (90 clozapine oral tablet,disintegrating ST; QL (90 00, 2.5, 25 clozapine oral tablet,disintegrating 50 ST; QL (80 per 30 days) clozapine oral tablet,disintegrating 200 ST; NM; NDS; QL (20 FANAPT ORAL TABLET, 0, 2, 2, 4, 6, 8 ST; NM; NDS; QL (60 FANAPT ORAL TABLETS,DOSE ST PACK (2)-2(2)- 4(2)- 6(2) fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5 ml fluphenazine hcl oral tablet, 0, 2.5, 5 haloperidol decanoate intramuscular (Haldol Decanoate) solution 00 /ml haloperidol decanoate intramuscular solution 00 /ml ( ml) haloperidol decanoate intramuscular (Haldol Decanoate) solution 50 /ml haloperidol decanoate intramuscular solution 50 /ml(ml) haloperidol lactate injection solution 5 /ml haloperidol lactate intramuscular syringe 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5,, 0, 2, 20, 5 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 56 56

65 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 /0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 56 /ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 /.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 /0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 /0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 /0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 40 /.35 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 /.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 /2.625 ML LATUDA ORAL TABLET 20, 20, 40, 60 NM; NDS; QL (0.75 per 28 days) NM; NDS; QL ( per 28 days) NM; NDS; QL (.5 per 28 days) QL (0.25 per 28 days) NM; NDS; QL (0.5 per 28 days) NM; NDS; QL (0.875 per 84 days) NM; NDS; QL (.35 per 84 days) NM; NDS; QL (.75 per 84 days) NM; NDS; QL (2.625 per 84 days) QL (30 LATUDA ORAL TABLET 80 QL (60 loxapine succinate oral capsule 0, 25, 5, 50 molindone oral tablet 0 QL (240 molindone oral tablet 25 QL (270 molindone oral tablet 5 QL (20 NUPLAZID ORAL CAPSULE 34 PA NSO; NM; NDS; QL (30 NUPLAZID ORAL TABLET 0 PA NSO; NM; NDS; QL (30 olanzapine intramuscular recon soln (Zyprexa) QL (30 0 olanzapine oral tablet 0, 5, 2.5, 20, 5, 7.5 (Zyprexa) QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 57 57

66 olanzapine oral tablet,disintegrating (Zyprexa Zydis) QL (30 0, 5, 20, 5 paliperidone oral tablet extended (Invega) QL (30 release 24hr.5, 3, 9 paliperidone oral tablet extended (Invega) QL (60 release 24hr 6 perphenazine oral tablet 6, 2, 4, 8 PERSERIS ABDOMINAL SUBCUTANEOUS NM; NDS; QL ( per 30 days) SUSPENSION,EXTENDED REL SYRING 20, 90 pimozide oral tablet, 2 quetiapine oral tablet 00, 200 (Seroquel) QL (90, 25, 50 quetiapine oral tablet 300, 400 (Seroquel) QL (60 quetiapine oral tablet extended (Seroquel XR) QL (30 release 24 hr 50, 200, 50 quetiapine oral tablet extended (Seroquel XR) QL (60 release 24 hr 300, 400 REXULTI ORAL TABLET 0.25 ST; NM; NDS; QL (20 REXULTI ORAL TABLET 0.5 ST; NM; NDS; QL (60 REXULTI ORAL TABLET, 2, 3, 4 ST; NM; NDS; QL (30 RISPERDAL CONSTA QL (2 per 28 days) INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 2.5 /2 ML, 25 /2 ML RISPERDAL CONSTA INTRAMUSCULAR NM; NDS; QL (2 per 28 days) SUSPENSION,EXTENDED REL RECON 37.5 /2 ML, 50 /2 ML risperidone oral solution /ml (Risperdal) QL (480 risperidone oral tablet 0.25 QL (60 risperidone oral tablet 0.5,, (Risperdal) QL (60 2, 3 risperidone oral tablet 4 (Risperdal) QL (20 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 58 58

67 risperidone oral tablet,disintegrating 0.25, 0.5,, 2 risperidone oral tablet,disintegrating 3, 4 SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 /24 HOUR, 5.7 /24 HOUR, 7.6 /24 HOUR thioridazine oral tablet 0, 00, 25, 50 thiothixene oral capsule, 0, 2, 5 trifluoperazine oral tablet, 0, 2, 5 VERSACLOZ ORAL SUSPENSION 50 /ML VRAYLAR ORAL CAPSULE.5, 3, 4.5, 6 VRAYLAR ORAL CAPSULE,DOSE PACK.5 ()- 3 (6) ziprasidone hcl oral capsule 20, 40, 60, 80 ziprasidone mesylate intramuscular recon soln 20 /ml (final conc.) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 QL (60 QL (20 ST; NM; NDS; QL (30 ST; NM; NDS; QL (540 ST; NM; NDS; QL (30 ST (Geodon) QL (60 (Geodon) QL (6 per 28 days) Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 /ml (Ziagen) QL (2 per 28 days) NM; NDS; QL (2 per 28 days) NM; NDS; QL ( per 28 days) abacavir oral tablet 300 (Ziagen) abacavir-lamivudine oral tablet 600- (Epzicom) 300 abacavir-lamivudine-zidovudine oral tablet (Trizivir) NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 59 59

68 APTIVUS (WITH VITAMIN E) NM; NDS ORAL SOLUTION 00 /ML APTIVUS ORAL CAPSULE 250 NM; NDS atazanavir oral capsule 50, 200, 300 (Reyataz) BIKTARVY ORAL TABLET 50- NM; NDS CABENUVA INTRAMUSCULAR NM; NDS SUSPENSION,EXTENDED RELEASE 400 /2 ML- 600 /2 ML, 600 /3 ML- 900 /3 ML CIMDUO ORAL TABLET NM; NDS COMPLERA ORAL TABLET 200- NM; NDS CRIXIVAN ORAL CAPSULE 200 DELSTRIGO ORAL TABLET 00- NM; NDS DESCOVY ORAL TABLET NM; NDS didanosine oral capsule,delayed release(dr/ec) 250, 400 DOVATO ORAL TABLET NM; NDS EDURANT ORAL TABLET 25 NM; NDS efavirenz oral capsule 200, 50 (Sustiva) efavirenz oral tablet 600 (Sustiva) efavirenz-emtricitabin-tenofov oral (Atripla) NM; NDS tablet efavirenz-lamivu-tenofov disop oral (Symfi Lo) NM; NDS tablet efavirenz-lamivu-tenofov disop oral (Symfi) NM; NDS tablet emtricitabine oral capsule 200 (Emtriva) emtricitabine-tenofovir (tdf) oral (Truvada) NM; NDS tablet 00-50, , , EMTRIVA ORAL SOLUTION 0 /ML 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 60 60

69 EPIVIR HBV ORAL SOLUTION 25 /5 ML (5 /ML) etravirine oral tablet 00, 200 (Intelence) NM; NDS EVOTAZ ORAL TABLET NM; NDS fosamprenavir oral tablet 700 (Lexiva) FUZEON SUBCUTANEOUS NM; NDS RECON SOLN 90 GENVOYA ORAL TABLET 50- NM; NDS INTELENCE ORAL TABLET 00 NM; NDS, 200 INTELENCE ORAL TABLET 25 INVIRASE ORAL TABLET 500 NM; NDS ISENTRESS HD ORAL TABLET NM; NDS 600 ISENTRESS ORAL POWDER IN PACKET 00 ISENTRESS ORAL TABLET 400 NM; NDS ISENTRESS ORAL TABLET,CHEWABLE 00, 25 JULUCA ORAL TABLET NM; NDS KALETRA ORAL TABLET QL (300 KALETRA ORAL TABLET NM; NDS; QL (20 per 30 days) lamivudine oral solution 0 /ml (Epivir) lamivudine oral tablet 00 (Epivir HBV) lamivudine oral tablet 50, 300 (Epivir) lamivudine-zidovudine oral tablet (Combivir) LEXIVA ORAL SUSPENSION 50 /ML lopinavir-ritonavir oral solution 400- (Kaletra) QL ( /5 ml lopinavir-ritonavir oral tablet (Kaletra) QL (300 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 6 6

70 lopinavir-ritonavir oral tablet (Kaletra) NM; NDS; QL (20 per 30 days) nevirapine oral suspension 50 /5 (Viramune) ml nevirapine oral tablet 200 nevirapine oral tablet extended release 24 hr 00 nevirapine oral tablet extended (Viramune XR) release 24 hr 400 NORVIR ORAL POWDER IN PACKET 00 NORVIR ORAL SOLUTION 80 /ML ODEFSEY ORAL TABLET NM; NDS 25 PIFELTRO ORAL TABLET 00 NM; NDS PREZCOBIX ORAL TABLET 800- NM; NDS 50 - PREZISTA ORAL SUSPENSION NM; NDS 00 /ML PREZISTA ORAL TABLET 50 NM; NDS, 600, 800 PREZISTA ORAL TABLET 75 RETROVIR INTRAVENOUS SOLUTION 0 /ML REYATAZ ORAL POWDER IN NM; NDS PACKET 50 ritonavir oral tablet 00 (Norvir) RUKOBIA ORAL TABLET NM; NDS EXTENDED RELEASE 2 HR 600 SELZENTRY ORAL SOLUTION 20 /ML SELZENTRY ORAL TABLET 50 NM; NDS, 300, 75 SELZENTRY ORAL TABLET 25 stavudine oral capsule 5, 20, 30, 40 STRIBILD ORAL TABLET NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 62 62

71 SYMTUZA ORAL TABLET 800- NM; NDS TEMIXYS ORAL TABLET NM; NDS tenofovir disoproxil fumarate oral (Viread) tablet 300 TIVICAY ORAL TABLET 0 TIVICAY ORAL TABLET 25, NM; NDS 50 TIVICAY PD ORAL TABLET FOR SUSPENSION 5 TRIUMEQ ORAL TABLET NM; NDS 300 TROGARZO INTRAVENOUS NM; NDS SOLUTION 200 /.33 ML (50 /ML) VEMLIDY ORAL TABLET 25 NM; NDS; QL (30 per 30 days) VIRACEPT ORAL TABLET 250 NM; NDS, 625 VIREAD ORAL POWDER 40 NM; NDS /SCOOP (40 /GRAM) VIREAD ORAL TABLET 50, NM; NDS 200, 250 VOCABRIA ORAL TABLET 30 zidovudine oral capsule 00 (Retrovir) zidovudine oral syrup 0 /ml (Retrovir) zidovudine oral tablet 300 Antivirals, Miscellaneous foscarnet intravenous solution 24 (Foscavir) PA BvD /ml oseltamivir oral capsule 30 (Tamiflu) QL (84 per 80 days) oseltamivir oral capsule 45 (Tamiflu) QL (48 per 80 days) oseltamivir oral capsule 75 (Tamiflu) QL (42 per 80 days) oseltamivir oral suspension for (Tamiflu) QL (540 per 80 days) reconstitution 6 /ml PREVYMIS INTRAVENOUS SOLUTION 240 /2 ML PA; NM; NDS; QL (336 per 28 days) PREVYMIS INTRAVENOUS SOLUTION 480 /24 ML PA; NM; NDS; QL (672 per 28 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 63 63

72 PREVYMIS ORAL TABLET 240, 480 PA; NM; NDS; QL (28 per 28 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 /ACTUATION QL (60 per 80 days) rimantadine oral tablet 00 (Flumadine) SYNAGIS INTRAMUSCULAR PA; NM; NDS SOLUTION 00 /ML, 50 /0.5 ML XOFLUZA ORAL TABLET 20, QL (4 per 80 days) 40 XOFLUZA ORAL TABLET 80 QL (2 per 80 days) Hcv Antivirals EPCLUSA ORAL TABLET , PA; NM; NDS; QL (28 per 28 days) HARVONI ORAL PELLETS IN PACKET PA; NM; NDS; QL (28 per 28 days) HARVONI ORAL PELLETS IN PACKET PA; NM; NDS; QL (56 per 28 days) HARVONI ORAL TABLET , PA; NM; NDS; QL (28 per 28 days) MAVYRET ORAL TABLET PA; NM; NDS; QL (84 per 28 days) VOSEVI ORAL TABLET PA; NM; NDS; QL (28 per 28 days) Interferons INTRON A INJECTION RECON PA NSO; NM; NDS SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION PA NSO; NM; NDS SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS SUBCUTANEOUS NM; NDS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS NM; NDS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS NM; NDS KIT 50 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 acyclovir oral suspension 200 /5 ml (Zovirax) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 64 64

73 acyclovir oral tablet 400, 800 acyclovir sodium intravenous recon PA BvD soln,000, 500 acyclovir sodium intravenous solution 50 /ml PA BvD adefovir oral tablet 0 (Hepsera) cidofovir intravenous solution 75 /ml NM; NDS entecavir oral tablet 0.5, (Baraclude) famciclovir oral tablet 25, 250, 500 ganciclovir sodium intravenous (Cytovene) PA BvD; NM; NDS recon soln 500 ganciclovir sodium intravenous PA BvD; NM; NDS solution 50 /ml ribavirin inhalation recon soln 6 (Virazole) PA BvD; NM; NDS gram ribavirin oral capsule 200 ribavirin oral tablet 200 valacyclovir oral tablet gram, 500 (Valtrex) valganciclovir oral recon soln 50 (Valcyte) NM; NDS /ml valganciclovir oral tablet 450 (Valcyte) VEKLURY INTRAVENOUS RECON SOLN 00 PA BvD; NM; NDS Blood Products/Modifiers/Volume Expanders Anticoagulants ELIQUIS DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 (74 TABS) ELIQUIS ORAL TABLET 2.5 QL (60 ELIQUIS ORAL TABLET 5 QL (74 enoxaparin subcutaneous solution (Lovenox) QL ( /3 ml enoxaparin subcutaneous syringe (Lovenox) QL (60 00 /ml, 50 /ml enoxaparin subcutaneous syringe (Lovenox) QL (48 20 /0.8 ml, 80 /0.8 ml 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 65 65

74 enoxaparin subcutaneous syringe 30 /0.3 ml enoxaparin subcutaneous syringe 40 /0.4 ml enoxaparin subcutaneous syringe 60 /0.6 ml fondaparinux subcutaneous syringe 0 /0.8 ml fondaparinux subcutaneous syringe 2.5 /0.5 ml fondaparinux subcutaneous syringe 5 /0.4 ml fondaparinux subcutaneous syringe 7.5 /0.6 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 warfarin oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO DVT-PE TREAT 30D START ORAL TABLETS,DOSE PACK 5 (42)- 20 (9) XARELTO ORAL TABLET 0, 20 XARELTO ORAL TABLET 5, 2.5 Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) DOPTELET (0 TAB PACK) ORAL TABLET 20 (Lovenox) QL (8 (Lovenox) QL (24 (Lovenox) QL (36 (Arixtra) NM; NDS; QL (24 per 30 days) (Arixtra) QL (5 (Arixtra) NM; NDS; QL (2 per 30 days) (Arixtra) NM; NDS; QL (8 per 30 days) (Jantoven) QL (30 QL (60 PA; NM; NDS; QL (20 PA; NM; NDS; QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 66 66

75 DOPTELET (5 TAB PACK) ORAL TABLET 20 PA; NM; NDS; QL (60 DOPTELET (30 TAB PACK) ORAL TABLET 20 PA; NM; NDS; QL (60 FULPHILA SUBCUTANEOUS PA; NM; NDS SYRINGE 6 /0.6 ML GRANIX SUBCUTANEOUS PA; NM; NDS SOLUTION 300 MCG/ML, 480 MCG/.6 ML GRANIX SUBCUTANEOUS PA; NM; NDS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT PA; NM; NDS; QL (30 HAEGARDA SUBCUTANEOUS RECON SOLN 3,000 UNIT PA; NM; NDS; QL (20 LEUKINE INJECTION RECON NM; NDS SOLN 250 MCG MOZOBIL SUBCUTANEOUS NM; NDS SOLUTION 24 /.2 ML (20 /ML) MULPLETA ORAL TABLET 3 PA; NM; NDS; QL (7 per 7 days) NEULASTA SUBCUTANEOUS PA; NM; NDS SYRINGE 6 /0.6 ML NIVESTYM INJECTION PA; NM; NDS SOLUTION 300 MCG/ML, 480 MCG/.6 ML NIVESTYM SUBCUTANEOUS PA; NM; NDS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NPLATE SUBCUTANEOUS PA; NM; NDS RECON SOLN 25 MCG, 250 MCG, 500 MCG NYVEPRIA SUBCUTANEOUS PA; NM; NDS SYRINGE 6 /0.6 ML ORLADEYO ORAL CAPSULE 0, 50 PA; NM; NDS; QL (30 PROMACTA ORAL POWDER IN PACKET 2.5 PA; NM; NDS; QL (90 PROMACTA ORAL POWDER IN PACKET 25 PA; NM; NDS; QL (80 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 67 67

76 PROMACTA ORAL TABLET 2.5 PA; NM; NDS; QL (90 PROMACTA ORAL TABLET 25 PA; NM; NDS; QL (30 PROMACTA ORAL TABLET 50, 75 PA; NM; NDS; QL (60 RETACRIT INJECTION PA; QL (2 per 28 days) SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML RETACRIT INJECTION PA; QL (4 per 28 days) SOLUTION 40,000 UNIT/ML UDENYCA SUBCUTANEOUS PA; NM; NDS SYRINGE 6 /0.6 ML ZARXIO INJECTION SYRINGE PA; NM; NDS 300 MCG/0.5 ML, 480 MCG/0.8 ML ZIEXTENZO SUBCUTANEOUS PA; NM; NDS SYRINGE 6 /0.6 ML Hematologic Agents, Miscellaneous ADAKVEO INTRAVENOUS SOLUTION 0 /ML PA; NM; NDS anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule CABLIVI INJECTION KIT PA; NM; NDS; QL (30 DROXIA ORAL CAPSULE 200, 300, 400 GIVLAARI SUBCUTANEOUS PA; NM; NDS SOLUTION 89 /ML protamine intravenous solution 0 /ml SIKLOS ORAL TABLET,000, PA 00 TAVALISSE ORAL TABLET 00, 50 PA; NM; NDS; QL (60 tranexamic acid intravenous solution (Cyklokapron),000 /0 ml (00 /ml) tranexamic acid oral tablet 650 (Lysteda) QL (30 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 2 hr QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 68 68

77 BRILINTA ORAL TABLET 60, 90 cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 (Plavix) dipyridamole oral tablet 25, 50, 75 pentoxifylline oral tablet extended release 400 prasugrel oral tablet 0, 5 (Effient) QL (30 Caloric Agents Caloric Agents AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 6%-D5W (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 6-5 % CLINIMIX 8%-D0W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 8-0 % CLINIMIX 8%-D4W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 8-4 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 69 69

78 CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 8%-D0W SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-0 % CLINIMIX E 8%-D4W SULFITEFREE INTRAVENOUS PARENTERAL SOLUTION 8-4 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 70 70

79 TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0., 0.2 PA BvD, 0.3 clonidine transdermal patch weekly (Catapres-TTS-) QL (4 per 28 days) 0. /24 hr clonidine transdermal patch weekly (Catapres-TTS-2) QL (4 per 28 days) 0.2 /24 hr clonidine transdermal patch weekly (Catapres-TTS-3) QL (8 per 28 days) 0.3 /24 hr doxazosin oral tablet, 2, 4 (Cardura), 8 droxidopa oral capsule 00, 200, 300 (Northera) PA; NM; NDS; QL (80 guanfacine oral tablet, 2 methyldopa oral tablet 250, 500 midodrine oral tablet 0, 2.5, 5 phenylephrine hcl injection solution (Vazculep) 0 /ml prazosin oral capsule, 2, 5 (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 6, 32, 4, 8 (Atacand) candesartan-hydrochlorothiazid oral tablet 6-2.5, , (Atacand HCT) EDARBI ORAL TABLET 40, 80 EDARBYCLOR ORAL TABLET , ENTRESTO ORAL TABLET QL (60, 49-5, eprosartan oral tablet 600 irbesartan oral tablet 50, 300, 75 (Avapro) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 7 7

80 irbesartan-hydrochlorothiazide oral (Avalide) tablet , losartan oral tablet 00, 25, (Cozaar) 50 losartan-hydrochlorothiazide oral (Hyzaar) tablet , 00-25, olmesartan oral tablet 20, 40, (Benicar) 5 olmesartan-amlodipin-hcthiazid oral (Tribenzor) tablet , , , , olmesartan-hydrochlorothiazide oral (Benicar HCT) tablet , , telmisartan oral tablet 20, 40, (Micardis) 80 telmisartan-amlodipine oral tablet (Twynsta) 40-0, 40-5, 80-0, 80-5 telmisartan-hydrochlorothiazid oral tablet , , (Micardis HCT) valsartan oral tablet 60, 320, (Diovan) 40, 80 valsartan-hydrochlorothiazide oral (Diovan HCT) tablet , 60-25, , , Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0, 20, (Lotensin) 40 benazepril oral tablet 5 benazepril-hydrochlorothiazide oral (Lotensin HCT) tablet 0-2.5, , benazepril-hydrochlorothiazide oral tablet captopril oral tablet 00, 2.5, 25, 50 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 72 72

81 captopril-hydrochlorothiazide oral tablet 25-5, 25-25, 50-5, enalapril maleate oral tablet 0, (Vasotec) 2.5, 20, 5 enalaprilat intravenous solution.25 /ml enalapril-hydrochlorothiazide oral (Vaseretic) tablet 0-25 enalapril-hydrochlorothiazide oral tablet EPANED ORAL SOLUTION /ML ST; QL (200 per 30 days) fosinopril oral tablet 0, 20, 40 fosinopril-hydrochlorothiazide oral tablet 0-2.5, lisinopril oral tablet 0, 2.5, (Zestril) 30, 40, 5 lisinopril oral tablet 20 (Prinivil) lisinopril-hydrochlorothiazide oral (Zestoretic) tablet 0-2.5, , moexipril oral tablet 5, 7.5 perindopril erbumine oral tablet 2, 4, 8 QBRELIS ORAL SOLUTION /ML ST; NM; NDS; QL (200 quinapril oral tablet 0, 20, (Accupril) 40, 5 quinapril-hydrochlorothiazide oral (Accuretic) tablet 0-2.5, , ramipril oral capsule.25, 0 (Altace), 2.5, 5 trandolapril oral tablet, 2, 4 Antiarrhythmic Agents amiodarone oral tablet 00, 200 (Pacerone), 400 disopyramide phosphate oral capsule 00, 50 (Norpace) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 73 73

82 dofetilide oral capsule 25 mcg, 250 (Tikosyn) mcg, 500 mcg flecainide oral tablet 00, 50, 50 lidocaine (pf) injection solution 0 (Xylocaine-MPF) /ml ( %) lidocaine (pf) intravenous syringe 00 /5 ml (2 %), 50 /5 ml ( %) mexiletine oral capsule 50, 200, 250 MULTAQ ORAL TABLET 400 pacerone oral tablet 00, 200, 400 procainamide injection solution 00 /ml, 500 /ml procainamide intravenous syringe 00 /ml propafenone oral capsule,extended (Rythmol SR) release 2 hr 225, 325, 425 propafenone oral tablet 50, 225, 300 quinidine gluconate oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200, 400 atenolol oral tablet 00, 25, (Tenormin) 50 atenolol-chlorthalidone oral tablet (Tenoretic 00) atenolol-chlorthalidone oral tablet (Tenoretic 50) betaxolol oral tablet 0, 20 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral (Ziac) tablet , , BYSTOLIC ORAL TABLET 0, 2.5, 20, 5 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 74 74

83 carvedilol oral tablet 2.5, 25 (Coreg), 3.25, 6.25 labetalol intravenous solution 5 /ml labetalol intravenous syringe 20 /4 ml (5 /ml) labetalol oral tablet 00, 200, 300 metoprolol succinate oral tablet (Toprol XL) extended release 24 hr 00, 200, 25, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-25, metoprolol ta-hydrochlorothiaz oral (Lopressor HCT) tablet metoprolol tartrate intravenous solution 5 /5 ml metoprolol tartrate oral tablet 00 (Lopressor), 50 metoprolol tartrate oral tablet 25 nadolol oral tablet 20, 40, 80 (Corgard) pindolol oral tablet 0, 5 propranolol intravenous solution /ml propranolol oral capsule,extended (Inderal LA) release 24 hr 20, 60, 60, 80 propranolol oral solution 20 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 20, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-25, sorine oral tablet 20, 60, 240, 80 sotalol af oral tablet 20, 60, 80 sotalol oral tablet 20, 60, (Sorine) 240, 80 timolol maleate oral tablet 0, 20, 5 Calcium-Channel Blocking Agents 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 75 75

84 cartia xt oral capsule,extended release 24hr 20, 80, 240, 300 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 2 hr 20, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release 24 hr 360 diltiazem hcl oral capsule,extended (Tiadylt ER) release 24 hr 420 diltiazem hcl oral capsule,extended (Cartia XT) release 24hr 20, 80, 240, 300 diltiazem hcl oral tablet 20, 30 (Cardizem), 60 diltiazem hcl oral tablet 90 dilt-xr oral capsule,ext.rel 24h degradable 20, 80, 240 matzim la oral tablet extended release 24 hr 80, 240, 300, 360, 420 taztia xt oral capsule,extended release 24 hr 20, 80, 240, 300, 360 tiadylt er oral capsule,extended release 24 hr 20, 80, 240, 300, 360, 420 verapamil intravenous syringe 2.5 /ml verapamil oral capsule, 24 hr er pellet ct 00, 200, 300 (Verelan PM) verapamil oral capsule,ext rel. pellets (Verelan) 24 hr 20, 80, 240, 360 verapamil oral tablet 20, 40, 80 verapamil oral tablet extended (Calan SR) release 20, 80, 240 Cardiovascular Agents, Miscellaneous CORLANOR ORAL SOLUTION 5 /5 ML QL (600 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 76 76

85 CORLANOR ORAL TABLET 5 QL (60, 7.5 digitek oral tablet 25 mcg (0.25 ), 250 mcg (0.25 ) digox oral tablet 25 mcg (0.25 ), 250 mcg (0.25 ) digoxin injection syringe 250 mcg/ml (0.25 /ml) digoxin oral tablet 25 mcg (0.25 (Digitek) ), 250 mcg (0.25 ) epinephrine injection auto-injector (EpiPen Jr) QL (4 0.5 /0.3 ml epinephrine injection auto-injector (Auvi-Q) QL (4 0.3 /0.3 ml epinephrine injection solution (Adrenalin) /ml hydralazine injection solution 20 /ml hydralazine oral tablet 0, 00, 25, 50 icatibant subcutaneous syringe 30 /3 ml (Firazyr) PA; NM; NDS; QL (8 metyrosine oral capsule 250 (Demser) NM; NDS ranolazine oral tablet extended (Ranexa) QL (60 release 2 hr,000 ranolazine oral tablet extended (Ranexa) QL (20 release 2 hr 500 SYMJEPI INJECTION SYRINGE QL (4 0.5 /0.3 ML, 0.3 /0.3 ML VYNDAMAX ORAL CAPSULE 6 PA; NM; NDS; QL (30 VYNDAQEL ORAL CAPSULE 20 PA; NM; NDS; QL (20 Dihydropyridines amlodipine oral tablet 0, 2.5, (Norvasc) 5 amlodipine-benazepril oral capsule (Lotrel) 0-20, 0-40, 5-0, 5-20 amlodipine-benazepril oral capsule 2.5-0, 5-40 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 77 77

86 amlodipine-olmesartan oral tablet (Azor) 0-20, 0-40, 5-20, 5-40 amlodipine-valsartan oral tablet 0- (Exforge) 60, 0-320, 5-60, amlodipine-valsartan-hcthiazid oral (Exforge HCT) tablet , , , , felodipine oral tablet extended release 24 hr 0, 2.5, 5 isradipine oral capsule 2.5, 5 KATERZIA ORAL SUSPENSION /ML ST; QL (300 per 30 days) nicardipine oral capsule 20, 30 nifedipine oral capsule 0, 20 nifedipine oral tablet extended (Procardia XL) release 24hr 30, 60, 90 nifedipine oral tablet extended (Adalat CC) release 30, 60, 90 Diuretics amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5,, 2 chlorothiazide sodium intravenous (Diuril IV) recon soln 500 chlorthalidone oral tablet 25, 50 furosemide injection solution 0 /ml furosemide injection syringe 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 20, 40, 80 (Lasix) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 78 78

87 hydrochlorothiazide oral capsule 2.5 hydrochlorothiazide oral tablet 2.5, 25, 50 indapamide oral tablet.25, 2.5 JYNARQUE ORAL TABLET 5, 30 JYNARQUE ORAL TABLETS, SEQUENTIAL 5 (AM)/ 5 (PM), 30 (AM)/ 5 (PM), 45 (AM)/ 5 (PM), 60 (AM)/ 30 (PM), 90 (AM)/ 30 (PM) metolazone oral tablet 0, 2.5, 5 spironolactone oral tablet 00, 25, 50 spironolacton-hydrochlorothiaz oral tablet torsemide oral tablet 0, 00, 20, 5 triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet triamterene-hydrochlorothiazid oral tablet Dyslipidemics amlodipine-atorvastatin oral tablet 0-0, 5-0 amlodipine-atorvastatin oral tablet 0-20, 0-40, 0-80, 5-20, 5-40, 5-80 amlodipine-atorvastatin oral tablet 2.5-0, , atorvastatin oral tablet 0, 20, 40, 80 cholestyramine (with sugar) oral powder in packet 4 gram cholestyramine light oral powder in packet 4 gram (Aldactone) (Aldactazide) (Maxzide-25) (Maxzide) (Caduet) PA; NM; NDS; QL (20 PA; NM; NDS; QL (56 per 28 days) (Caduet) QL (30 (Lipitor) QL (30 (Questran) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 79 79

88 colesevelam oral powder in packet (WelChol) 3.75 gram colesevelam oral tablet 625 (WelChol) colestipol oral packet 5 gram (Colestid) colestipol oral tablet gram (Colestid) EZALLOR SPRINKLE ORAL ST; QL (30 CAPSULE, SPRINKLE 0, 20, 40, 5 ezetimibe oral tablet 0 (Zetia) QL (30 ezetimibe-simvastatin oral tablet 0- (Vytorin 0-0) QL (30 0 ezetimibe-simvastatin oral tablet 0- (Vytorin 0-20) QL (30 20 ezetimibe-simvastatin oral tablet 0- (Vytorin 0-40) QL (30 40 ezetimibe-simvastatin oral tablet 0- (Vytorin 0-80) QL (30 80 fenofibrate micronized oral capsule 30, 34, 200, 43, 67 fenofibrate nanocrystallized oral (Tricor) tablet 45, 48 fenofibrate oral tablet 60, 54 fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 35, 45 fluvastatin oral capsule 20, 40 QL (60 gemfibrozil oral tablet 600 (Lopid) JUXTAPID ORAL CAPSULE 0, 30, 40, 60 PA; NM; NDS; QL (30 JUXTAPID ORAL CAPSULE 20 PA; NM; NDS; QL (90 JUXTAPID ORAL CAPSULE 5 PA; NM; NDS; QL (45 LIVALO ORAL TABLET, 2 QL (30, 4 lovastatin oral tablet 0, 20, 40 NEXLETOL ORAL TABLET 80 QL (30 NEXLIZET ORAL TABLET 80-0 QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 80 80

89 niacin oral tablet 500 (Niacor) niacin oral tablet extended release 24 (Niaspan Extended- hr,000, 500, 750 Release) niacor oral tablet 500 omega-3 acid ethyl esters oral (Lovaza) QL (20 capsule gram PRALUENT PEN QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 50 /ML, 75 /ML pravastatin oral tablet 0, 80 pravastatin oral tablet 20, 40 QL (30 prevalite oral powder in packet 4 gram rosuvastatin oral tablet 0, 20 (Crestor) QL (30, 40, 5 simvastatin oral tablet 0, 20, (Zocor) QL (30 40, 80 simvastatin oral tablet 5 QL (30 VASCEPA ORAL CAPSULE 0.5 QL (240 GRAM VASCEPA ORAL CAPSULE QL (20 GRAM Renin-Angiotensin-Aldosterone System Inhibitors aliskiren oral tablet 50, 300 (Tekturna) CAROSPIR ORAL SUSPENSION 25 /5 ML ST; QL (600 per 30 days) eplerenone oral tablet 25, 50 (Inspra) Vasodilators BIDIL ORAL TABLET isosorbide dinitrate oral tablet 0, 20, 30 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide mononitrate oral tablet 0, 20 isosorbide mononitrate oral tablet extended release 24 hr 20, 30, 60 minitran transdermal patch 24 hour 0. /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr minoxidil oral tablet 0, 2.5 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 8 8

90 nitroglycerin intravenous solution 50 /0 ml (5 /ml) nitroglycerin sublingual tablet 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0. /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Central Nervous System Agents Central Nervous System Agents atomoxetine oral capsule 0, 8 (Nitrostat) (Minitran) (Strattera) QL (60, 25, 40 atomoxetine oral capsule 00, 60 (Strattera) QL (30, 80 AUBAGIO ORAL TABLET 4, 7 PA; NM; NDS; QL (30 AUSTEDO ORAL TABLET 2, 9 PA; NM; NDS; QL (20 AUSTEDO ORAL TABLET 6 PA; NM; NDS; QL (60 AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML PA; NM; NDS; QL ( per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 caffeine citrate intravenous solution 60 /3 ml (20 /ml) caffeine citrate oral solution 60 /3 ml (20 /ml) clonidine hcl oral tablet extended release 2 hr 0. COPAXONE SUBCUTANEOUS SYRINGE 20 /ML COPAXONE SUBCUTANEOUS SYRINGE 40 /ML dalfampridine oral tablet extended release 2 hr 0 dexmethylphenidate oral tablet 0, 2.5, 5 PA; NM; NDS; QL ( per 28 days) PA; NM; NDS; QL (5 (Cafcit) PA BvD (Kapvay) QL (20 PA; NM; NDS; QL (30 PA; NM; NDS; QL (2 per 28 days) (Ampyra) PA; QL (60 (Focalin) QL (60 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 82 82

91 dextroamphetamine oral capsule, extended release 0, 5, 5 (Dexedrine Spansule) QL (20 dextroamphetamine oral tablet 0 (Zenzedi) QL (80 dextroamphetamine oral tablet 5 (Zenzedi) QL (90 dextroamphetamine-amphetamine (Adderall XR) QL (30 oral capsule,extended release 24hr 0, 5, 5 dextroamphetamine-amphetamine (Adderall XR) QL (60 oral capsule,extended release 24hr 20, 25, 30 dextroamphetamine-amphetamine (Adderall) QL (60 oral tablet 0, 2.5, 5, 20, 30, 5, 7.5 dimethyl fumarate oral capsule,delayed release(dr/ec) 20 (Tecfidera) PA; NM; NDS; QL (4 per 7 days) dimethyl fumarate oral capsule,delayed release(dr/ec) 20 (4)- 240 (46) (Tecfidera) PA; NM; NDS dimethyl fumarate oral capsule,delayed release(dr/ec) 240 ENSPRYNG SUBCUTANEOUS SYRINGE 20 /ML flumazenil intravenous solution 0. /ml GILENYA ORAL CAPSULE 0.25, 0.5 glatiramer subcutaneous syringe 20 /ml glatiramer subcutaneous syringe 40 /ml glatopa subcutaneous syringe 20 /ml glatopa subcutaneous syringe 40 /ml guanfacine oral tablet extended release 24 hr, 2, 3, 4 KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 /0.4 ML lithium carbonate oral capsule 50, 300, 600 (Tecfidera) PA; NM; NDS; QL (60 PA; NM; NDS PA; NM; NDS; QL (30 (Copaxone) PA; NM; NDS; QL (30 (Copaxone) PA; NM; NDS; QL (2 per 28 days) PA; NM; NDS; QL (30 PA; NM; NDS; QL (2 per 28 days) (Intuniv ER) QL (30 PA; NM; NDS; QL (.2 per 28 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 83 83

92 lithium carbonate oral tablet 300 lithium carbonate oral tablet (Lithobid) extended release 300 lithium carbonate oral tablet extended release 450 MAVENCLAD (0 TABLET PA; NM; NDS PACK) ORAL TABLET 0 MAVENCLAD (4 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAVENCLAD (5 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAVENCLAD (6 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAVENCLAD (7 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAVENCLAD (8 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAVENCLAD (9 TABLET PACK) PA; NM; NDS ORAL TABLET 0 MAYZENT ORAL TABLET 0.25 PA; NM; NDS; QL (2 per 28 days) MAYZENT ORAL TABLET 2 PA; NM; NDS; QL (30 MAYZENT STARTER PACK PA; NM; NDS ORAL TABLETS,DOSE PACK 0.25 (2 TABS) metadate er oral tablet extended QL (90 release 20 methylphenidate hcl oral capsule, er QL (30 biphasic , 20, 40, 50, 60 methylphenidate hcl oral capsule, er QL (60 biphasic methylphenidate hcl oral capsule,er (Ritalin LA) QL (30 biphasic , 20, 40 methylphenidate hcl oral capsule,er (Ritalin LA) QL (60 biphasic methylphenidate hcl oral capsule,er QL (30 biphasic methylphenidate hcl oral solution 0 (Methylin) QL (900 /5 ml, 5 /5 ml methylphenidate hcl oral tablet 0, 20, 5 (Ritalin) QL (90 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 84 84

93 methylphenidate hcl oral tablet QL (90 extended release 0 methylphenidate hcl oral tablet (Metadate ER) QL (90 extended release 20 methylphenidate hcl oral tablet QL (30 extended release 24hr 8 (bx rating), 27 (bx rating), 54 (bx rating) methylphenidate hcl oral tablet (Concerta) QL (30 extended release 24hr 8, 27, 54 methylphenidate hcl oral tablet (Concerta) QL (60 extended release 24hr 36 methylphenidate hcl oral tablet QL (60 extended release 24hr 36 (bx rating) PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML PA; NM; NDS; QL ( per 28 days) PLEGRIDY SUBCUTANEOUS PA; NM; NDS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PA; NM; NDS; QL ( per 28 days) PLEGRIDY SUBCUTANEOUS PA; NM; NDS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS SOLUTION 30 /00 ML PA; NM; NDS; QL (2800 per 28 days) riluzole oral tablet 50 (Rilutek) QL (60 SAVELLA ORAL TABLET 00 QL (60, 2.5, 25, 50 SAVELLA ORAL TABLETS,DOSE PACK 2.5 (5)-25 (8)-50 (42) tetrabenazine oral tablet 2.5, 25 (Xenazine) PA; NM; NDS; QL (2 per 28 days) VUMERITY ORAL CAPSULE,DELAYED PA; NM; NDS; QL (20 RELEASE(DR/EC) 23 Contraceptives Contraceptives afirmelle oral tablet mcg 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 85 85

94 altavera (28) oral tablet alyacen /35 (28) oral tablet -35 -mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg amethia oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) apri oral tablet aranelle (28) oral tablet 0.5// mcg ashlyna oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) aubra eq oral tablet mcg aurovela.5/30 (2) oral tablet mcg aurovela /20 (2) oral tablet -20 -mcg aurovela 24 fe oral tablet -20 mcg (24)/75 (4) aurovela fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) aurovela fe -20 (28) oral tablet -20 mcg (2)/75 (7) aviane oral tablet mcg ayuna oral tablet azurette (28) oral tablet x2 /0.0 x 5 balziva (28) oral tablet mcg bekyree (28) oral tablet x2 /0.0 x 5 blisovi 24 fe oral tablet -20 mcg (24)/75 (4) blisovi fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) blisovi fe /20 (28) oral tablet - 20 mcg (2)/75 (7) briellyn oral tablet mcg camila oral tablet 0.35 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 86 86

95 caziant (28) oral tablet 0./.25/ mcg chateal eq (28) oral tablet cryselle (28) oral tablet mcg cyclafem /35 (28) oral tablet -35 -mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg cyred eq oral tablet dasetta /35 (28) oral tablet -35 mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg daysee oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) deblitane oral tablet 0.35 desog-e.estradiol/e.estradiol oral (Azurette (28)) tablet x2 /0.0 x 5 desogestrel-ethinyl estradiol oral (Apri) tablet drospirenone-ethinyl estradiol oral (Jasmiel (28)) tablet drospirenone-ethinyl estradiol oral (Syeda) tablet elinest oral tablet mcg ELLA ORAL TABLET 30 QL (6 per 365 days) eluryng vaginal ring QL ( per 28 days) /24 hr emoquette oral tablet enpresse oral tablet (6)/75-40 (5)/25-30(0) enskyce oral tablet errin oral tablet 0.35 estarylla oral tablet mcg ethynodiol diac-eth estradiol oral (Kelnor /35 (28)) tablet -35 -mcg ethynodiol diac-eth estradiol oral tablet -50 -mcg (Kelnor -50 (28)) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 87 87

96 etonogestrel-ethinyl estradiol vaginal (EluRyng) QL ( per 28 days) ring /24 hr falmina (28) oral tablet mcg femynor oral tablet mcg hailey 24 fe oral tablet -20 mcg (24)/75 (4) hailey fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) hailey fe /20 (28) oral tablet - 20 mcg (2)/75 (7) hailey oral tablet mcg heather oral tablet 0.35 iclevia oral tablets,dose pack,3 QL (9 per 84 days) month mcg (9) incassia oral tablet 0.35 introvale oral tablets,dose pack,3 QL (9 per 84 days) month mcg (9) isibloom oral tablet jaimiess oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) jasmiel (28) oral tablet jencycla oral tablet 0.35 juleber oral tablet junel.5/30 (2) oral tablet mcg junel /20 (2) oral tablet -20 mcg junel fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) junel fe /20 (28) oral tablet -20 mcg (2)/75 (7) junel fe 24 oral tablet -20 mcg (24)/75 (4) kalliga oral tablet kariva (28) oral tablet x2 /0.0 x 5 kelnor /35 (28) oral tablet -35 mcg kelnor -50 (28) oral tablet -50 mcg 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 88 88

97 kurvelo (28) oral tablet l norgest/e.estradiol-e.estrad oral (LoJaimiess) QL (9 per 84 days) tablets,dose pack,3 month mcg (84)/0 mcg (7) l norgest/e.estradiol-e.estrad oral (Amethia) QL (9 per 84 days) tablets,dose pack,3 month mcg (84)/0 mcg (7) larin.5/30 (2) oral tablet mcg larin /20 (2) oral tablet -20 mcg larin 24 fe oral tablet -20 mcg (24)/75 (4) larin fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) larin fe /20 (28) oral tablet -20 mcg (2)/75 (7) larissia oral tablet mcg lessina oral tablet mcg levonest (28) oral tablet (6)/75-40 (5)/25-30(0) levonorgestrel-ethinyl estrad oral (Afirmelle) tablet mcg levonorgestrel-ethinyl estrad oral (Altavera (28)) tablet levonorgestrel-ethinyl estrad oral (Iclevia) QL (9 per 84 days) tablets,dose pack,3 month mcg (9) levonorg-eth estrad triphasic oral (Enpresse) tablet (6)/75-40 (5)/25-30(0) levora-28 oral tablet lillow (28) oral tablet lojaimiess oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) loryna (28) oral tablet low-ogestrel (28) oral tablet mcg lo-zumandimine (28) oral tablet lutera (28) oral tablet mcg lyleq oral tablet 0.35 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 89 89

98 lyza oral tablet 0.35 marlissa (28) oral tablet microgestin fe /20 (28) oral tablet -20 mcg (2)/75 (7) mili oral tablet mcg mono-linyah oral tablet mcg necon 0.5/35 (28) oral tablet mcg nikki (28) oral tablet norethindrone (contraceptive) oral (Camila) tablet 0.35 norethindrone ac-eth estradiol oral (Aurovela.5/30 (2)) tablet mcg norethindrone ac-eth estradiol oral (Aurovela /20 (2)) tablet -20 -mcg norethindrone-e.estradiol-iron oral (Gemmily) capsule -20 mcg (24)/75 (4) norethindrone-e.estradiol-iron oral (Aurovela Fe -20 (28)) tablet -20 mcg (2)/75 (7) norethindrone-e.estradiol-iron oral (Aurovela Fe.5/30 tablet.5-30 mcg (2)/75 (7) (28)) norgestimate-ethinyl estradiol oral (Tri-Lo-Estarylla) tablet 0.8/0.25/ mcg norgestimate-ethinyl estradiol oral (Tri Femynor) tablet 0.8/0.25/ mcg (28) norgestimate-ethinyl estradiol oral (Estarylla) tablet mcg norlyda oral tablet 0.35 nortrel 0.5/35 (28) oral tablet mcg nortrel /35 (2) oral tablet -35 mcg (2) nortrel /35 (28) oral tablet -35 mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg nylia 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg nymyo oral tablet mcg 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 90 90

99 orsythia oral tablet mcg philith oral tablet mcg pimtrea (28) oral tablet x2 /0.0 x 5 pirmella oral tablet 0.5/0.75/ - 35 mcg, -35 -mcg portia 28 oral tablet previfem oral tablet mcg reclipsen (28) oral tablet setlakin oral tablets,dose pack,3 QL (9 per 84 days) month mcg (9) sharobel oral tablet 0.35 simliya (28) oral tablet x2 /0.0 x 5 simpesse oral tablets,dose pack,3 QL (9 per 84 days) month mcg (84)/0 mcg (7) SLYND ORAL TABLET 4 (28) sprintec (28) oral tablet mcg sronyx oral tablet mcg syeda oral tablet tarina 24 fe oral tablet -20 mcg (24)/75 (4) tarina fe -20 eq (28) oral tablet -20 mcg (2)/75 (7) tri femynor oral tablet 0.8/0.25/ mcg (28) tri-estarylla oral tablet 0.8/0.25/ mcg (28) tri-legest fe oral tablet -20(5)/- 30(7) /-35mcg (9) tri-linyah oral tablet 0.8/0.25/ mcg (28) tri-lo-estarylla oral tablet 0.8/0.25/ mcg tri-lo-marzia oral tablet 0.8/0.25/ mcg tri-lo-mili oral tablet 0.8/0.25/ mcg 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 9 9

100 tri-lo-sprintec oral tablet 0.8/0.25/ mcg tri-mili oral tablet 0.8/0.25/ mcg (28) tri-nymyo oral tablet 0.8/0.25/ mcg (28) tri-previfem (28) oral tablet 0.8/0.25/ mcg (28) tri-sprintec (28) oral tablet 0.8/0.25/ mcg (28) trivora (28) oral tablet (6)/75-40 (5)/25-30(0) tri-vylibra lo oral tablet 0.8/0.25/ mcg tri-vylibra oral tablet 0.8/0.25/ mcg (28) tulana oral tablet 0.35 tyblume oral tablet,chewable mcg velivet triphasic regimen (28) oral tablet 0./.25/ mcg vestura (28) oral tablet vienva oral tablet mcg viorele (28) oral tablet x2 /0.0 x 5 volnea (28) oral tablet x2 /0.0 x 5 vyfemla (28) oral tablet mcg vylibra oral tablet mcg wera (28) oral tablet mcg xulane transdermal patch weekly QL (3 per 28 days) mcg/24 hr zafemy transdermal patch weekly QL (3 per 28 days) mcg/24 hr zarah oral tablet zovia -35 (28) oral tablet -35 mcg zovia -35e tablet outer -35 -mcg zumandimine (28) oral tablet Dental And Oral Agents 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 92 92

101 Dental And Oral Agents cevimeline oral capsule 30 (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.2 % denta 5000 plus dental cream. % dentagel dental gel. % oralone dental paste 0. % paroex oral rinse mucous membrane mouthwash 0.2 % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5, 7.5 (Salagen (pilocarpine)) sf 5000 plus dental cream. % sodium fluoride dental solution 0.2 % (PreviDent) sodium fluoride-pot nitrate dental (Fluoridex Sensitivity paste.-5 % Relief) triamcinolone acetonide dental paste 0. % (Oralone) Dermatological Agents Dermatological Agents, Other accutane oral capsule 0, 20, 30, 40 acitretin oral capsule 0, 25 (Soriatane) acitretin oral capsule 7.5 acyclovir topical cream 5 % (Zovirax) QL (5 per 4 days) acyclovir topical ointment 5 % (Zovirax) QL (30 ammonium lactate topical cream 2 % ammonium lactate topical lotion 2 (Skin Treatment) % BD SINGLE USE SWAB calcipotriene scalp solution % QL (20 calcipotriene topical cream % (Dovonex) QL (20 calcipotriene topical ointment % DENAVIR TOPICAL CREAM % NM; NDS fluorouracil topical cream 0.5 % (Carac) NM; NDS fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % QL (20 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 93 93

102 imiquimod topical cream in packet 5 (Aldara) QL (24 % ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD TOPICAL PADS, MEDICATED methoxsalen oral capsule,liqdfilled,rapid NM; NDS rel 0 PANRETIN TOPICAL GEL 0. % NM; NDS; QL (80 per 30 days) podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.0 % PA; NM; NDS; QL (30 SANTYL TOPICAL OINTMENT QL ( UNIT/GRAM VALCHLOR TOPICAL GEL 0.06 NM; NDS % VEREGEN TOPICAL OINTMENT NM; NDS 5 % zenatane oral capsule 0, 20, 30, 40 Dermatological Antibacterials clindamycin phosphate topical foam (Evoclin) QL (00 % clindamycin phosphate topical (Cleocin T) QL (80 solution % clindamycin phosphate topical swab (Clindacin ETZ) % clindamycin-benzoyl peroxide topical (Neuac) gel.2 %( % base) -5 % clindamycin-benzoyl peroxide topical (Benzaclin) gel -5 % ery pads topical swab 2 % erythromycin with ethanol topical gel (Erygel) QL (80 2 % erythromycin with ethanol topical QL (80 solution 2 % erythromycin-benzoyl peroxide (Benzamycin) topical gel 3-5 % gentamicin topical cream 0. % QL (20 gentamicin topical ointment 0. % QL (20 metronidazole topical cream 0.75 % (Rosadan) metronidazole topical gel 0.75 % (Rosadan) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 94 94

103 metronidazole topical gel % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin topical ointment 2 % (Centany) QL (220 neomycin-polymyxin b gu irrigation solution ,000 unit/ml rosadan topical cream 0.75 % selenium sulfide topical lotion 2.5 % silver sulfadiazine topical cream % (SSD) ssd topical cream % sulfacetamide sodium (acne) topical (Klaron) suspension 0 % Dermatological Anti-Inflammatory Agents ala-cort topical cream % ala-scalp topical lotion 2 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical foam (Luxiq) 0.2 % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical (Diprolene (augmented)) ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % (Temovate) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 95 95

104 clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam (Olux-E) 0.05 % desonide topical cream 0.05 % (DesOwen) desonide topical lotion 0.05 % (DesOwen) desonide topical ointment 0.05 % desoximetasone topical cream 0.05 (Topicort) QL (20 %, 0.25 % desoximetasone topical gel 0.05 % (Topicort) QL (20 desoximetasone topical ointment 0.05 (Topicort) QL (20 %, 0.25 % diflorasone topical ointment 0.05 % QL (80 EUCRISA TOPICAL OINTMENT 2 % fluocinolone topical cream 0.0 % fluocinolone topical cream % (Synalar) fluocinolone topical ointment (Synalar) % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone propionate topical cream (Cutivate) 0.05 % fluticasone propionate topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone 2.5% cream 2.5 % hydrocortisone butyrate topical QL (20 cream 0. % hydrocortisone butyrate topical lotion 0. % (Locoid) QL (236 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 96 96

105 hydrocortisone butyrate topical QL (20 ointment 0. % hydrocortisone butyrate topical solution 0. % QL (20 hydrocortisone topical cream % (Ala-Cort) hydrocortisone topical cream with (Procto-Med HC) perineal applicator 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % pimecrolimus topical cream % (Elidel) QL (00 prednicarbate topical ointment 0. % procto-med hc topical cream with perineal applicator 2.5 % procto-pak topical cream with perineal applicator % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % tacrolimus topical ointment 0.03 %, (Protopic) QL (00 0. % triamcinolone acetonide topical cream % triamcinolone acetonide topical (Triderm) cream 0. %, 0.5 % triamcinolone acetonide topical lotion %, 0. % triamcinolone acetonide topical ointment %, 0. %, 0.5 % triamcinolone acetonide topical (Trianex) ointment 0.05 % Dermatological Retinoids adapalene topical cream 0. % (Differin) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 97 97

106 adapalene topical gel 0. % (Differin) ALTRENO TOPICAL LOTION 0.05 % PA tazarotene topical cream 0. % (Tazorac) TAZORAC TOPICAL CREAM 0.05 % tretinoin topical cream % (Avita) PA tretinoin topical cream 0.05 %, 0. % (Retin-A) PA tretinoin topical gel 0.0 % (Retin-A) PA tretinoin topical gel % (Avita) PA tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32" BD VEO INS 0.3 ML 6MMX3G (/2) 0.3 ML 3 GAUGE X 5/64" BD VEO INS SYRING ML 6MMX3G ML 3 GAUGE X 5/64" BD VEO INS SYRN 0.5 ML 6MMX3G /2 ML 3 GAUGE X 5/64" GAUZE PADS & DRESSINGS - PADS 2 X 2 TOPICAL BANDAGE 2 X 2 " INSULIN SYRINGE-NEEDLE U- (Ultilet Insulin Syringe) 00 SYRINGE 0.3 ML 29 GAUGE INSULIN SYRINGE-NEEDLE U- (Advocate Syringes) 00 SYRINGE ML 29 GAUGE X /2" INSULIN SYRINGE-NEEDLE U- (Lite Touch Insulin 00 SYRINGE /2 ML 28 GAUGE Syringe) PEN NEEDLE, DIABETIC (st Tier Unifine NEEDLE 29 GAUGE X /2" Pentips) SM STERILE PADS 2" X 2" 2"X2", STERILE 2 X 2 " 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 98 98

107 SURE COMFORT 0.5 ML SYRINGE 0.5 ML 29 GAUGE X /2" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ALDURAZYME INTRAVENOUS SOLUTION 2.9 /5 ML CERDELGA ORAL CAPSULE 84 CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT NM; NDS PA; NM; NDS NM; NDS ELAPRASE INTRAVENOUS NM; NDS SOLUTION 6 /3 ML ELITEK INTRAVENOUS RECON NM; NDS SOLN.5, 7.5 FABRAZYME INTRAVENOUS PA; NM; NDS RECON SOLN 35, 5 GALAFOLD ORAL CAPSULE 23 PA; NM; NDS; QL (4 per 28 days) KANUMA INTRAVENOUS PA; NM; NDS SOLUTION 2 /ML KRYSTEXXA INTRAVENOUS PA BvD; NM; NDS SOLUTION 8 /ML MEPSEVII INTRAVENOUS PA; NM; NDS SOLUTION 2 /ML miglustat oral capsule 00 (Zavesca) PA; NM; NDS; QL (90 NAGLAZYME INTRAVENOUS NM; NDS SOLUTION 5 /5 ML nitisinone oral capsule 0, 2, (Orfadin) PA; NM; NDS 5 NITYR ORAL TABLET 0, 2 PA; NM; NDS, 5 ORFADIN ORAL CAPSULE 20 PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 99 99

108 ORFADIN ORAL SUSPENSION 4 /ML PALYNZIQ SUBCUTANEOUS SYRINGE 0 /0.5 ML, 2.5 /0.5 ML, 20 /ML PULMOZYME INHALATION SOLUTION /ML REVCOVI INTRAMUSCULAR SOLUTION 2.4 /.5 ML (.6 /ML) sapropterin oral tablet,soluble 00 STRENSIQ SUBCUTANEOUS SOLUTION 8 /0.45 ML, 28 /0.7 ML, 40 /ML, 80 /0.8 ML VIMIZIM INTRAVENOUS SOLUTION 5 /5 ML ( /ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-32,000-42,000 UNIT, 5,000-47,000-63,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-79,000-05,000 UNIT, 3,000-0,000-4,000-UNIT, 40,000-26,000-68,000 UNIT, 5,000-7,000-24,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous PA; NM; NDS PA; NM; NDS PA BvD; NM; NDS PA; NM; NDS (Kuvan) NM; NDS PA; NM; LA; NDS PA; NM; NDS NM; NDS alcaine ophthalmic (eye) drops 0.5 % apraclonidine ophthalmic (eye) drops 0.5 % atropine ophthalmic (eye) drops % (Isopto Atropine) azelastine nasal aerosol,spray 37 QL (30 per 25 days) mcg (0. %) azelastine nasal spray,non-aerosol QL (30 per 25 days) mcg (0.5 %) azelastine ophthalmic (eye) drops 0.05 % 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 00 00

109 bepotastine besilate ophthalmic (eye) (Bepreve) ST drops.5 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) (Cyclogyl) drops 0.5 %, %, 2 % CYSTADROPS OPHTHALMIC (EYE) DROPS 0.37 % PA; NM; NDS; QL (20 per 28 days) CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % PA; NM; NDS; QL (60 per 28 days) epinastine ophthalmic (eye) drops 0.05 % ipratropium bromide nasal QL (30 per 28 days) spray,non-aerosol 2 mcg (0.03 %) ipratropium bromide nasal QL (5 per 0 days) spray,non-aerosol 42 mcg (0.06 %) olopatadine nasal spray,non-aerosol (Patanase) QL ( % olopatadine ophthalmic (eye) drops (Eye Allergy Itch- 0. % Redness Rlf) olopatadine ophthalmic (eye) drops (Eye Allergy Itch Relief) 0.2 % proparacaine ophthalmic (eye) drops (Alcaine) 0.5 % TEPEZZA INTRAVENOUS PA; NM; NDS RECON SOLN 500 Eye, Ear, Nose, Throat Anti- Infectives Agents acetic acid otic (ear) solution 2 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (Polycin) (eye) ointment 500-0,000 unit/gram bleph-0 ophthalmic (eye) drops 0 % ciprofloxacin hcl ophthalmic (eye) (Ciloxan) drops 0.3 % ciprofloxacin-dexamethasone otic (Ciprodex) QL (7.5 per 7 days) (ear) drops,suspension % erythromycin ophthalmic (eye) QL (3.5 per 4 days) ointment 5 /gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % (Zymaxid) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 0 0

110 gentak ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin ophthalmic (eye) drops 0.3 % hydrocortisone-acetic acid otic (ear) drops -2 % levofloxacin ophthalmic (eye) drops 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g- 0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0, unit-/ml neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-0,000- /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-0,000- /ml-unit/ml- % neo-polycin hc ophthalmic (eye) ointment ,000 -unit/g- % neo-polycin ophthalmic (eye) ointment ,000 -unitunit/g (Vigamox) (Neo-Polycin HC) (Neo-Polycin) (Maxitrol) (Maxitrol) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 02 02

111 ofloxacin ophthalmic (eye) drops 0.3 (Ocuflox) % ofloxacin otic (ear) drops 0.3 % polycin ophthalmic (eye) ointment 500-0,000 unit/gram polymyxin b sulf-trimethoprim (Polytrim) ophthalmic (eye) drops 0,000 unit- /ml sulfacetamide sodium ophthalmic (Bleph-0) (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfacetamide-prednisolone ophthalmic (eye) drops 0 %-0.23 % (0.25 %) tobramycin ophthalmic (eye) drops (Tobrex) 0.3 % tobramycin-dexamethasone (TobraDex) ophthalmic (eye) drops,suspension % trifluridine ophthalmic (eye) drops % ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti- Inflammatory Agents ALREX OPHTHALMIC (EYE) ST DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % BROMSITE OPHTHALMIC (EYE) DROPS % dexamethasone sodium phosphate ophthalmic (eye) drops 0. % diclofenac sodium ophthalmic (eye) drops 0. % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % EYSUVIS OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % QL (8.3 per 4 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 03 03

112 flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluocinolone acetonide oil otic (ear) drops 0.0 % fluorometholone ophthalmic (eye) drops,suspension 0. % flurbiprofen sodium ophthalmic (eye) drops 0.03 % fluticasone propionate nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % INVELTYS OPHTHALMIC (EYE) DROPS,SUSPENSION % ketorolac ophthalmic (eye) drops 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % LOTEMAX SM OPHTHALMIC (EYE) DROPS,GEL 0.38 % loteprednol etabonate ophthalmic (eye) drops,gel 0.5 % loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 % mometasone nasal spray,non-aerosol 50 mcg/actuation prednisolone acetate ophthalmic (eye) drops,suspension % prednisolone sodium phosphate ophthalmic (eye) drops % PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack QL (50 per 25 days) (DermOtic Oil) (FML Liquifilm) (24 Hour Allergy Relief) QL (6 (Acular) QL (0 per 25 days) (Lotemax) (Lotemax) (Nasonex) QL (34 (Pred Forte) QL (60 ST; QL (32 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 04 04

113 cimetidine hcl oral solution 300 /5 ml cimetidine oral tablet 200 (Acid Reducer (cimetidine)) cimetidine oral tablet 300, 400, 800 esomeprazole magnesium oral (Nexium) QL (30 capsule,delayed release(dr/ec) 20 esomeprazole magnesium oral (Nexium) QL (60 capsule,delayed release(dr/ec) 40 esomeprazole sodium intravenous recon soln 20 esomeprazole sodium intravenous (Nexium IV) recon soln 40 famotidine (pf) intravenous solution 20 /2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 /50 ml famotidine intravenous solution 0 /ml famotidine oral suspension 40 /5 ml (8 /ml) famotidine oral tablet 20 (Acid Controller) famotidine oral tablet 40 (Pepcid) lansoprazole oral capsule,delayed (Prevacid 24Hr) QL (30 release(dr/ec) 5 lansoprazole oral capsule,delayed (Prevacid) QL (60 release(dr/ec) 30 misoprostol oral tablet 00 mcg, 200 (Cytotec) mcg nizatidine oral capsule 50, 300 nizatidine oral solution 50 /0 ml omeprazole oral capsule,delayed release(dr/ec) 0, 20, 40 omeprazole-sodium bicarbonate oral (Zegerid) ST; QL (30 capsule gram, 40-. gram pantoprazole intravenous recon soln (Protonix) 40 pantoprazole oral tablet,delayed release (dr/ec) 20 (Protonix) QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 05 05

114 pantoprazole oral tablet,delayed (Protonix) QL (60 release (dr/ec) 40 rabeprazole oral tablet,delayed (AcipHex) QL (30 release (dr/ec) 20 sucralfate oral tablet gram (Carafate) Gastrointestinal Agents, Other CARBAGLU ORAL TABLET, NM; NDS DISPERSIBLE 200 constulose oral solution 0 gram/5 ml cromolyn oral concentrate 00 /5 (Gastrocrom) ml dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 20 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet (Lomotil) enulose oral solution 0 gram/5 ml GATTEX 30-VIAL PA; NM; NDS SUBCUTANEOUS KIT 5 generlac oral solution 0 gram/5 ml glycopyrrolate oral tablet, 2 kionex (with sorbitol) oral suspension gram/60 ml lactulose oral solution 0 gram/5 ml (Constulose) LINZESS ORAL CAPSULE 45 QL (30 MCG, 290 MCG, 72 MCG LOKELMA ORAL POWDER IN QL (34 PACKET 0 GRAM LOKELMA ORAL POWDER IN PACKET 5 GRAM QL (30 loperamide oral capsule 2 (Anti-Diarrheal (loperamide)) lubiprostone oral capsule 24 mcg, 8 (Amitiza) QL (60 mcg methscopolamine oral tablet 2.5, 5 metoclopramide hcl injection solution 5 /ml 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 06 06

115 metoclopramide hcl injection syringe 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 (Reglan) MOVANTIK ORAL TABLET 2.5 QL (30, 25 OCALIVA ORAL TABLET 0, 5 PA; NM; NDS; QL (30 propantheline oral tablet 5 RAVICTI ORAL LIQUID. PA; NM; NDS GRAM/ML RELISTOR ORAL TABLET 50 PA; NM; NDS; QL (90 RELISTOR SUBCUTANEOUS SOLUTION 2 /0.6 ML PA; NM; NDS; QL (6.8 per 28 days) RELISTOR SUBCUTANEOUS SYRINGE 2 /0.6 ML PA; NM; NDS; QL (6.8 per 28 days) RELISTOR SUBCUTANEOUS SYRINGE 8 /0.4 ML PA; NM; NDS; QL (.2 per 28 days) sodium phenylbutyrate oral tablet (Buphenyl) NM; NDS 500 sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension 5-20 gram/60 ml ursodiol oral capsule 300 ursodiol oral tablet 250 (URSO 250) ursodiol oral tablet 500 (URSO Forte) XERMELO ORAL TABLET 250 PA; NM; NDS; QL (90 Laxatives CLENPIQ ORAL SOLUTION GRAM -2 GRAM/60 ML gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 07 07

116 SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate(phosphat bind) oral capsule 667 calcium acetate(phosphat bind) oral tablet 667 lanthanum oral tablet,chewable (Fosrenol) NM; NDS,000, 500, 750 PHOSLYRA ORAL SOLUTION 667 (69 CALCIUM)/5 ML sevelamer carbonate oral powder in (Renvela) NM; NDS packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 (Renvela) sevelamer hcl oral tablet 400 sevelamer hcl oral tablet 800 (Renagel) VELPHORO ORAL TABLET,CHEWABLE 500 Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 0, 25, 5, 50 flavoxate oral tablet 00 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25, 50 oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet (Ditropan XL) extended release 24hr 0, 5 oxybutynin chloride oral tablet extended release 24hr 5 tolterodine oral capsule,extended (Detrol LA) release 24hr 2, 4 tolterodine oral tablet, 2 (Detrol) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 08 08

117 TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4, 8 trospium oral capsule,extended release 24hr 60 trospium oral tablet 20 Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release (Uroxatral) QL (30 24 hr 0 dutasteride oral capsule 0.5 (Avodart) dutasteride-tamsulosin oral capsule, (Jalyn) er multiphase 24 hr finasteride oral tablet 5 (Proscar) tamsulosin oral capsule 0.4 (Flomax) terazosin oral capsule, 0, 2, 5 THIOLA EC ORAL TABLET,DELAYED RELEASE (DR/EC) 00, 300 PA; NM; NDS tiopronin oral tablet 00 (Thiola) NM; NDS Heavy Metal Antagonists Heavy Metal Antagonists clovique oral capsule 250 PA; NM; NDS; QL (240 deferasirox oral granules in packet (Jadenu Sprinkle) PA; NM; NDS 80, 360, 90 deferasirox oral tablet 80, 360 (Jadenu) PA; NM; NDS deferasirox oral tablet 90 (Jadenu) PA deferasirox oral tablet, dispersible (Exjade) PA 25 deferasirox oral tablet, dispersible (Exjade) PA; NM; NDS 250, 500 deferiprone oral tablet 500 (Ferriprox) PA; NM; NDS deferoxamine injection recon soln 2 PA gram deferoxamine injection recon soln (Desferal) PA 500 FERRIPROX,000 TAB(2X/DAY),000 PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 09 09

118 FERRIPROX ORAL SOLUTION 00 /ML FERRIPROX ORAL TABLET,000 PA; NM; NDS PA; NM; NDS penicillamine oral capsule 250 (Cuprimine) PA; NM; NDS penicillamine oral tablet 250 (Depen Titratabs) PA; NM; NDS trientine oral capsule 250 (Clovique) PA; NM; NDS; QL (240 Hormonal Agents, Stimulant/Replacement/Modify ing Androgens ANADROL-50 ORAL TABLET 50 danazol oral capsule 00, 200, 50 oxandrolone oral tablet 0, 2.5 testosterone cypionate intramuscular oil 00 /ml, 200 /ml testosterone cypionate intramuscular oil 200 /ml ( ml) testosterone enanthate intramuscular oil 200 /ml testosterone transdermal gel in metered-dose pump 2.5 /.25 gram ( %) testosterone transdermal gel in metered-dose pump /.25 gram (.62 %) testosterone transdermal gel in packet % (25 /2.5gram), % (50 /5 gram) testosterone transdermal solution in metered pump w/app 30 /actuation (.5 ml) XYOSTED SUBCUTANEOUS AUTO-INJECTOR 00 /0.5 ML, 50 /0.5 ML, 75 /0.5 ML Estrogens And Antiestrogens amabelz oral tablet , -0.5 (Oxandrin) PA; NM; NDS (Depo-Testosterone) PA PA PA; QL (5 per 28 days) (Vogelxo) PA; QL (300 per 30 days) (AndroGel) PA; QL (50 per 30 days) (AndroGel) PA; QL (300 per 30 days) PA; QL (80 per 30 days) PA; QL (2 per 28 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 0 0

119 dotti transdermal patch semiweekly QL (8 per 28 days) /24 hr, /24 hr, 0.05 /24 hr, /24 hr, 0. /24 hr DUAVEE ORAL TABLET estradiol oral tablet 0.5,, 2 (Estrace) estradiol transdermal patch (Dotti) QL (8 per 28 days) semiweekly /24 hr, /24 hr, 0.05 /24 hr, /24 hr, 0. /24 hr estradiol transdermal patch weekly (Climara) QL (4 per 28 days) /24 hr, /24 hr, 0.05 /24 hr, 0.06 /24 hr, /24 hr, 0. /24 hr estradiol vaginal cream 0.0 % (0. (Estrace) /gram) estradiol vaginal tablet 0 mcg (Yuvafem) QL (8 per 28 days) estradiol valerate intramuscular oil (Delestrogen) 20 /ml, 40 /ml estradiol-norethindrone acet oral (Amabelz) tablet FEMRING VAGINAL RING 0.05 QL ( per 84 days) /24 HR, 0. /24 HR fyavolv oral tablet mcg, -5 -mcg jinteli oral tablet -5 -mcg lyllana transdermal patch QL (8 per 28 days) semiweekly /24 hr, /24 hr, 0.05 /24 hr, /24 hr, 0. /24 hr mimvey oral tablet -0.5 norethindrone ac-eth estradiol oral (Fyavolv) tablet mcg, -5 -mcg PREMARIN INJECTION RECON SOLN 25 PREMARIN ORAL TABLET 0.3, 0.45, 0.625, 0.9,.25 PREMARIN VAGINAL CREAM /GRAM 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊

120 PREMPHASE ORAL TABLET (4)/ (4) PREMPRO ORAL TABLET , , , raloxifene oral tablet 60 (Evista) yuvafem vaginal tablet 0 mcg QL (8 per 28 days) Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 00 betamethasone acet,sod phos (Celestone Soluspan) injection suspension 6 /ml dexamethasone 0.5 /5 ml liq 0.5 /5 ml dexamethasone oral elixir 0.5 /5 ml dexamethasone oral tablet 0.5, (Decadron) 0.75, 4, 6 dexamethasone oral tablet,.5, 2 dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phos (pf) injection syringe 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, 4 /ml dexamethasone sodium phosphate injection syringe 4 /ml EMFLAZA ORAL SUSPENSION /ML PA; NM; NDS; QL (9 per 28 days) EMFLAZA ORAL TABLET 8 PA; NM; NDS; QL (30 EMFLAZA ORAL TABLET 30, 36, 6 PA; NM; NDS; QL (60 fludrocortisone oral tablet 0. HEMADY ORAL TABLET 20 hydrocortisone oral tablet 0, 20 (Cortef), 5 methylprednisolone acetate injection (Depo-Medrol) suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6, 32, 4, 8 (Medrol) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 2 2

121 methylprednisolone oral tablets,dose (Medrol (Pak)) pack 4 methylprednisolone sodium succ injection recon soln 25, 40 methylprednisolone sodium succ intravenous recon soln,000, 500 (Solu-Medrol) prednisolone 5 /5 ml soln a/f, d/f PA BvD 5 /5 ml (3 /ml) prednisolone oral solution 5 /5 PA BvD ml prednisolone sodium phosphate oral PA BvD solution 25 /5 ml (5 /ml) prednisolone sodium phosphate oral (Pediapred) PA BvD solution 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml PA BvD prednisone oral tablet, 0, PA BvD 2.5, 20, 5, 50 prednisone oral tablets,dose pack 0, 0 (48 pack), 5, 5 (48 pack) SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN,000 /8 ML, 00 /2 ML, 250 /2 ML, 500 /4 ML triamcinolone acetonide injection (Kenalog) suspension 40 /ml Pituitary ACTHAR INJECTION GEL 80 UNIT/ML PA; NM; NDS; QL (35 per 28 days) BYNFEZIA SUBCUTANEOUS NM; NDS PEN INJECTOR 2,500 MCG/ML desmopressin injection solution 4 (DDAVP) mcg/ml desmopressin nasal spray with pump 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0.2 (DDAVP) EGRIFTA SUBCUTANEOUS RECON SOLN 2 PA; NM; NDS; QL (30 EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 PA; NM; NDS; QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 3 3

122 INCRELEX SUBCUTANEOUS NM; NDS SOLUTION 0 /ML LUPRON DEPOT (3 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT.25 LUPRON DEPOT NM; NDS INTRAMUSCULAR SYRINGE KIT 3.75, 7.5 LUPRON DEPOT-PED (3 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 30 LUPRON DEPOT-PED NM; NDS INTRAMUSCULAR KIT.25, 5 MYCAPSSA ORAL CAPSULE,DELAYED PA; NM; NDS; QL (20 RELEASE(DR/EC) 20 NORDITROPIN FLEXPRO PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 0 /.5 ML (6.7 /ML), 5 /.5 ML (0 /ML), 30 /3 ML (0 /ML), 5 /.5 ML (3.3 /ML) octreotide acetate injection solution,000 mcg/ml, 200 mcg/ml octreotide acetate injection solution (Sandostatin) 00 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) ORGOVYX ORAL TABLET 20 PA NSO; NM; NDS ORILISSA ORAL TABLET 50 PA; NM; NDS; QL (28 per 28 days) ORILISSA ORAL TABLET 200 PA; NM; NDS; QL (56 per 28 days) SANDOSTATIN LAR DEPOT NM; NDS INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 0, 20, 30 SEROSTIM SUBCUTANEOUS RECON SOLN 4, 5, 6 PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 4 4

123 SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 /ML ( ML), 0.6 /ML ( ML), 0.9 /ML ( ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 /0.5 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 /0.2 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 /0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 0, 5, 20, 25, 30 SUPPRELIN LA IMPLANT KIT 50 (65 MCG/DAY) SYNAREL NASAL SPRAY,NON- AEROSOL 2 /ML TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 Progestins hydroxyprogesterone cap(ppres) intramuscular oil 250 /ml medroxyprogesterone intramuscular suspension 50 /ml medroxyprogesterone intramuscular syringe 50 /ml medroxyprogesterone oral tablet 0, 2.5, 5 megestrol oral suspension 400 /0 ml (40 /ml) norethindrone acetate oral tablet 5 progesterone intramuscular oil 50 /ml progesterone micronized oral capsule 00, 200 Thyroid And Antithyroid Agents PA; NM; NDS; QL (60 PA NSO; NM; NDS; QL (0.5 per 28 days) PA NSO; NM; NDS; QL (0.2 per 28 days) PA NSO; NM; NDS; QL (0.3 per 28 days) PA; NM; NDS NM; NDS; QL ( per 360 days) NM; NDS NM; NDS; QL ( per 68 days) PA; NM; NDS (Makena) NM; NDS (Depo-Provera) QL ( per 84 days) (Depo-Provera) QL ( per 84 days) (Provera) (Aygestin) (Prometrium) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 5 5

124 levothyroxine oral tablet 00 mcg, (Euthyrox) 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg (Levo-T) liothyronine oral tablet 25 mcg, 5 (Cytomel) mcg, 50 mcg methimazole oral tablet 0, 5 (Tapazole) propylthiouracil oral tablet 50 Immunological Agents Immunological Agents ACTEMRA ACTPEN PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 62 /0.9 ML ACTEMRA INTRAVENOUS PA; NM; NDS SOLUTION 200 /0 ML (20 /ML), 400 /20 ML (20 /ML), 80 /4 ML (20 /ML) ACTEMRA SUBCUTANEOUS PA; NM; NDS SYRINGE 62 /0.9 ML ARCALYST SUBCUTANEOUS NM; NDS RECON SOLN 220 AVSOLA INTRAVENOUS RECON PA; NM; NDS SOLN 00 azathioprine oral tablet 50 (Imuran) PA BvD azathioprine sodium injection recon PA BvD soln 00 BENLYSTA INTRAVENOUS PA; NM; NDS RECON SOLN 20, 400 BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 /ML PA; NM; NDS; QL (8 per 28 days) BENLYSTA SUBCUTANEOUS SYRINGE 200 /ML PA; NM; NDS; QL (8 per 28 days) CIMZIA POWDER FOR RECONST PA; NM; NDS SUBCUTANEOUS KIT 400 (200 X 2 VIALS) CIMZIA SUBCUTANEOUS PA; NM; NDS SYRINGE KIT 400 /2 ML (200 /ML X 2) COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 50 /ML PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 6 6

125 COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 50 /ML COSENTYX SUBCUTANEOUS SYRINGE 75 /0.5 ML cyclosporine intravenous solution 250 /5 ml cyclosporine modified oral capsule 00, 25 cyclosporine modified oral capsule 50 cyclosporine modified oral solution 00 /ml cyclosporine oral capsule 00, 25 ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 /ML ( ML) ENBREL SUBCUTANEOUS RECON SOLN 25 ( ML) ENBREL SUBCUTANEOUS SOLUTION 25 /0.5 ML ENBREL SUBCUTANEOUS SYRINGE 25 /0.5 ML (0.5), 50 /ML ( ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 /ML ( ML) everolimus (immunosuppressive) oral tablet 0.25 everolimus (immunosuppressive) oral tablet 0.5, 0.75 FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMIFANT INTRAVENOUS SOLUTION 5 /ML GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAGARD S-D (IGA < MCG/ML) INTRAVENOUS RECON SOLN 0 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % PA; NM; NDS PA; NM; NDS (Sandimmune) PA BvD (Gengraf) PA BvD PA BvD (Gengraf) PA BvD (Sandimmune) PA BvD PA; NM; NDS PA; NM; NDS PA; NM; NDS PA; NM; NDS PA; NM; NDS (Zortress) PA BvD (Zortress) PA BvD; NM; NDS PA BvD; NM; NDS PA; NM; NDS PA BvD; NM; NDS PA BvD; NM; NDS PA BvD; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 7 7

126 GAMMAPLEX INTRAVENOUS PA BvD; NM; NDS SOLUTION 0 %, 0 % (00 ML), 0 % (200 ML) GAMUNEX-C INJECTION PA BvD; NM; NDS SOLUTION GRAM/0 ML (0 %), 0 GRAM/00 ML (0 %), 2.5 GRAM/25 ML (0 %), 20 GRAM/200 ML (0 %), 40 GRAM/400 ML (0 %), 5 GRAM/50 ML (0 %) gengraf oral capsule 00, 25 PA BvD gengraf oral solution 00 /ml PA BvD HUMIRA PEN CROHNS-UC-HS PA; NM; NDS START SUBCUTANEOUS PEN INJECTOR KIT 40 /0.8 ML HUMIRA PEN PSOR-UVEITS- PA; NM; NDS ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 /0.8 ML HUMIRA PEN SUBCUTANEOUS PA; NM; NDS PEN INJECTOR KIT 40 /0.8 ML HUMIRA SUBCUTANEOUS PA; NM; NDS SYRINGE KIT 40 /0.8 ML HUMIRA(CF) PEDI CROHNS PA; NM; NDS STARTER SUBCUTANEOUS SYRINGE KIT 80 /0.8 ML, 80 /0.8 ML-40 /0.4 ML HUMIRA(CF) PEN CROHNS-UC- PA; NM; NDS HS SUBCUTANEOUS PEN INJECTOR KIT 80 /0.8 ML HUMIRA(CF) PEN PEDIATRIC PA; NM; NDS UC SUBCUTANEOUS PEN INJECTOR KIT 80 /0.8 ML HUMIRA(CF) PEN PSOR-UV- PA; NM; NDS ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 /0.8 ML-40 /0.4 ML HUMIRA(CF) PEN PA; NM; NDS SUBCUTANEOUS PEN INJECTOR KIT 40 /0.4 ML, 80 /0.8 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 0 /0. ML, 20 /0.2 ML, 40 /0.4 ML PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 8 8

127 HYQVIA SUBCUTANEOUS PA BvD; NM; NDS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) ILARIS (PF) SUBCUTANEOUS PA; NM; NDS SOLUTION 50 /ML ILUMYA SUBCUTANEOUS PA; NM; NDS SYRINGE 00 /ML INFLECTRA INTRAVENOUS PA; NM; NDS RECON SOLN 00 KEVZARA SUBCUTANEOUS PA; NM; NDS PEN INJECTOR 50 /.4 ML, 200 /.4 ML KEVZARA SUBCUTANEOUS PA; NM; NDS SYRINGE 50 /.4 ML, 200 /.4 ML KINERET SUBCUTANEOUS PA; NM; NDS SYRINGE 00 /0.67 ML leflunomide oral tablet 0, 20 (Arava) mycophenolate mofetil (hcl) (CellCept Intravenous) PA BvD intravenous recon soln 500 mycophenolate mofetil oral capsule (CellCept) PA BvD 250 mycophenolate mofetil oral (CellCept) PA BvD; NM; NDS suspension for reconstitution 200 /ml mycophenolate mofetil oral tablet (CellCept) PA BvD 500 NULOJIX INTRAVENOUS PA BvD; NM; NDS RECON SOLN 250 OCTAGAM INTRAVENOUS PA BvD; NM; NDS SOLUTION 0 %, 5 % OLUMIANT ORAL TABLET PA; NM; NDS, 2 ORENCIA (WITH MALTOSE) PA; NM; NDS INTRAVENOUS RECON SOLN 250 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 25 /ML PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 9 9

128 ORENCIA SUBCUTANEOUS PA; NM; NDS SYRINGE 25 /ML, 50 /0.4 ML, 87.5 /0.7 ML OTEZLA ORAL TABLET 30 PA; NM; NDS OTEZLA STARTER ORAL PA; NM; NDS TABLETS,DOSE PACK 0 (4)- 20 (4)-30 (47), 0 (4)- 20 (4)-30 (9) PRIVIGEN INTRAVENOUS PA BvD; NM; NDS SOLUTION 0 % PROGRAF INTRAVENOUS PA BvD SOLUTION 5 /ML PROGRAF ORAL GRANULES IN PA BvD; ST PACKET 0.2, RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 0 /0.2 ML, 2.5 /0.25 ML, 5 /0.3 ML, 7.5 /0.35 ML, 20 /0.4 ML, 22.5 /0.45 ML, 25 /0.5 ML, 30 /0.6 ML, 7.5 /0.5 ML REMICADE INTRAVENOUS PA; NM; NDS RECON SOLN 00 RENFLEXIS INTRAVENOUS PA; NM; NDS RECON SOLN 00 RIDAURA ORAL CAPSULE 3 NM; NDS RINVOQ ORAL TABLET PA; NM; NDS EXTENDED RELEASE 24 HR 5 sirolimus oral solution /ml (Rapamune) PA BvD; NM; NDS sirolimus oral tablet 0.5, (Rapamune) PA BvD sirolimus oral tablet 2 (Rapamune) PA BvD; NM; NDS SKYRIZI SUBCUTANEOUS PEN PA; NM; NDS INJECTOR 50 /ML SKYRIZI SUBCUTANEOUS PA; NM; NDS SYRINGE 50 /ML, 75 /0.83 ML SKYRIZI SUBCUTANEOUS PA; NM; NDS SYRINGE KIT 50/.66ML(75 /0.83 ML X2) STELARA INTRAVENOUS PA; NM; NDS SOLUTION 30 /26 ML STELARA SUBCUTANEOUS SOLUTION 45 /0.5 ML PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 20 20

129 STELARA SUBCUTANEOUS PA; NM; NDS SYRINGE 45 /0.5 ML, 90 /ML tacrolimus oral capsule 0.5, (Prograf) PA BvD, 5 TALTZ AUTOINJECTOR PA; NM; NDS SUBCUTANEOUS AUTO- INJECTOR 80 /ML TALTZ SYRINGE (2 PACK) PA; NM; NDS SUBCUTANEOUS SYRINGE 80 /ML TALTZ SYRINGE (3 PACK) PA; NM; NDS SUBCUTANEOUS SYRINGE 80 /ML TALTZ SYRINGE PA; NM; NDS SUBCUTANEOUS SYRINGE 80 /ML TREMFYA SUBCUTANEOUS PA; NM; NDS AUTO-INJECTOR 00 /ML TREMFYA SUBCUTANEOUS PA; NM; NDS SYRINGE 00 /ML TYSABRI INTRAVENOUS PA; NM; LA; NDS SOLUTION 300 /5 ML XELJANZ ORAL SOLUTION PA; NM; NDS /ML XELJANZ ORAL TABLET 0, PA; NM; NDS 5 XELJANZ XR ORAL TABLET PA; NM; NDS EXTENDED RELEASE 24 HR, 22 ZORTRESS ORAL TABLET PA BvD; NM; NDS Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 2 2

130 BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT PA BvD PA BvD PA BvD QL (.5 per 365 days) QL (.5 per 365 days) PA BvD 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 22 22

131 INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENQUADFI (PF) INTRAMUSCULAR SOLUTION 0 MCG/0.5 ML MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-20 MCG-5 LF/0.5 ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 23 23

132 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML PA BvD PA BvD PA BvD QL (2 per 365 days) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 24 24

133 VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 QL (2 per 365 days) QL ( per 365 days) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 (Lotronex) alosetron oral tablet (Lotronex) NM; NDS balsalazide oral capsule 750 (Colazal) budesonide oral capsule,delayed,extend.release 3 (Entocort EC) DIPENTUM ORAL CAPSULE 250 ST; NM; NDS hydrocortisone rectal enema 00 /60 ml (Cortenema) mesalamine oral capsule (with del rel (Delzicol) tablets) 400 mesalamine oral capsule,extended (Apriso) release 24hr gram mesalamine oral tablet,delayed (Lialda) release (dr/ec).2 gram mesalamine oral tablet,delayed (Asacol HD) release (dr/ec) 800 mesalamine rectal suppository,000 (Canasa) sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 (Azulfidine EN-tabs)

134 UCERIS RECTAL FOAM 2 /ACTUATION Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 /75 QL (300 per 28 days) ml alendronate oral tablet 0, 5 QL (30 alendronate oral tablet 35 QL (4 per 28 days) alendronate oral tablet 70 (Fosamax) QL (4 per 28 days) calcitonin (salmon) injection solution (Miacalcin) NM; NDS 200 unit/ml calcitonin (salmon) nasal spray,nonaerosol QL (3.7 per 28 days) 200 unit/actuation calcitriol intravenous solution mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 (Rocaltrol) mcg calcitriol oral solution mcg/ml (Rocaltrol) cinacalcet oral tablet 30 (Sensipar) QL (60 cinacalcet oral tablet 60 (Sensipar) NM; NDS; QL (60 per 30 days) cinacalcet oral tablet 90 (Sensipar) NM; NDS; QL (20 per 30 days) doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg EVENITY SUBCUTANEOUS SYRINGE 05 /.7 ML, PA; NM; NDS; QL ( /2.34ML ( 05/.7MLX2) ibandronate intravenous solution 3 QL (3 per 84 days) /3 ml ibandronate intravenous syringe 3 QL (3 per 84 days) /3 ml ibandronate oral tablet 50 (Boniva) QL ( per 28 days) NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 25 PA; NM; NDS; QL (2 per 28 days) MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30, 90 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 26 26

135 pamidronate intravenous solution 30 /0 ml (3 /ml), 60 /0 ml (6 /ml), 90 /0 ml (9 /ml) paricalcitol oral capsule mcg, 2 (Zemplar) mcg paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS QL ( per 80 days) SYRINGE 60 /ML RAYALDEE ORAL QL (60 CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 50 (Actonel) QL ( per 28 days) risedronate oral tablet 30, 5 QL (30 risedronate oral tablet 35 (Actonel) QL (4 per 28 days) risedronate oral tablet 35 (2 QL (4 per 28 days) pack), 35 (4 pack) risedronate oral tablet,delayed release (dr/ec) 35 (Atelvia) QL (4 per 28 days) TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,20 MCG/.56 ML) XGEVA SUBCUTANEOUS SOLUTION 20 /.7 ML (70 /ML) zoledronic acid intravenous recon soln 4 zoledronic acid intravenous solution 4 /5 ml zoledronic acid-mannitol-water intravenous piggyback 5 /00 ml Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS PA; QL (.56 per 30 days) PA; NM; NDS (Reclast) QL (00 per 300 days) PA; NM; NDS SOLUTION 00 MCG/0.5 ML buspirone oral tablet 0, 5, 30, 5, 7.5 CYSTADANE ORAL POWDER NM; NDS GRAM/.7 ML dexrazoxane hcl intravenous recon soln 250, 500 NM; NDS diazoxide oral suspension 50 /ml (Proglycem) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 27 27

136 ELMIRON ORAL CAPSULE 00 QL (90 ENDARI ORAL POWDER IN PACKET 5 GRAM PA; NM; NDS; QL (80 EVRYSDI ORAL RECON SOLN PA; NM; NDS 0.75 /ML EXONDYS-5 INTRAVENOUS PA; NM; LA; NDS SOLUTION 50 /ML fomepizole intravenous solution NM; NDS gram/ml GVOKE HYPOPEN 2-PACK SUBCUTANEOUS AUTO- INJECTOR 0.5 /0. ML, /0.2 ML GVOKE PFS -PACK SYRINGE SUBCUTANEOUS SYRINGE 0.5 /0. ML, /0.2 ML hydroxyzine pamoate oral capsule 00 hydroxyzine pamoate oral capsule 25, 50 (Vistaril) KEVEYIS ORAL TABLET 50 PA; NM; NDS; QL (20 leucovorin calcium injection recon soln 00, 200, 350, 50, 500 leucovorin calcium injection solution 0 /ml leucovorin calcium oral tablet 0, 5, 25, 5 levocarnitine (with sugar) oral (Carnitor) solution 00 /ml levocarnitine oral tablet 330 (Carnitor) levoleucovorin calcium intravenous (Fusilev) NM; NDS recon soln 50 mesna intravenous solution 00 (Mesnex) /ml MESNEX ORAL TABLET 400 NM; NDS OXLUMO SUBCUTANEOUS PA; NM; NDS SOLUTION 94.5 /0.5 ML pyridostigmine bromide oral syrup 60 /5 ml (Mestinon) 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 28 28

137 pyridostigmine bromide oral tablet 30 pyridostigmine bromide oral tablet (Mestinon) 60 pyridostigmine bromide oral tablet extended release 80 (Mestinon Timespan) RECTIV RECTAL OINTMENT 0.4 QL (30 % (W/W) TAKHZYRO SUBCUTANEOUS SOLUTION 300 /2 ML (50 PA; NM; NDS; QL (4 per 28 days) /ML) THALOMID ORAL CAPSULE 00, 50, 200, 50 PA NSO; NM; NDS; QL (60 TOTECT INTRAVENOUS RECON NM; NDS SOLN 500 TYBOST ORAL TABLET 50 QL (30 VISTOGARD ORAL GRANULES IN PACKET 0 GRAM NM; NDS; QL (24 per 4 days) XURIDEN ORAL GRANULES IN PACKET 2 GRAM PA; NM; NDS; QL (20 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 25, 250 acetazolamide sodium injection recon soln 500 ALPHAGAN P OPHTHALMIC (EYE) DROPS 0. % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION % betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.03 % QL (2.5 per 25 days) brimonidine ophthalmic (eye) drops (Alphagan P) 0.5 % brimonidine ophthalmic (eye) drops 0.2 % carteolol ophthalmic (eye) drops % 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 29 29

138 COMBIGAN OPHTHALMIC (EYE) DROPS % dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol ophthalmic (eye) drops /ml latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) DROPS 0.0 % methazolamide oral tablet 25, 50 metipranolol ophthalmic (eye) drops 0.3 % pilocarpine hcl ophthalmic (eye) drops %, 2 %, 4 % RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % ROCKLATAN OPHTHALMIC (EYE) DROPS % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % travoprost ophthalmic (eye) drops % VYZULTA OPHTHALMIC (EYE) DROPS % XELPROS OPHTHALMIC (EYE) DROPS, EMULSION % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Replacement Preparations Replacement Preparations calcium chloride intravenous syringe 00 /ml (0 %) d5 % and 0.9 % sodium chloride intravenous parenteral solution (Trusopt) (Cosopt) (Xalatan) QL (2.5 per 25 days) QL (2.5 per 25 days) (Isopto Carpine) QL (2.5 per 25 days) QL (2.5 per 25 days) (Timoptic) (Timoptic-XE) (Travatan Z) QL (2.5 per 25 days) QL (5 ST; QL (2.5 per 25 days) QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 30 30

139 d5 %-0.45 % sodium chloride intravenous parenteral solution ISOLYTE S IV SOLUTION-EXCEL SINGLE USE ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m20 oral tablet,er particles/crystals 20 meq magnesium sulfate in d5w intravenous piggyback gram/00 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION potassium chloride intravenous solution 2 meq/ml, 2 meq/ml (20 ml) potassium chloride oral capsule, extended release 0 meq, 8 meq PA BvD PA BvD PA BvD PA BvD 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 3 3

140 potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium citrate oral tablet extended release 0 meq (,080 ) potassium citrate oral tablet extended release 5 meq potassium citrate oral tablet extended release 5 meq (540 ) sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride 0.9 % intravenous piggyback Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION (K-Tab) (Klor-Con M0) (Klor-Con M20) (Urocit-K 0) (Urocit-K 5) (Urocit-K 5) QL (60 QL (2 QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 32 32

141 BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml budesonide inhalation suspension for nebulization /2 ml FLOVENT 00 MCG DISKUS 00 MCG/ACTUATION FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL (60 (Pulmicort) PA BvD; QL (20 per 30 days) (Pulmicort) PA BvD; QL (60 per 30 days) QL (60 QL (20 QL (60 QL (20 QL (2 QL (24 QL (2.2 SYMBICORT INHALATION HFA QL (30.6 AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral tablet 0 (Singulair) montelukast oral tablet,chewable 4 (Singulair), 5 zafirlukast oral tablet 0, 20 (Accolate) Bronchodilators albuterol 5 /ml solution 5 /ml PA BvD; QL (20 per 30 days) albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (ProAir HFA) QL (7 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 33 33

142 albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020503) albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020983) albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.25 /3 ml, 2.5 /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 /0.5 ml albuterol sulfate oral syrup 2 /5 ml albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 2 hr 4, 8 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION QL (3.4 QL (36 PA BvD; QL (360 per 30 days) PA BvD; QL (20 per 30 days) QL (60 QL (25.8 per 28 days) QL (0.7 QL (8 elixophyllin oral elixir 80 /5 ml ipratropium bromide inhalation solution 0.02 % PA BvD; QL (32.5 per 30 days) ipratropium-albuterol inhalation solution for nebulization (2.5 base)/3 ml PA BvD; QL (540 per 30 days) metaproterenol oral syrup 0 /5 ml PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION QL (2 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 34 34

143 SEREVENT DISKUS QL (60 INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT QL (4 INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER QL (30 INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STIOLTO RESPIMAT QL (4 INHALATION MIST MCG/ACTUATION terbutaline oral tablet 2.5, 5 terbutaline subcutaneous solution NM; NDS /ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release 2 hr 300, 450 theophylline oral tablet extended release 24 hr 400, 600 TRELEGY ELLIPTA QL (60 INHALATION BLISTER WITH DEVICE MCG, MCG Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 /ml (20 %) (Acetadote) acetylcysteine solution 00 /ml (0 %), 200 /ml (20 %) PA BvD BRONCHITOL INHALATION CAPSULE, W/INHALATION DEVICE 40 CINQAIR INTRAVENOUS SOLUTION 0 /ML cromolyn inhalation solution for nebulization 20 /2 ml DALIRESP ORAL TABLET 250 MCG DALIRESP ORAL TABLET 500 MCG NM; NDS; QL (560 per 28 days) PA; NM; NDS PA BvD QL (28 per 28 days) QL (30 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 35 35

144 ESBRIET ORAL CAPSULE 267 PA; NM; NDS; QL (270 ESBRIET ORAL TABLET 267 PA; NM; NDS; QL (270 ESBRIET ORAL TABLET 80 PA; NM; NDS; QL (90 FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 /ML PA; NM; NDS; QL ( per 28 days) FASENRA SUBCUTANEOUS SYRINGE 30 /ML PA; NM; NDS; QL ( per 28 days) KALYDECO ORAL GRANULES IN PACKET 25, 50, 75 PA; NM; NDS; QL (56 per 28 days) KALYDECO ORAL TABLET 50 PA; NM; NDS; QL (56 per 28 days) NUCALA SUBCUTANEOUS AUTO-INJECTOR 00 /ML PA; NM; LA; NDS; QL (3 per 28 days) NUCALA SUBCUTANEOUS RECON SOLN 00 PA; NM; LA; NDS; QL (3 per 28 days) NUCALA SUBCUTANEOUS SYRINGE 00 /ML PA; NM; LA; NDS; QL (3 per 28 days) OFEV ORAL CAPSULE 00, 50 PA; NM; NDS; QL (60 ORKAMBI ORAL GRANULES IN PACKET 00-25, PA; NM; NDS; QL (56 per 28 days) ORKAMBI ORAL TABLET 00- PA; NM; NDS; QL (20 25, PROLASTIN C,000 /20 ML VL PRICE/ONE,L/F,SUV,000 (+/-)/20 ML PROLASTIN-C INTRAVENOUS RECON SOLN,000 SYMDEKO ORAL TABLETS, SEQUENTIAL (D)/ 50 (N), (D)/ 75 (N) TRIKAFTA ORAL TABLETS, SEQUENTIAL (D) /50 (N), (D)/75 (N) XOLAIR SUBCUTANEOUS RECON SOLN 50 PA BvD; NM; NDS PA BvD; NM; NDS PA; NM; NDS; QL (56 per 28 days) PA; NM; NDS; QL (84 per 28 days) PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 36 36

145 XOLAIR SUBCUTANEOUS SYRINGE 50 /ML, 75 /0.5 ML Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0, 20, 5 PA; NM; NDS chlorzoxazone oral tablet 250 NM; NDS; QL (20 per 30 days) chlorzoxazone oral tablet 500 cyclobenzaprine oral tablet 0, 5 dantrolene oral capsule 00 dantrolene oral capsule 25, 50 (Dantrium) methocarbamol oral tablet 500, 750 revonto intravenous recon soln 20 tizanidine oral tablet 2 tizanidine oral tablet 4 (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 50, 200 (Nuvigil) PA; QL (30, 250, 50 BELSOMRA ORAL TABLET 0 QL (30, 5, 20, 5 eszopiclone oral tablet, 2, 3 (Lunesta) QL (30 HETLIOZ LQ ORAL SUSPENSION 4 /ML PA; NM; NDS; QL (50 HETLIOZ ORAL CAPSULE 20 PA; NM; NDS; QL (30 SUNOSI ORAL TABLET 50, PA; QL (30 75 XYREM ORAL SOLUTION 500 /ML PA; NM; LA; NDS; QL (540 zaleplon oral capsule 0, 5 QL (30 zolpidem oral tablet 0, 5 (Ambien) QL (30 zolpidem oral tablet,ext release multiphase 2.5, 6.25 (Ambien CR) QL (30 Vasodilating Agents 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 37 37

146 Vasodilating Agents ADEMPAS ORAL TABLET 0.5,,.5, 2, 2.5 PA; NM; NDS; QL (90 alyq oral tablet 20 PA; QL (60 ambrisentan oral tablet 0, 5 (Letairis) PA; NM; NDS; QL (30 epoprostenol (glycine) intravenous (Flolan) PA; NM; NDS recon soln 0.5,.5 OPSUMIT ORAL TABLET 0 PA; NM; NDS; QL (30 sildenafil (pulm.hypertension) intravenous solution 0 /2.5 ml (Revatio) PA; NM; NDS; QL (37.5 per day) sildenafil (pulm.hypertension) oral (Revatio) PA; QL (90 tablet 20 tadalafil (pulm. hypertension) oral (Alyq) PA; QL (60 tablet 20 tadalafil oral tablet 2.5, 5 (Cialis) PA; QL (30 TRACLEER ORAL TABLET 25, 62.5 PA; NM; LA; NDS; QL (60 TRACLEER ORAL TABLET FOR SUSPENSION 32 PA; NM; NDS; QL (2 per 28 days) treprostinil sodium injection solution /ml, 0 /ml, 2.5 /ml, 5 /ml (Remodulin) PA; NM; NDS TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 /2.9 ML (0.6 /ML) UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) PA; NM; NDS PA; NM; NDS; QL (60 PA; NM; NDS; QL (240 PA; NM; NDS 您可在本表格的頂端, 找到表格中各縮寫含意的相關資訊 38 38

147 INDEX (Not sure A abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine ABELCET ABRAXANE... 8 acamprosate... 8 acarbose accutane acebutolol acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid acetylcysteine acitretin ACTEMRA... 5 ACTEMRA ACTPEN... 5 ACTHAR... 2 ACTHIB (PF) ACTIMMUNE acyclovir... 64, 92 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 20 ADAKVEO adapalene ADCETRIS... 8 adefovir ADEMPAS adriamycin... 8 adrucil... 8 ADVAIR DISKUS... 3 ADVAIR HFA... 3 AFINITOR... 9 AFINITOR DISPERZ... 9 afirmelle a-hydrocort... AKYNZEO (FOSNETUPITANT) AKYNZEO (NETUPITANT) 50 ala-cort ala-scalp albendazole albuterol sulfate... 32, 33 alcaine alclometasone ALDURAZYME ALECENSA... 9 alendronate alfuzosin ALIMTA... 9 ALIQOPA... 9 aliskiren allopurinol alosetron ALPHAGAN P alprazolam... 9, 0 ALREX altavera (28) ALTRENO ALUNBRIG... 9 alyacen /35 (28) alyacen 7/7/7 (28) alyq amabelz... 0 amantadine hcl AMBISOME ambrisentan amethia amiloride amiloride-hydrochlorothiazide AMINOSYN II 5 % AMINOSYN-PF 7 % (SULFITE-FREE) amiodarone amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 5 amoxicillin-pot clavulanate... 5, 6 amphotericin b ampicillin... 6 ampicillin sodium... 6 ampicillin-sulbactam... 6 ANADROL anagrelide anastrozole... 9 ANORO ELLIPTA APOKYN apraclonidine aprepitant apri APTIOM APTIVUS APTIVUS (WITH VITAMIN E) I-

148 aranelle (28) ARCALYST... 5 aripiprazole... 54, 55 ARISTADA ARISTADA INITIO armodafinil ARNUITY ELLIPTA... 3 arsenic trioxide... 9 ascomp with codeine... 3 asenapine maleate ashlyna ASPARLAS... 9 aspirin-dipyridamole ASSURE ID INSULIN SAFETY atazanavir atenolol atenolol-chlorthalidone atomoxetine... 8 atorvastatin atovaquone atovaquone-proguanil atropine ATROVENT HFA AUBAGIO... 8 aubra eq aurovela.5/30 (2) aurovela /20 (2) aurovela 24 fe aurovela fe.5/30 (28) aurovela fe -20 (28) AUSTEDO... 8 AVASTIN... 9 aviane AVONEX... 8 AVSOLA... 5 ayuna AYVAKIT... 9 azacitidine... 9 azathioprine... 5 azathioprine sodium... 5 azelastine azithromycin... 4 AZOPT aztreonam... 5 azurette (28) B bacitracin..., 00 bacitracin-polymyxin b baclofen balsalazide BALVERSA... 9 balziva (28) BAVENCIO... 9 BAXDELA... 6 BCG VACCINE, LIVE (PF) 2 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYR (HALF UNIT) BD VEO INSULIN SYRINGE UF bekyree (28) BELEODAQ... 9 BELSOMRA benazepril benazepril-hydrochlorothiazide BENDEKA BENLYSTA... 5 benztropine bepotastine besilate BESPONSA betamethasone acet,sod phos betamethasone dipropionate.. 94 betamethasone valerate betamethasone, augmented... 94, 95 BETASERON... 8 betaxolol... 74, 28 bethanechol chloride bexarotene BEXSERO... 2 bicalutamide BICILLIN L-A... 6 BIDIL BIKTARVY bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BLENREP bleomycin bleph BLINCYTO blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP... 2 BORTEZOMIB BOSULIF BRAFTOVI BREO ELLIPTA... 3 BREZTRI AEROSPHERE.. 33 briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine BROMSITE BRONCHITOL BRUKINSA budesonide... 24, 3 bumetanide... 77, 78 buprenorphine... 3 buprenorphine hcl... 3, 8 buprenorphine-naloxone... 9 bupropion hcl bupropion hcl (smoking deter). 9 buspirone butalbital-acetaminop-caf-cod. 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff. 3 butalbital-aspirin-caffeine... 3 butorphanol... 3 I-2

149 BYNFEZIA... 2 BYSTOLIC C CABENUVA cabergoline CABLIVI CABOMETYX caffeine citrate... 8 calcipotriene... 92, 93 calcitonin (salmon) calcitriol calcium acetate(phosphat bind) calcium chloride CALQUENCE camila candesartan... 7 candesartan-hydrochlorothiazid... 7 CAPLYTA CAPRELSA captopril captopril-hydrochlorothiazide 72 CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin CAROSPIR carteolol cartia xt carvedilol caspofungin CAYSTON... 5 caziant (28) cefaclor... 2 cefadroxil... 2, 3 cefazolin... 3 cefdinir... 3 cefepime... 3 cefixime... 3 cefotaxime... 3 cefoxitin... 3 cefoxitin in dextrose, iso-osm 3 cefpodoxime... 3 cefprozil... 3 ceftazidime... 3 ceftriaxone... 3 cefuroxime axetil... 3 cefuroxime sodium... 4 celecoxib... 6 CELONTIN cephalexin... 4 CERDELGA CEREZYME cevimeline CHANTIX... 9 CHANTIX CONTINUING MONTH BOX... 9 CHANTIX STARTING MONTH BOX... 9 chateal eq (28) chloramphenicol sod succinate... chlordiazepoxide hcl... 0 chlorhexidine gluconate chloroquine phosphate chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar).. 79 cholestyramine light ciclopirox cidofovir cilostazol CIMDUO cimetidine cimetidine hcl CIMZIA... 5 CIMZIA POWDER FOR RECONST... 5 cinacalcet CINQAIR CINRYZE ciprofloxacin... 7 ciprofloxacin hcl... 7, 0 ciprofloxacin in 5 % dextrose 7 ciprofloxacin-dexamethasone... 0 citalopram cladribine clarithromycin... 4 clemastine CLENPIQ clindamycin hcl... clindamycin in 5 % dextrose.. clindamycin pediatric... clindamycin phosphate..., 48, 93 clindamycin-benzoyl peroxide CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX 6%-D5W (SULFITE-FREE) CLINIMIX 8%- D0W(SULFITE-FREE) CLINIMIX 8%- D4W(SULFITE-FREE) CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE I-3

150 CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 8%-D0W SULFITEFREE CLINIMIX E 8%-D4W SULFITEFREE clobazam clobetasol clobetasol-emollient clofarabine clomipramine clonazepam... 0 clonidine clonidine hcl... 70, 82 clopidogrel clorazepate dipotassium... 0 clotrimazole clotrimazole-betamethasone clovique clozapine COARTEM codeine sulfate... 3 codeine-butalbital-asa-caff... 3 colchicine colesevelam colestipol colistin (colistimethate na)... COMBIGAN COMBIVENT RESPIMAT. 33 COMETRIQ... 2 COMPLERA compro constulose COPAXONE COPIKTRA... 2 CORLANOR COSENTYX... 6 COSENTYX (2 SYRINGES)... 5 COSENTYX PEN (2 PENS) 6 COTELLIC... 2 CREON CRIXIVAN cromolyn... 00, 05, 34 cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide... 2 CYCLOPHOSPHAMIDE... 2 cyclosporine... 6 cyclosporine modified... 6 cyproheptadine CYRAMZA... 2 cyred eq CYSTADANE CYSTADROPS CYSTARAN D d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dalfampridine DALIRESP danazol dantrolene DANYELZA... 2 dapsone DAPTACEL (DTAP PEDIATRIC) (PF)... 2 daptomycin... DARZALEX... 2 DARZALEX FASPRO... 2 dasetta /35 (28) dasetta 7/7/7 (28) DAURISMO... 2 daysee deblitane decitabine... 2 deferasirox deferiprone deferoxamine DELSTRIGO demeclocycline... 7 DENAVIR denta 5000 plus dentagel DESCOVY desipramine desmopressin... 2 desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol.. 86 desonide desoximetasone desvenlafaxine succinate dexamethasone... dexamethasone sodium phos (pf)... dexamethasone sodium phosphate... 03, dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 0 % in water (d0w) dextrose 5 % in water (d5w).. 69 DIACOMIT diazepam... 0, 35 diazoxide diclofenac epolamine... 6 diclofenac potassium... 6 diclofenac sodium... 6, 03 diclofenac-misoprostol... 6 dicloxacillin... 6 dicyclomine didanosine DIFICID... 4 diflorasone diflunisal... 6 digitek I-4

151 digox digoxin dihydroergotamine DILANTIN diltiazem hcl dilt-xr dimenhydrinate... 5 dimethyl fumarate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 9 divalproex docetaxel... 2 dofetilide donepezil DOPTELET (0 TAB PACK)66 DOPTELET (5 TAB PACK)66 DOPTELET (30 TAB PACK)66 dorzolamide dorzolamide-timolol dotti... 0 DOVATO doxazosin doxepin doxercalciferol doxorubicin... 2 doxorubicin, peg-liposomal... 2 doxy doxycycline hyclate... 7, 8 doxycycline monohydrate... 8 DRIZALMA SPRINKLE dronabinol... 5 droperidol... 5 drospirenone-ethinyl estradiol 86 DROXIA droxidopa DUAVEE... 0 DUEXIS... 6 duloxetine DUREZOL dutasteride dutasteride-tamsulosin E econazole EDARBI... 7 EDARBYCLOR... 7 EDURANT efavirenz efavirenz-emtricitabin-tenofov efavirenz-lamivu-tenofov disop EGRIFTA... 2 EGRIFTA SV... 3 ELAPRASE ELIGARD ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest ELIQUIS ELIQUIS DVT-PE TREAT 30D START ELITEK elixophyllin ELLA ELMIRON eluryng EMCYT EMEND... 5 EMFLAZA... EALITY PEN EALITY SYRINGE emoquette EMPLICITI EMSAM emtricitabine emtricitabine-tenofovir (tdf).. 60 EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide 72 ENBREL... 6 ENBREL MINI... 6 ENBREL SURECLICK... 6 ENDARI endocet... 3 ENGERIX-B (PF)... 2 ENGERIX-B PEDIATRIC (PF)... 2 ENHERTU enoxaparin enpresse enskyce ENSPRYNG entacapone entecavir ENTRESTO... 7 enulose EPANED EPCLUSA EPIDIOLEX epinastine epinephrine epitol EPIVIR HBV eplerenone epoprostenol (glycine) eprosartan... 7 ERBITUX ergoloid ERIVEDGE ERLEADA erlotinib errin ertapenem... 5 ery pads erythromycin... 4, 0 erythromycin ethylsuccinate.. 4 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET I-5

152 escitalopram oxalate esomeprazole magnesium esomeprazole sodium estarylla estazolam... 0 estradiol... 0 estradiol valerate... 0 estradiol-norethindrone acet. 0 eszopiclone ethambutol ethosuximide ethynodiol diac-eth estradiol.. 87 etodolac... 6 etonogestrel-ethinyl estradiol. 87 ETOPOPHOS etoposide etravirine EUCRISA EVENITY everolimus (antineoplastic) everolimus (immunosuppressive)... 6 EVOTAZ EVRYSDI exemestane EXONDYS EYSUVIS EZALLOR SPRINKLE ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (28) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os)04 FANAPT FARXIGA FARYDAK FASENRA FASENRA PEN febuxostat felbamate felodipine FEMRING... 0 femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized.. 79 fenofibric acid (choline) fenoprofen... 6 fentanyl... 4 fentanyl citrate... 4 FERRIPROX FERRIPROX (2 TIMES A DAY) FETZIMA FIASP FLEXTOUCH U-00 INSULIN FIASP PENFILL U-00 INSULIN FIASP U-00 INSULIN finasteride FINTEPLA FIRVANQ... 2 flavoxate FLEBOGAMMA DIF... 6 flecainide FLOVENT DISKUS FLOVENT HFA floxuridine fluconazole fluconazole in nacl (iso-osm) 46 flucytosine fludrocortisone... flumazenil flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluorometholone fluorouracil... 22, 93 fluoxetine fluphenazine decanoate fluphenazine hcl flurazepam... 0 flurbiprofen... 7 flurbiprofen sodium flutamide fluticasone propionate... 95, 03 fluvastatin fluvoxamine fomepizole fondaparinux fosamprenavir fosaprepitant... 5 foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOTIVDA FULPHILA fulvestrant furosemide FUZEON fyavolv... 0 FYCOMPA G gabapentin GALAFOLD galantamine GAMIFANT... 6 GAMMAGARD LIQUID... 6 GAMMAGARD S-D (IGA < MCG/ML)... 6 GAMMAPLEX... 7 GAMMAPLEX (WITH SORBITOL)... 6 GAMUNEX-C... 7 ganciclovir sodium GARDASIL 9 (PF)... 2 gatifloxacin... 0 GATTEX 30-VIAL I-6

153 GAUZE PADS & DRESSINGS - PADS 2 X , 98 gavilyte-c gavilyte-g gavilyte-n GAVRETO GAZYVA gemcitabine gemfibrozil generlac gengraf... 7 gentak... 0 gentamicin..., 94, 0 gentamicin sulfate (ped) (pf).. gentamicin sulfate (pf)... GENVOYA GILENYA GILOTRIF GIVLAARI glatiramer glatopa glimepiride glipizide glipizide-metformin glyburide glyburide micronized glyburide-metformin glycopyrrolate glydo... 8 granisetron (pf)... 5 granisetron hcl... 5 GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine... 70, 83 GVOKE HYPOPEN 2-PACK GVOKE PFS -PACK SYRINGE H HAEGARDA hailey hailey 24 fe hailey fe.5/30 (28) hailey fe /20 (28) halobetasol propionate... 95, 96 haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF)... 2 heather HEMADY... heparin (porcine) heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HERCEPTIN HYLECTA HERZUMA HETLIOZ HETLIOZ LQ HIBERIX (PF)... 2 HUMIRA... 7 HUMIRA PEN... 7 HUMIRA PEN CROHNS-UC- HS START... 7 HUMIRA PEN PSOR- UVEITS-ADOL HS... 7 HUMIRA(CF)... 7 HUMIRA(CF) PEDI CROHNS STARTER... 7 HUMIRA(CF) PEN... 7 HUMIRA(CF) PEN CROHNS- UC-HS... 7 HUMIRA(CF) PEN PEDIATRIC UC... 7 HUMIRA(CF) PEN PSOR-UV- ADOL HS... 7 HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 4 hydrocodone-ibuprofen... 4 hydrocortisone... 96,, 24 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid... 0 hydromorphone... 4 hydromorphone (pf)... 4 hydroxychloroquine hydroxyprogesterone cap(ppres)... 4 hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYQVIA... 8 I ibandronate IBRANCE ibu... 7 ibuprofen... 7 icatibant iclevia ICLUSIG IDHIFA ifosfamide ILARIS (PF)... 8 ILEVRO ILUMYA... 8 imatinib IMBRUVICA IMFINZI imipenem-cilastatin... 5 imipramine hcl imipramine pamoate imiquimod IMLYGIC IMOVAX RABIES VACCINE (PF)... 2 IMPAVIDO INBRIJA incassia INCRELEX... 3 I-7

154 indapamide indomethacin... 7 INFANRIX (DTAP) (PF) INFLECTRA... 8 INFUGEM INLYTA INQOVI INREBIC INSULIN SYRINGE-NEEDLE U , 98 INTELENCE INTRALIPID INTRON A introvale INVEGA SUSTENNA INVEGA TRINZA... 56, 57 INVELTYS INVIRASE IPOL ipratropium bromide... 00, 33 ipratropium-albuterol irbesartan... 7 irbesartan-hydrochlorothiazide... 7 IRESSA irinotecan ISENTRESS... 60, 6 ISENTRESS HD isibloom ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD... 92, 93 isosorbide dinitrate... 8 isosorbide mononitrate... 8 isradipine itraconazole ivermectin IXEMPRA IXIARO (PF) J jaimiess JAKAFI jantoven JARDIANCE jasmiel (28) JEMPERLI jencycla JENTADUETO JENTADUETO XR jinteli... 0 juleber JULUCA... 6 junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID... 79, 80 JYNARQUE K KALETRA... 6 kalliga KALYDECO KANJINTI KANUMA kariva (28) KATERZIA kelnor /35 (28) kelnor -50 (28) KESIMPTA PEN ketoconazole ketoprofen... 7 ketorolac... 7, 03 KEVEYIS KEVZARA... 8 KEYTRUDA KINERET... 8 KINRIX (PF) kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK klor-con m klor-con m klor-con m KLOXXADO... 9 KORLYM KOSELUGO KRINTAFEL KRYSTEXXA kurvelo (28) KYNMOBI KYPROLIS L l norgest/e.estradiol-e.estrad.. 88 labetalol lactulose lamivudine... 6 lamivudine-zidovudine... 6 lamotrigine... 35, 36 lansoprazole lanthanum LANTUS SOLOSTAR U-00 INSULIN LANTUS U-00 INSULIN lapatinib larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) larissia latanoprost LATUDA LAZANDA... 4 leflunomide... 8 LENVIMA lessina letrozole leucovorin calcium LEUKERAN I-8

155 LEUKINE leuprolide levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 7, 0 levofloxacin in d5w... 7 levoleucovorin calcium levonest (28) levonorgestrel-ethinyl estrad.. 88 levonorg-eth estrad triphasic.. 88 levora levothyroxine... 5 LEXIVA... 6 LIBTAYO lidocaine... 8 lidocaine (pf)... 8, 73 lidocaine hcl... 8 lidocaine viscous... 8 lidocaine-prilocaine... 8 lillow (28) linezolid... 2 linezolid in dextrose 5%... 2 linezolid-0.9% sodium chloride... 2 LINZESS liothyronine... 5 lisinopril lisinopril-hydrochlorothiazide 72 lithium carbonate LIVALO lojaimiess LOKELMA LONSURF loperamide lopinavir-ritonavir... 6 lorazepam... 0 lorazepam intensol... 0 LORBRENA loryna (28) losartan... 7 losartan-hydrochlorothiazide. 7 LOTEMAX LOTEMAX SM loteprednol etabonate lovastatin low-ogestrel (28) loxapine succinate lo-zumandimine (28) lubiprostone LUCEMYRA... 9 LUMAKRAS LUMIGAN LUMOXITI LUPRON DEPOT... 3 LUPRON DEPOT (3 MONTH)... 26, 3 LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED... 3 LUPRON DEPOT-PED (3 MONTH)... 3 lutera (28) lyleq lyllana... 0 LYNPARZA LYSODREN lyza M magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water. 30 malathion maprotiline marlissa (28) MARPLAN MARQIBO MATULANE matzim la MAVENCLAD (0 TABLET PACK) MAVENCLAD (4 TABLET PACK) MAVENCLAD (5 TABLET PACK) MAVENCLAD (6 TABLET PACK) MAVENCLAD (7 TABLET PACK) MAVENCLAD (8 TABLET PACK) MAVENCLAD (9 TABLET PACK) MAVYRET MAYZENT MAYZENT STARTER PACK meclizine... 5 medroxyprogesterone... 4 mefenamic acid... 7 mefloquine megestrol... 26, 4 MEKINIST MEKTOVI meloxicam... 7 melphalan hcl memantine... 38, 39 MENACTRA (PF) MENQUADFI (PF) MENVEO A-C-Y-W-35-DIP (PF) MEPSEVII mercaptopurine meropenem... 5 meropenem-0.9% sodium chloride... 5 mesalamine mesna MESNEX metadate er metaproterenol I-9

156 metformin methadone... 4 methadose... 4 methazolamide methenamine hippurate... 2 methimazole... 5 methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyldopa methylphenidate hcl... 83, 84 methylprednisolone... 2 methylprednisolone acetate.. methylprednisolone sodium succ... 2 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 2, 48, 94 metronidazole in nacl (iso-os) 2 metyrosine mexiletine miconazole microgestin fe /20 (28) midazolam... 0 midodrine miglitol miglustat mili mimvey... 0 minitran... 8 minocycline... 8 minoxidil... 8 mirtazapine misoprostol MITIGARE mitoxantrone M-M-R II (PF) moexipril molindone mometasone... 96, 03 mondoxyne nl... 8 MONJUVI mono-linyah montelukast morphine... 4, 5 MORPHINE... 4, 5 morphine concentrate... 4 MOVANTIK moxifloxacin... 7, 0 MOZOBIL MULPLETA MULTAQ mupirocin MVASI MYCAPSSA... 3 mycophenolate mofetil... 8 mycophenolate mofetil (hcl) 8 MYLOTARG MYRBETRIQ N nabumetone... 7 nadolol nafcillin... 6 nafcillin in dextrose iso-osm.. 6 NAGLAZYME naloxone... 9 naltrexone... 9 NAMZARIC naproxen... 7 naproxen-esomeprazole... 7 naratriptan NARCAN... 9 NATACYN... 0 nateglinide NATPARA NAYZILAM necon 0.5/35 (28) nefazodone neomycin... neomycin-bacitracin-poly-hc 0 neomycin-bacitracin-polymyxin... 0 neomycin-polymyxin b gu neomycin-polymyxin b- dexameth... 0 neomycin-polymyxingramicidin... 0 neomycin-polymyxin-hc... 0, 02 neo-polycin neo-polycin hc NEPHRAMINE 5.4 % NERLYNX NEULASTA NEUPRO nevirapine... 6 NEXAVAR NEXLETOL NEXLIZET niacin niacor nicardipine NICOTROL... 9 nifedipine nikki (28) nilutamide NINLARO nitazoxanide nitisinone nitrofurantoin macrocrystal... 2 nitrofurantoin monohyd/m-cryst... 2 nitroglycerin... 8 NITYR NIVESTYM nizatidine NORDITROPIN FLEXPRO 3 norethindrone (contraceptive) 89 norethindrone acetate... 4 I-0

157 norethindrone ac-eth estradiol... 89, 0 norethindrone-e.estradiol-iron 89 norgestimate-ethinyl estradiol 89 norlyda NORMOSOL-M IN 5 % DEXTROSE nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline... 4 NORVIR... 6 NOVOLIN 70/30 U-00 INSULIN NOVOLIN FLEXPEN U NOVOLIN N FLEXPEN NOVOLIN N NPH U-00 INSULIN NOVOLIN R FLEXPEN NOVOLIN R REGULAR U- 00 INSULN NOVOLOG FLEXPEN U-00 INSULIN NOVOLOG MIX U-00 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-00 INSULIN NOVOLOG U-00 INSULIN ASPART NOXAFIL NPLATE NUBEQA NUCALA NULOJIX... 8 NUPLAZID NUTRILIPID nyamyc nylia 7/7/7 (28) nymyo nystatin nystatin-triamcinolone nystop NYVEPRIA O OCALIVA OCTAGAM... 8 octreotide acetate... 3 ODEFSEY... 6 ODOMZO OFEV ofloxacin OGIVRI olanzapine olmesartan... 7 olmesartan-amlodipin-hcthiazid... 7 olmesartan-hydrochlorothiazide... 7 olopatadine OLUMIANT... 8 omega-3 acid ethyl esters omeprazole omeprazole-sodium bicarbonate ONCASPAR ondansetron... 5 ondansetron hcl... 5 ondansetron hcl (pf)... 5 ONGENTYS ONIVYDE ONTRUZANT ONUREG OPDIVO OPSUMIT oralone ORENCIA... 9 ORENCIA (WITH MALTOSE)... 8 ORENCIA CLICKJECT... 8 ORFADIN ORGOVYX... 3 ORILISSA... 3 ORKAMBI ORLADEYO orsythia oseltamivir OSMOLEX ER OTEZLA... 9 OTEZLA STARTER... 9 oxaliplatin oxandrolone oxazepam... 0 oxcarbazepine OXLUMO OXTELLAR XR oxybutynin chloride oxycodone... 5 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 OXYCONTIN... 5 oxymorphone... 5 OZEMPIC P pacerone paclitaxel PADCEV paliperidone PALYNZIQ pamidronate PANRETIN pantoprazole paricalcitol paroex oral rinse paromomycin paroxetine hcl... 4 PAXIL... 4 PEDIARIX (PF) PEDVAX HIB (PF) PEGASYS PEGINTRON PEMAZYRE PEN NEEDLE, DIABETIC I-

158 penicillamine penicillin g potassium... 6 penicillin g procaine... 6 penicillin v potassium... 6 PENNSAID... 8 PENTACEL (PF) pentamidine pentoxifylline PEPAXTO perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline... 4 PERSERIS pfizerpen-g... 6 phenelzine... 4 phenobarbital phenylephrine hcl phenytoin phenytoin sodium phenytoin sodium extended... 36, 37 PHESGO philith PHOSLYRA PIFELTRO... 6 pilocarpine hcl... 92, 29 pimecrolimus pimozide pimtrea (28) pindolol pioglitazone piperacillin-tazobactam... 6 PIQRAY pirmella piroxicam... 8 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY podofilox POLIVY polycin polymyxin b sulfate... 2 polymyxin b sulf-trimethoprim POMALYST portia PORTRAZZA posaconazole potassium chloride... 30, 3 potassium chloride-0.45 % nacl... 3 potassium citrate... 3 PRALUENT PEN pramipexole prasugrel pravastatin prazosin prednicarbate prednisolone... 2 prednisolone acetate prednisolone sodium phosphate... 03, 2 prednisone... 2 pregabalin PREMARIN... 0, PREMPHASE... PREMPRO... PRETOMANID prevalite previfem PREVYMIS PREZCOBIX... 6 PREZISTA PRIFTIN PRIMAQUINE primidone PRIVIGEN... 9 PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine... 5 prochlorperazine edisylate... 5 prochlorperazine maleate... 5 procto-med hc procto-pak proctosol hc proctozone-hc progesterone... 4 progesterone micronized... 4 PROGRAF... 9 PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 48, 5, 52 promethegan propafenone propantheline proparacaine propranolol... 74, 75 propranolol-hydrochlorothiazid propylthiouracil... 5 PROQUAD (PF) PROSOL 20 % protamine protriptyline... 4 PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide pyrimethamine Q QBRELIS QINLOCK QUADRACEL (PF) quetiapine... 57, 58 quinapril quinapril-hydrochlorothiazide 73 quinidine gluconate I-2

159 quinidine sulfate quinine sulfate R RABAVERT (PF) rabeprazole RADICAVA raloxifene... ramipril ranolazine rasagiline RASUVO (PF)... 9 RAVICTI RAYALDEE reclipsen (28) RECOMBIVAX HB (PF) RECTIV REGRANEX RELENZA DISKHALER RELISTOR REMICADE... 9 RENFLEXIS... 9 repaglinide... 42, 43 repaglinide-metformin RESTASIS RETACRIT RETEVMO RETROVIR REVCOVI REVLIMID revonto REXULTI REYATAZ RHOPRESSA RIABNI ribavirin RIDAURA... 9 rifabutin rifampin riluzole rimantadine RINVOQ... 9 risedronate RISPERDAL CONSTA risperidone ritonavir RITUXAN RITUXAN HYCELA rivastigmine rivastigmine tartrate rizatriptan ROCKLATAN ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROZLYTREK RUBRACA rufinamide RUKOBIA RUXIENCE RYBELSUS RYBREVANT RYDAPT S SANDOSTATIN LAR DEPOT... 3 SANTYL sapropterin SARCLISA SAVELLA... 84, 85 scopolamine base SECUADO selegiline hcl selenium sulfide SELZENTRY SEREVENT DISKUS SEROSTIM... 3 sertraline... 4 setlakin sevelamer carbonate sevelamer hcl sf 5000 plus sharobel SHINGRIX (PF) SIGNIFOR... 4 SIKLOS sildenafil (pulm.hypertension)... 36, 37 silver sulfadiazine SIMBRINZA simliya (28) simpesse simvastatin sirolimus... 9 SIRTURO SKYRIZI... 9 SLYND sodium chloride 0.45 %... 3 sodium chloride 0.9 %... 3 sodium fluoride sodium fluoride-pot nitrate sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLIQUA 00/ SOLTAMOX SOLU-CORTEF ACT-O-VIAL (PF)... 2 SOMATULINE DEPOT... 4 SOMAVERT... 4 sorine sotalol sotalol af SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPRAVATO... 4 sprintec (28) SPRITAM SPRYCEL I-3

160 sps (with sorbitol) sronyx ssd stavudine STELARA... 9, 20 STIOLTO RESPIMAT STIVARGA STRENSIQ streptomycin... STRIBILD SUBLOCADE... 9 subvenite sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 94 sulfacetamide-prednisolone.. 02 sulfadiazine... 7 sulfamethoxazole-trimethoprim... 7 sulfasalazine sulindac... 8 sumatriptan sumatriptan succinate SUNOSI SUPPRELIN LA... 4 SUPREP BOWEL PREP KIT SURE COMFORT INS. SYR. U SUTENT syeda SYLVANT SYMBICORT SYMDEKO SYMJEPI SYMLINPEN SYMLINPEN SYMPAZAN SYMTUZA SYNAGIS SYNAREL... 4 SYNDROS SYNERCID... 2 SYNJARDY SYNJARDY XR SYNRIBO T TABLOID TABRECTA tacrolimus... 96, 20 tadalafil tadalafil (pulm. hypertension) TAFINLAR TAGRISSO TAKHZYRO TALTZ AUTOINJECTOR.. 20 TALTZ SYRINGE TALTZ SYRINGE (2 PACK) TALTZ SYRINGE (3 PACK) TALZENNA tamoxifen tamsulosin TARGRETIN tarina 24 fe tarina fe -20 eq (28) TASIGNA TAVALISSE tazarotene TAZORAC taztia xt TAZVERIK TDVAX TECENTRIQ TEFLARO... 4 telmisartan... 7 telmisartan-amlodipine... 7 telmisartan-hydrochlorothiazid... 7 temazepam... 0 TEMIXYS TEMODAR temsirolimus tencon... 5 TENIVAC (PF) tenofovir disoproxil fumarate 62 TEPEZZA TEPMETKO terazosin terbinafine hcl terbutaline terconazole... 48, 49 testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) tetrabenazine tetracycline... 8 THALOMID theophylline THIOLA EC thioridazine thiotepa thiothixene tiadylt er tiagabine TIBSOVO TICE BCG tigecycline... 8 timolol maleate... 75, 29 tinidazole tiopronin TIVICAY TIVICAY PD tizanidine TOBI PODHALER... tobramycin..., 02 tobramycin in % nacl... tobramycin sulfate... tobramycin-dexamethasone. 02 tolmetin... 8 tolterodine topiramate I-4

161 toposar topotecan toremifene torsemide TOTECT TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TOVIAZ TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril tranexamic acid tranylcypromine... 4 TRAVASOL 0 % travoprost TRAZIMERA trazodone... 4 TREANDA TRECATOR TRELEGY ELLIPTA TRELSTAR... 3 TREMFYA treprostinil sodium tretinoin tretinoin (antineoplastic)... 3 tri femynor triamcinolone acetonide.. 92, 96, 97, 2 triamterene-hydrochlorothiazid triazolam... 0 trientine tri-estarylla trifluoperazine trifluridine trihexyphenidyl TRIKAFTA tri-legest fe tri-linyah... 9 tri-lo-estarylla... 9 tri-lo-marzia... 9 tri-lo-mili... 9 tri-lo-sprintec... 9 trilyte with flavor packets trimethoprim... 2 tri-mili... 9 trimipramine... 4 TRINTELLIX... 4 tri-nymyo... 9 tri-previfem (28)... 9 TRIPTODUR... 4 tri-sprintec (28)... 9 TRIUMEQ trivora (28)... 9 tri-vylibra... 9 tri-vylibra lo... 9 TRODELVY... 3 TROGARZO TROPHAMINE 0 % trospium TRULICITY TRUMENBA TRUSELTIQ... 3 TRUXIMA... 3 TUKYSA... 3 tulana... 9 TURALIO... 3 TWINRIX (PF) tyblume... 9 TYBOST TYMLOS TYPHIM VI TYSABRI TYVASO U UBRELVY UCERIS UDENYCA UKONIQ... 3 UNITUXIN... 3 UPTRAVI ursodiol V valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) 37 valrubicin... 3 valsartan... 7 valsartan-hydrochlorothiazide 72 VALTOCO vancomycin... 2 VAQTA (PF)... 23, 24 VARIVAX (PF) VASCEPA VECTIBIX... 3 VEKLURY VELCADE... 3 velivet triphasic regimen (28) 9 VELPHORO VEMLIDY VENCLEXTA... 3, 32 VENCLEXTA STARTING PACK venlafaxine... 4 verapamil VEREGEN VERSACLOZ VERZENIO vestura (28)... 9 vicodin hp... 5 VICTOZA 3-PAK vienva... 9 vigabatrin vigadrone VIIBRYD... 4, 42 VIMIZIM VIMPAT vinblastine vincasar pfs I-5

162 vincristine vinorelbine viorele (28)... 9 VIRACEPT VIREAD VISTOGARD VITRAKVI VIZIMPRO VOCABRIA volnea (28)... 9 voriconazole VOSEVI VOTRIENT VPRIV VRAYLAR... 58, 59 VUMERITY vyfemla (28)... 9 vylibra... 9 VYNDAMAX VYNDAQEL VYXEOS VYZULTA W warfarin wera (28)... 9 X XADAGO XALKORI XARELTO XARELTO DVT-PE TREAT 30D START XATMEP XCOPRI XCOPRI MAINTENANCE PACK XCOPRI TITRATION PACK XELJANZ XELJANZ XR XELPROS XERMELO XGEVA XHANCE XIFAXAN... 2 XIGDUO XR XOFLUZA XOLAIR XOSPATA XPOVIO... 32, 33 XTAMPZA ER... 5, 6 XTANDI xulane... 9 XULTOPHY 00/ XURIDEN XYOSTED XYREM Y YERVOY YF-VAX (PF) YONDELIS YONSA yuvafem... Z zafemy... 9 zafirlukast zaleplon ZALTRAP zarah ZARXIO zebutal... 6 ZEJULA ZELBORAF zenatane ZENPEP ZEPZELCA zidovudine ZIEXTENZO ZIOPTAN (PF) ziprasidone hcl ziprasidone mesylate ZIRABEV ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan... 49, 50 zolpidem zonisamide ZORBTIVE... 4 ZORTRESS ZOSTAVAX (PF) zovia /35e (28) zovia -35 (28) ZTLIDO... 8 ZULRESSO zumandimine (28) ZYDELIG ZYKADIA ZYLET ZYNLONTA ZYPREXA RELPREVV ZYTIGA I-6

163 o o o o o o o o