H3129_RX16_52_CH Alternate Format North Shore-LIJ FIDA LiveWell (Medicare-Medicaid 計劃 ) 2016 年給付藥物清單 ( 處方集 ) 此清單列出參與者在 North Shore-LIJ FIDA LiveWell (

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1 North Shore-LIJ FIDA LiveWell (Medicare-Medicaid 計劃 ) 給付藥物清單 ( 處方集 ) 2016 年 我們能讓您輕鬆獲得高品質照護 請詳閱 : 本文件包含有關此照護計劃所承保藥物的資訊 參與者服務部 :(855) NSLIJHealthPlans.com/FIDALiveWell H3129_RX16_52_CH Alternate Format

2 H3129_RX16_52_CH Alternate Format North Shore-LIJ FIDA LiveWell (Medicare-Medicaid 計劃 ) 2016 年給付藥物清單 ( 處方集 ) 此清單列出參與者在 North Shore-LIJ FIDA LiveWell (Medicare-Medicaid 計劃 ) 中可取得的藥物 North Shore-LIJ Health Plan, Inc. 是一項管理式的照護計劃, 與 Medicare 和紐約州衛生署 (New York State Department of Health) (Medicaid) 具有合約關係, 透過完全整合的雙優惠 (Fully Integrated Duals Advantage, FIDA) 示範計劃, 使參與者同時享有兩種方案的福利 給付藥物清單和 / 或藥局和提供者網路可能會在全年中隨時發生變更 如果進行的變更會對您造成 影響, 我們會事先寄送通知給您 福利可能會在每年 1 月 1 日發生變更 您隨時可以造訪 North Shore-LIJ FIDA LiveWell 的網站 :NSLIJHealthPlans.com/FIDALiveWell 或致電參與者服務部 :(855) , 聯絡 North Shore-LIJ FIDA LiveWell, 以取得最新的給 付藥物清單 可能會有特定限制 如需詳細資訊, 請致電 North Shore-LIJ FIDA LiveWell 參與者服務部或參閱 North Shore-LIJ FIDA LiveWell 參與者手冊 所有給付藥物目前不須負擔共付額 您可以免費獲得該資訊的其他格式, 例如點字版 大字版或音訊版 請致電 :(855) 及 711; 服務時間為上午 8 時至晚上 8 時 此為免付費專線 Puede obtener esta información de manera gratuita en otros idiomas. Llame al (855) y TTY/TDD 711 de lunes a domingos de 8:00 am a 8:00 pm. La llamada es gratuita. 您可免費取得以其他語言撰寫的資訊 請於週一至週日上午 8 時至下午 8 時致電 (855) , TTY/TDD 使用者 :711 此為免付費電話 Данная информация доступна бесплатно на других языках.звоните по номеру (855) или 711 (линия TTY/TDD) с понедельника по воскресенье с 8:00 до 20:00. Звонок бесплатный. 이정보는다른언어로도제공됩니다 ( 무료 ). 월요일-일요일 8:00 am 8:00 pm 중 (855) 나 TTY/TDD 711 로전화주십시오. 통화료는무료입니다. 此給付藥物清單截至 2015 年 9 月 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 1

3 Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan (855) ak nan TTY/TDD (pou moun ki gen pwoblèm tande oswa moun ki bèbè) 711 de lendi a dimanch 8:00 am - 8:00 pm. Apèl la gratis. È possibile ricevere queste informazioni in altre lingue gratuitamente.contatta il (855) e TTY/TDD 711 dal lunedì alla domenica dalle ore 8:00 alle ore 20:00. Il servizio è gratuito. 紐約州已推出稱為 獨立消費者倡權網路 (Independent Consumer Advocacy Network, ICAN) 的參與者申訴方案, 為參與者免費提供與 North Shore-LIJ FIDA LiveWell 服務相關的保密協助 ICAN 免費聯絡專線 : ; 網址 :icannys.org FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 2

4 常見問題 (FAQ) 若您對於給付藥物清單有任何問題, 可在此處尋找問題解答 您可以閱讀所有常見問題解答以深入瞭解 相關資訊, 或者直接搜尋問題與解答 1. 給付藥物清單中涵蓋哪些處方藥?( 我們將給付藥物清單簡稱為 藥物清單 ) 給付藥物清單第 11 頁起所列的藥物即 North Shore-LIJ FIDA LiveWell 給物 凡屬我們醫療網路的 藥局均供應此類藥物 屬於我們醫療網路的藥局係指與我們簽約合作, 為您提供服務的藥局 我們稱這些藥局為 醫療網路藥局 North Shore-LIJ FIDA LiveWell 將給付藥物清單中的所有藥物, 唯必須符合下列條件 : 您的醫師或其他開立處方者表示您需要這些藥物改善病情或維持健康 ; 這些藥物是改善您健康狀況的必備醫療藥物 ; 並且 您在 North Shore-LIJ FIDA LiveWell 醫療網路藥局領取處方藥 North Shore-LIJ FIDA LiveWell 對於取得特定藥物可能會規定其他步驟 ( 請參閱以下第 5 個問題 ) 在部分情況下, 您必須先採取某些行動 ( 例如 : 嘗試其他藥物 ), 才能取得特定藥物 您也可以上網取得我們的最新給付藥物清單, 網址 :NSLIJHealthPlans.com/FIDALiveWell; 或者致電 (855) 與參與者服務部聯絡 2. 藥物清單是否會變更? 會 North Shore-LIJ FIDA LiveWell 在計劃年度內可能隨時添加或移除藥物清單中的藥物 一般而言, 藥物清單只有在以下情況才會變更 : 新的藥物具有和目前藥物清單中藥物一樣好的效果 ; 或 我們發現某藥物不安全 我們也可能會變更藥物規定 例如, 我們可能會 : 決定某藥物需要或不需要事先批准 ( 事先批准是指在您取得藥物前, 由 North Shore-LIJ FIDA LiveWell 或跨學科小組 (Interdisciplinary Team, IDT) 給予的許可 ) FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 3

5 新增或變更您可以取得的藥量規定 ( 稱為 數量限制 ) 新增或變更某藥物的階段式療法限制 ( 階段式療法表示在我們供應其他藥物前, 您必須先 嘗試特定藥物 ) ( 如需關於這些藥物規定的詳細資訊, 請參閱第 10 頁 ) 我們將您正在服用的某藥物從藥物清單中移除時會通知您 此外, 在變更給付藥物規定時, 我們也會向您發佈通知 針對藥物清單內容變更的情形, 以下第 3 4 和 7 個問題均有詳細資訊 您也可以隨時上網取得 North Shore-LIJ FIDA LiveWell 的最新給付藥物清單, 網址 : NSLIJHealthPlans.com/FIDALiveWell 或者致電 (855) 與參與者服務部聯絡, 瞭解最新的藥物清單 3. 如果發現較便宜的藥物具有和目前藥物清單中的藥物一樣好的效果, 會如何處理? 如果發現較便宜的藥物具有和目前藥物清單中的藥物一樣好的效果, 則會採取以下處理方式 : 在您下次領取處方藥時, 藥劑師會給您較便宜的藥物 如果您和您的提供者認為較便宜的藥物不適合您, 您的提供者可請藥劑師繼續提供您現在所用的藥物 North Shore-LIJ FIDA LiveWell 可能會決定將較昂貴的藥物從藥物清單中移除 如果您目前服用的藥物是我們預計從藥物清單中移除的藥物 ( 因為發現效果相同的較便宜藥物 ), 我們會在移除前至少 60 天通知您 ; 或者在您下次要求領藥時向您告知 在藥物清單變更生效之前, 我們仍會供應您 60 天藥量 如果您近期曾前往領取該處方藥, 福利說明將包含相關通知 如果您近期未領取過該處方藥, 但過去 180 天內曾使用過該藥物, 則我們會寄信通知您變更項目 無論是哪種情況, 您都會在藥物清單變更生效前至少 60 天收到通知 4. 如果我們發現某藥物不安全, 該如何處理? 若食品藥物管理局 (Food and Drug Administration, FDA) 認為您目前正在服用的藥物不安全, 我們會立即將其從藥物清單中移除 我們也會寄信並致電通知您, 向您告知不安全的藥物已從我們的藥物清單中移除 此外, 我們也會寄信通知您的處方醫師或執業人員, 以便根據您的健康情況使用其他替代藥物 若您有任何問題, 請直接與您的醫師聯絡, 或者致電 (855) 聯絡 North Shore-LIJ FIDA LiveWell FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 4

6 5. 是否有任何藥物給付約束或限制? 或者在取得特定藥物前是否需要先採取其 他措施? 是 部分藥物有給付規定或供應藥量限制 在部分情況下, 您或您的醫師必須先採取某些行動, 才能取 得此類藥物 例如 : 事先批准 ( 或稱為事先授權 ): 針對某些藥物, 您或您的醫師或其他開立處方者必須先取得 North Shore-LIJ FIDA LiveWell 或跨學科小組的許可, 才能領取處方藥 若您未取得批准, North Shore-LIJ FIDA LiveWell 可能無法供應該藥物 數量限制 :North Shore-LIJ FIDA LiveWell 有時會限制您可以取得的藥量 階段式療法 : 有時候,North Shore-LIJ FIDA LiveWell 會要求您採取階段式療法 這表示, 為治療您的病情, 您必須依特定順序服用藥物 您可能必須先嘗試某種藥物, 然後我們才會供應其他藥物 若您的醫師認為第一種藥物對您的病情無效, 則我們會給付第二種藥物 請參閱從第 11 頁開始的表格內容, 瞭解您的藥物是否有額外規定或限制 您也可以造訪我們的網站 NSLIJHealthPlans.com/FIDALiveWell 取得詳細資訊 我們已將事先授權和階段式療法限制的相關說明文件公佈在網站上 您也可以要求我們傳送副本給您 您可以針對這些限制提出 例外情況 要求 請參閱第 11 個問題, 瞭解關於例外情況的詳細資訊 如果您正在接受護理機構或其他長期照護機構的服務, 所需藥物並未列於藥物清單, 或者您無法輕易取得所需藥物, 我們都可以提供協助 無論您是否為新加入 North Shore-LIJ FIDA LiveWell 的成員, 我們都會為您給付所需藥物的 31 天 ( 除非您的處方藥天數少於 31 天 ) 應急藥量 此可讓您有時間諮詢醫師或其他開立處方者 他們可協助您確認藥物清單中是否有其他類似的可替代藥物, 或是否需要提出例外情況申請 請參閱第 11 個問題, 瞭解關於例外情況的詳細資訊 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 5

7 6. 要如何知道您需要的藥物是否有限制規定, 或者是否必須採取某些行動才能 取得藥物? 第 11 頁的給付藥物清單中, 有一欄的名稱為, 您可從中瞭解相關資訊 7. 如果我們變更部分藥物的給付規定, 會出現什麼情況? 例如 : 我們針對某藥物加上事先授權 ( 批准 ) 數量限制和/ 或階段式療法限制 如果我們針對某藥物加上事先批准 數量限制和 / 或階段式療法限制, 我們會通知您 我們會在新增限制前至少 60 天或您下次要求領藥時向您告知 在藥物清單變更生效之前, 我們仍會供應您 60 天藥量 此可讓您有時間向醫師或其他開立處方者諮詢後續因應措施 8. 如何搜尋藥物清單上的藥物? 共有兩種搜尋方式 : 您可以依照字母順序搜尋 ( 若您知道藥物的英文拼法 ); 或者 您可以依病情搜尋 若要依照字母順序搜尋, 請至第 91 頁的 按字母順序排列 一節, 然後從清單中尋找藥物名稱 若要依病情搜尋, 請參閱第 11 頁標示 依病情排序藥物清單 的區段 此區段的藥物是依照它們所治療的醫療情況類型分門別類 例如, 如果您有心臟疾病, 則應從該類別尋找 您可從中找到治療心臟疾病的藥物 9. 如果您要服用的藥物不在藥物清單中, 該如何處理? 如果藥物清單中沒有您需要的藥物, 請致電 (855) 洽詢參與者服務部 如果您發現 North Shore-LIJ FIDA LiveWell 並未給付該藥物, 可採取下列任一行動 : 請參與者服務部提供和您想要服用的藥物類似的藥物清單, 然後您再將此清單交給醫師或其他開立處方者, 由他們從藥物清單中開立和您想要服用的藥物類似的藥物 或者 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 6

8 您可以要求計劃部門或跨學科 (IDT) 小組允許例外情況, 給付您需要的藥物 請參閱第 11 個 問題, 瞭解關於例外情況的詳細資訊 10. 如果您是新加入 North Shore-LIJ FIDA LiveWell 計劃的成員, 在藥物清單 中找不到您需要的藥物, 或者無法取得藥物, 該如何處理? 我們可以協助您 我們必須在您加入 North Shore-LIJ FIDA LiveWell 計劃後的前 90 天內, 根據需要暫時供應最多 90 天的藥量 此可讓您有時間諮詢醫師或其他開立處方者 他們可協助您確認藥物清單中是否有其他類似的可替代藥物, 或是否需要提出例外情況申請 若您符合下列情況, 我們將暫時為您供應最多 90 天的藥量 : 您目前服用的藥物並未列入我們的藥物清單 ; 或者 健康計劃規定不允許您取得開立的處方藥量 ; 或者 該藥物必須事先取得 North Shore-LIJ FIDA LiveWell 或跨學科小組的批准 ; 或 您目前服用的藥物受限於階段式療法 如果您正在接受護理機構或其他長期照護機構服務, 則可續領最多 93 天的處方藥量 您可以在加入計劃的前 90 天期間, 多次領取處方藥 此可讓您的開立處方者有時間將藥物更換成藥物清單中的藥物, 或者提出例外情況申請 若參與者目前的藥物治療並未在 Shore-LIJ FIDA LiveWell 的給付範圍, 或者必須遵循事先授權 階段式療法或數量限制規定, 我們允許這些參與者享有有意義的過渡方式 此包括 : 年初加入 North Shore-LIJ FIDA LiveWell 計劃的新參與者 年初從其他承保計劃加入 North Shore-LIJ FIDA LiveWell 計劃的新合格參與者 年初後從某計劃轉換到其他計劃的個人 居住在長期照護機構 (long-term care, LTC) 的參與者, 包括入住 LTC 機構或從 LTC 辦理出院的參與者 在某些情況下, 目前的參與者會受到不同合約年份間處方集變更的影響 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 7

9 如果您入住長期照護機構或從長期照護機構辦理出院,North Shore-LIJ FIDA LiveWell 除了會供應 90 天 臨時藥量, 還會視情況提供最多 31 天的應急藥量 如需詳細資訊, 請致電 (855) 聯絡 North Shore-LIJ FIDA LiveWell 11. 您是否可以提出例外情況申請, 要求給付您的藥物? 可以 您可以向 North Shore-LIJ FIDA LiveWell 或跨專業團隊提出例外情況申請, 要求給付未列入藥物清單中的藥物 您也可以要求 North Shore-LIJ FIDA LiveWell 或 IDT 變更藥物規定 例如,North Shore-LIJ FIDA LiveWell 可能會限制我們給量 如果您的藥物有使用限制, 您可以要求我們或 IDT 變更限制並擴大給付範圍 其他範例 : 您可以要求我們或 IDT 取消階段式療法限制或事先授權規定 12. 取得例外情況核准需要多久時間? 首先, 您的開立處方者必須向 North Shore-LIJ FIDA LiveWell 或跨學科小組提供聲明, 表示支持您提出例外情況申請 在我們收到聲明後的 72 小時內, 您即可獲知例外情況要求是否通過核准 如果您或您的開立處方者認為您的健康狀況無法等待 72 小時的決策時間, 您可要求加快例外情況的申請處理程序 此為快速裁決 如果您的開立處方者支持您的申請, 您可在收到開立處方者支持聲明後的 24 小時內知道裁決結果 13. 如何提出例外情況申請? 若要提出例外情況申請, 請致電您的照護管理師 您的照護管理師將協助您和服務提供者提出例外情況申請 14. 學名藥是什麼? 學名藥是指成分和原廠藥相同的藥物, 通常價格會比原廠藥低, 但通常沒有知名藥廠掛名 學名藥已通過食品藥物管理局 (FDA) 核准 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 8

10 North Shore-LIJ FIDA LiveWell 給付的範圍包括原廠藥和學名藥 15. OTC 藥物是什麼? OTC 是 非處方 (over-the-counter) 的縮寫 North Shore-LIJ FIDA LiveWell 給付部分 OTC 藥物, 須由您的提供者開立處方 您可以參閱 North Shore-LIJ FIDA LiveWell 藥物清單, 瞭解給付的 OTC 藥物 16. North Shore-LIJ FIDA LiveWell 是否給付 OTC 非藥物產品? North Shore-LIJ FIDA LiveWell 給付部分 OTC 非藥物產品, 例如 : 紗布 紗布繃帶和纖維營養補充品, 須由提供者開立處方 您可以參閱 North Shore-LIJ FIDA LiveWell 藥物清單, 瞭解給付的 OTC 非藥物產品 17. 您的共付額是多少? 您不需要為藥物清單中的藥物支付共付額 18. 藥物級別是什麼? 級別是指藥物的不同分組 North Shore-LIJ FIDA LiveWell 藥物清單中的每種藥物都屬於三個級別中的一個, 這三個級別的藥物都不需要您支付共付額 級別 1 是指學名藥 級別 2 是指原廠藥 級別 3 是指非 Medicare (Medicaid) 計劃的藥物 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 9

11 給付藥物清單 下一頁起所列的給付藥物清單可讓您瞭解 North Shore-LIJ FIDA LiveWell 給付藥物的相關資訊 如果您在此清單中找不到您的藥物, 請參閱第 91 頁起的 索引 一節 表格第一欄列出藥物名稱 原廠藥是以字母大寫表示 ( 例如 :TYLENOL); 學名藥則以小寫斜體字母表示 ( 例如 :acetominophen) 欄中的資訊會說明 North Shore-LIJ FIDA LiveWell 對於給付藥物是否有任何規定 以下是 欄所用的代碼意義 : * = 此為 Medicaid 計劃藥物, 適用不同的上訴規定 NM = No mail-order ( 沒有郵購 ): 未透過郵購服務提供 B/D = 所列的藥物可能是 Part B 或 Part D LA = Limited Availability ( 供應限制 ): 並非所有藥局均提供藥物 ; 或是藥物運送 交遞或病患取得有特殊規定 PA = Prior authorization/approval ( 事先授權 / 核准 ): 您必須在取得藥物前先通過 North Shore-LIJ FIDA LiveWell 或跨學科小組 (IDT) 核准 QL = Quantity limit ( 數量限制 ): 該藥物有數量限制 ST = Step therapy ( 階段式療法 ): 您必須先嘗試其他藥物才能取得該藥物 PA = Prior authorization/approval ( 事先授權 / 核准 ): 您必須在取得藥物前先通過 North Shore-LIJ FIDA LiveWell 或跨學科小組 (IDT) 核准 注意 : 如果藥物名稱旁邊有星號 (*) 註記, 表示該藥物不是 Part D 藥物 此類藥物適用不同的上訴規定 上訴是您認為裁決有誤時, 要求審查並更改給付裁決的正式途徑 例如,North Shore-LIJ FIDA LiveWell 或跨學科小組 (IDT) 可能會決定您需要的藥物不受或不再受 Medicare 或 Medicaid 承保 如果您或您的醫師或其他開立處方者不同意此決定, 您可以上訴 如需上訴辦法說明, 請致電 (855) 聯絡參與者服務部, 或致電 聯絡 獨立消費者倡權網路 (Independent Consumer Advocacy Network, ICAN) 您也可以參閱 參與者手冊 瞭解如何提出裁決上訴 FIDA LiveWell 聯絡 此為免付費專線 如需詳細資訊, 請造訪 NSLIJHealthPlans.com/FIDALiveWell? 10

12 給付藥物清單 ( 依病情列示 ) 藥物名稱 級別 您要支 止痛劑 - 治療疼痛和發炎的藥物 痛風藥 - 治療痛風的藥物 其他 Allopurinol TABS 100 MG, 300 MG COLCRYS TABS.6 MG 2 $0 QL:120 錠 / 30 天 Colchicine w/ Probenecid ULORIC TABS 40 MG, 80 MG 2 $0 ST Probenecid TABS 500 MG Acetaminophen CHEW 80 MG 3 $0 NM, * Acetaminophen 500 MG/15ML LIQD 160 MG/5ML, 3 $0 NM, * APAP 500 LIQD 500 MG/5ML 3 $0 NM, * Acetaminophen SOLN 160 MG/5ML, 80 MG/0.8ML 3 $0 NM, * FEBROL SOLN 325 MG/5ML 3 $0 NM, * ACEPHEN SUPP 120 MG 3 $0 NM, * Acetaminophen SUPP 325 MG, 650 MG 3 $0 NM, * FEVERALL INFANTS SUPP 80 MG 3 $0 NM, * Acetaminophen SUSP 160 MG/5ML, 80 MG/0.8ML 3 $0 NM, * TRIAMINIC FEVER REDUCER P 160 MG/5ML SYRP 3 $0 NM, * Acetaminophen TABS 325 MG, 500 MG 3 $0 NM, * ACETAMINOPHEN 8 HOUR TABS 650 MG 3 $0 NM, * Acetaminophen TBCR 650 MG 3 $0 NM, * Acetaminophen TBDP 160 MG, 80 MG 3 $0 NM, * Aspirin SUPP 300 MG, 600 MG 3 $0 NM, * Aspirin TABS 325 MG, 81 MG 3 $0 NM, * Aspirin TBEC 325 MG, 500 MG, 650 MG 3 $0 NM, * Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide) 3 $0 NM, * Ibuprofen CAPS 200 MG 3 $0 NM, * Ibuprofen CHEW 100 MG 3 $0 NM, * Ibuprofen SUSP 100 MG/5ML, 50 MG/1.25ML 3 $0 NM, * ADVIL JUNIOR STRENGTH TABS 100 MG 3 $0 NM, * Ibuprofen TABS 200 MG 3 $0 NM, * NAPROXEN SODIUM CAPS 220 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 11

13 Naproxen Sodium TABS 220 MG 3 $0 NM, * 非類固醇抗發炎劑 - 治療疼痛和發炎的藥物 Celecoxib CAPS 100 MG, 200 MG, 400 MG, 50 MG QL:60 顆膠囊 / 30 天 Diclofenac Potassium TABS 50 MG Diclofenac Sodium TB MG Diclofenac Sodium TBEC 25 MG, 50 MG, 75 MG Diflunisal TABS 500 MG Etodolac CAPS 200 MG, 300 MG Etodolac TABS 400 MG, 500 MG Etodolac TB MG, 500 MG, 600 MG Flurbiprofen TABS 100 MG, 50 MG Ibuprofen SUSP 100 MG/5ML Ibuprofen TABS 400 MG, 600 MG, 800 MG Ketoprofen CAPS 50 MG, 75 MG MELOXICAM SUSP 7.5 MG/5ML Meloxicam TABS 15 MG, 7.5 MG Nabumetone TABS 500 MG, 750 MG Naproxen SUSP 125 MG/5ML Naproxen TABS 250 MG, 375 MG, 500 MG Naproxen TBEC 375 MG, 500 MG Naproxen Sodium TABS 275 MG, 550 MG Piroxicam CAPS 10 MG, 20 MG Sulindac TABS 150 MG, 200 MG 類鴉片止痛劑 - 治療疼痛的藥物 Acetaminophen w/ Codeine SOLN QL:5000 毫升 / 30 天 Acetaminophen w/ Codeine TABS QL:400 錠 / 30 天 Butorphanol Tartrate SOLN 1 MG/ML, 2 MG/ML Nalbuphine HCl SOLN 10 MG/ML, 20 MG/ML Tramadol HCl TABS 50 MG QL:240 錠 / 30 天 Tramadol-Acetaminophen QL:240 錠 / 30 天 類鴉片止痛劑 CII - 治療疼痛的藥物 Fentanyl 75 MCG/HR PT MCG/HR, 50 MCG/HR, PA, QL:10 片貼布 / 30 天 Fentanyl PT72 12 MCG/HR, 25 MCG/HR QL:10 片貼布 / 30 天 Fentanyl Citrate LPOP 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 2 $0 PA, QL:120 菱形錠劑 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 12

14 FENTORA TABS 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG 2 $0 PA, QL:120 錠 / 30 天 Hydrocodone-Acetaminophen SOLN QL:5400 毫升 / 30 天 Hydrocodone-Acetaminophen TABS QL:360 錠 / 30 天 Hydrocodone-Ibuprofen QL:150 錠 / 30 天 Hydromorphone HCl LIQD 1 MG/ML Hydromorphone HCl SOLN 500 MG/50ML B/D Hydromorphone HCl TABS 2 MG, 4 MG, 8 MG QL:270 錠 / 30 天 Methadone HCl CONC 10 MG/ML QL:120 毫升 / 30 天 Methadone HCl SOLN 10 MG/5ML, 5 MG/5ML QL:600 毫升 / 30 天 Methadone HCl TABS 10 MG, 5 MG QL:240 錠 / 30 天 Morphine Sulfate 50 MG, 60 MG CP24 10 MG, 20 MG, 30 MG, QL:60 顆膠囊 / 30 天 Morphine Sulfate CP MG, 80 MG 2 $0 QL:60 顆膠囊 / 30 天 DURAMORPH SOLN.5 MG/ML, 1 MG/ML B/D MORPHINE SULFATE 20 MG/5ML, 20 MG/ML SOLN 10 MG/5ML, Morphine Sulfate SOLN 2 MG/ML,.5 MG/ML, 1MG/ML, 1 MG/ML, 10 MG/ML, 15 MG/ML, 4 MG/ML, 8 MG/ML Morphine Sulfate SOLN 2 MG/ML,.5 MG/ML, 1MG/ML, 1 MG/ML, 10 MG/ML, 15 MG/ML, 4 MG/ML, 8 MG/ML MORPHINE SULFATE SOLN 2 MG/ML,.5 MG/ ML, 1 MG/ML, 1 MG/ML, 10 MG/ML, 15 MG/ML, 4 MG/ML, 8 MG/ML B/D B/D B/D MORPHINE SULFATE TABS 15 MG, 30 MG QL:180 錠 / 30 天 Morphine Sulfate TBCR 100 MG, 15 MG, 30 MG, QL:90 錠 / 30 天 60 MG Morphine Sulfate TBCR 200 MG QL:60 錠 / 30 天 Morphine Sulfate Beads CP MG, 30 MG, QL:60 顆膠囊 / 30 天 45 MG, 60 MG, 75 MG, 90 MG Oxycodone HCl CAPS 5 MG QL:180 顆膠囊 / 30 天 Oxycodone HCl CONC 100 MG/5ML OXYCODONE HCL SOLN 5 MG/5ML Oxycodone HCl TABS 10 MG, 15 MG, 20 MG, QL:180 錠 / 30 天 30 MG, 5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 13

15 Oxycodone w/ Acetaminophen 2 $0 QL:1800 毫升 / 30 天 Oxycodone w/ Acetaminophen TABS QL:360 錠 / 30 天 Oxycodone w/ Acetaminophen TABS QL:360 錠 / 30 天 麻醉藥 - 麻醉藥物 局部麻醉藥 Lidocaine HCl (Local Anesth.) SOLN.5%, 1%, 1.5%, 2% 抗感染 - 治療感染的藥物 抗菌 - 其他 B/D Amikacin Sulfate SOLN 1 GM/4ML, 500 MG/2ML Gentamicin in Saline Gentamicin Sulfate SOLN 10 MG/ML, 40 MG/ML Neomycin Sulfate TABS 500 MG Paromomycin Sulfate CAPS 250 MG Streptomycin Sulfate SOLR 1 GM Sulfadiazine TABS 500 MG 2 $0 Tobramycin NEBU 300 MG/5ML 2 $0 NM, B/D Tobramycin Sulfate SOLN 1.2 GM/30ML, 10 MG/ ML, 40 MG/ML, 80 MG/2ML Tobramycin Sulfate SOLR 1.2 GM Tobramycin Sulfate in Saline 2 $0 抗感染 - 其他 ALBENZA TABS 200 MG 2 $0 Atovaquone SUSP 750 MG/5ML 2 $0 Aztreonam SOLR 1 GM, 2 GM AZACTAM IN ISO-OSMOTIC DE 2 $0 CAYSTON SOLR 75 MG 2 $0 NM, PA, LA Clindamycin HCl CAPS 150 MG, 300 MG, 75 MG Clindamycin Palmitate Hydrochloride SOLR 75 MG/5ML Clindamycin Phosphate SOLN 150 MG/ML, 300 MG/2ML, 600 MG/4ML, 900 MG/6ML, 9000 MG/60ML Clindamycin Phosphate in D5W Colistimethate Sodium SOLR 150 MG Dapsone TABS 100 MG, 25 MG CUBICIN SOLR 500 MG 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 14

16 INVANZ SOLR 1 GM 2 $0 Imipenem-Cilastatin Ivermectin TABS 3 MG Linezolid SOLN 2 MG/ML 2 $0 ZYVOX SUSR 100 MG/5ML 2 $0 LINEZOLID TABS 600 MG 2 $0 ZYVOX TABS 600 MG 2 $0 Meropenem SOLR 1 GM, 500 MG Methenamine Hippurate TABS 1 GM Metronidazole TABS 250 MG, 500 MG Metronidazole in NaCl ALINIA SUSR 100 MG/5ML 2 $0 ALINIA TABS 500 MG 2 $0 Nitrofurantoin Macrocrystal CAPS 100 MG, 50 MG 2 $0 PA, 如果年滿 65 歲, 每曆年 90 天限制 Nitrofurantoin Monohyd Macro CAPS 100 MG 2 $0 PA, 如果年滿 65 歲, 每曆年 90 天限制 NEBUPENT SOLR 300 MG 2 $0 B/D PENTAM 300 SOLR 300 MG 2 $0 BILTRICIDE TABS 600 MG 2 $0 DARAPRIM TABS 25 MG 2 $0 SYNERCID 2 $0 Sulfamethoxazole-Trimethoprim SIVEXTRO SOLR 200 MG 2 $0 SIVEXTRO TABS 200 MG 2 $0 TYGACIL SOLR 50 MG 2 $0 Trimethoprim TABS 100 MG Vancomycin HCl CAPS 125 MG, 250 MG 2 $0 Vancomycin HCl 5000 MG, 750 MG 抗真菌 - 治療真菌感染的藥物 SOLR 10 GM, 1000 MG, 500 MG, Amphotericin B SOLR 50 MG B/D ABELCET SUSP 5 MG/ML 2 $0 B/D AMBISOME SUSR 50 MG 2 $0 B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 15

17 CANCIDAS SOLR 50 MG, 70 MG 2 $0 Fluconazole SUSR 10 MG/ML, 40 MG/ML Fluconazole TABS 100 MG, 150 MG, 200 MG, 50 MG Fluconazole in Dextrose Fluconazole in NaCl Flucytosine CAPS 250 MG, 500 MG 2 $0 Griseofulvin Microsize SUSP 125 MG/5ML Griseofulvin Microsize TABS 500 MG Griseofulvin Ultramicrosize TABS 125 MG, 250 MG Itraconazole CAPS 100 MG PA Ketoconazole TABS 200 MG PA MYCAMINE SOLR 100 MG, 50 MG 2 $0 Nystatin TABS UNIT NOXAFIL SUSP 40 MG/ML 2 $0 NOXAFIL TBEC 100 MG 2 $0 Terbinafine HCl TABS 250 MG QL:90 錠 / 365 天 Voriconazole SOLR 200 MG Voriconazole SUSR 40 MG/ML 2 $0 Voriconazole TABS 200 MG, 50 MG 2 $0 抗真菌 - 治療瘧疾的藥物 COARTEM 2 $0 Atovaquone-Proguanil HCl TABS Atovaquone-Proguanil HCl TABS Chloroquine Phosphate TABS 250 MG, 500 MG Mefloquine HCl TABS 250 MG PRIMAQUINE PHOSPHATE TABS 26.3 MG 2 $0 Quinine Sulfate CAPS 324 MG PA 抗逆轉錄病毒劑 - 抑制 HIV/AIDS 感染的藥物 ZIAGEN SOLN 20 MG/ML 2 $0 Abacavir Sulfate TABS 300 MG REYATAZ CAPS 150 MG, 200 MG, 300 MG 2 $0 REYATAZ PACK 50 MG 2 $0 TYBOST TABS 150 MG 2 $0 PREZISTA SUSP 100 MG/ML 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 16

18 PREZISTA TABS 150 MG, 600 MG, 75 MG, 800 MG 2 $0 RESCRIPTOR TABS 100 MG, 200 MG 2 $0 Didanosine 400 MG CPDR 125 MG, 200 MG, 250 MG, VIDEX PEDIATRIC SOLR 2 GM, 4 GM 2 $0 TIVICAY TABS 50 MG 2 $0 SUSTIVA CAPS 200 MG, 50 MG 2 $0 SUSTIVA TABS 600 MG 2 $0 VITEKTA TABS 150 MG, 85 MG 2 $0 EMTRIVA CAPS 200 MG 2 $0 EMTRIVA SOLN 10 MG/ML 2 $0 FUZEON SOLR 90 MG 2 $0 NM INTELENCE TABS 100 MG, 200 MG, 25 MG 2 $0 LEXIVA SUSP 50 MG/ML 2 $0 LEXIVA TABS 700 MG 2 $0 CRIXIVAN CAPS 200 MG, 400 MG 2 $0 Lamivudine SOLN 10 MG/ML Lamivudine TABS 150 MG, 300 MG SELZENTRY TABS 150 MG, 300 MG 2 $0 VIRACEPT TABS 250 MG, 625 MG 2 $0 NEVIRAPINE SUSP 50 MG/5ML Nevirapine TABS 200 MG VIRAMUNE XR TB MG 2 $0 Nevirapine TB MG ISENTRESS CHEW 100 MG, 25 MG 2 $0 ISENTRESS PACK 100 MG 2 $0 ISENTRESS TABS 400 MG 2 $0 EDURANT TABS 25 MG 2 $0 NORVIR CAPS 100 MG 2 $0 NORVIR SOLN 80 MG/ML 2 $0 NORVIR TABS 100 MG 2 $0 INVIRASE CAPS 200 MG 2 $0 INVIRASE TABS 500 MG 2 $0 Stavudine CAPS 15 MG, 20 MG, 30 MG, 40 MG Stavudine SOLR 1 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 17

19 VIREAD POWD 40 MG/GM 2 $0 VIREAD TABS 150 MG, 200 MG, 250 MG, 300 MG 2 $0 APTIVUS CAPS 250 MG 2 $0 APTIVUS SOLN 100 MG/ML 2 $0 Zidovudine CAPS 100 MG RETROVIR IV INFUSION SOLN 10 MG/ML 2 $0 Zidovudine SYRP 50 MG/5ML Zidovudine TABS 300 MG 抗逆轉錄病毒綜合藥劑 - 抑制 HIV/AIDS 感染的藥物 EPZICOM 2 $0 Abacavir Sulfate-Lamivudine-Zidovudine 2 $0 TRIUMEQ 2 $0 EVOTAZ 2 $0 PREZCOBIX 2 $0 ATRIPLA 2 $0 STRIBILD 2 $0 COMPLERA 2 $0 TRUVADA 2 $0 QL:30 錠 / 30 天 Lamivudine-Zidovudine 2 $0 KALETRA TABS 2 $0 抗結核劑 - 治療結核病的藥物 Aminosalicylic Acid PACK 4 GM 2 $0 SIRTURO TABS 100 MG 2 $0 PA, LA CAPASTAT SULFATE SOLR 1 GM 2 $0 Cycloserine CAPS 250 MG 2 $0 Ethambutol HCl TABS 100 MG, 400 MG TRECATOR TABS 250 MG 2 $0 Isoniazid SOLN 100 MG/ML Isoniazid SYRP 50 MG/5ML Isoniazid TABS 100 MG, 300 MG RIFATER 2 $0 Pyrazinamide TABS 500 MG Rifabutin CAPS 150 MG Rifampin CAPS 150 MG, 300 MG Rifampin SOLR 600 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 18

20 PRIFTIN TABS 150 MG 2 $0 抗病毒 - 治療病毒感染的藥物 Acyclovir CAPS 200 MG Acyclovir SUSP 200 MG/5ML Acyclovir TABS 400 MG, 800 MG Acyclovir Sodium SOLN 50 MG/ML B/D Acyclovir Sodium SOLR 500 MG B/D Adefovir Dipivoxil TABS 10 MG 2 $0 BARACLUDE SOLN.05 MG/ML 2 $0 Entecavir TABS.5 MG, 1 MG 2 $0 Famciclovir TABS 125 MG, 250 MG, 500 MG Foscarnet Sodium SOLN 24 MG/ML Ganciclovir Sodium SOLR 500 MG B/D EPIVIR HBV SOLN 5 MG/ML 2 $0 Lamivudine (HBV) TABS 100 MG HARVONI 2 $0 NM, PA TAMIFLU CAPS 30 MG, 45 MG, 75 MG 2 $0 TAMIFLU SUSR 6 MG/ML 2 $0 PEG-INTRON REDIPEN KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON KIT 120 MCG/0.5ML, 150MCG/0.5ML, 80 MCG/0.5ML 2 $0 NM, PA 2 $0 NM, PA PEG-INTRON KIT 50 MCG/0.5ML 2 $0 NM, PA Ribavirin (Hepatitis C) CAPS 200 MG NM REBETOL SOLN 40 MG/ML 2 $0 NM Ribavirin (Hepatitis C) TABS 200 MG, 400 MG NM Ribavirin (Hepatitis C) TABS 400 MG, 600 MG 2 $0 NM Ribavirin (Hepatitis C) TABS 400 MG, 600 MG 2 $0 NM MODERIBA 1200 DOSE PACK TABS 600 MG 2 $0 NM Rimantadine Hydrochloride TABS 100 MG SOVALDI TABS 400 MG 2 $0 NM, PA TYZEKA TABS 600 MG 2 $0 Valacyclovir HCl TABS 1000 MG, 500 MG VALCYTE SOLR 50 MG/ML 2 $0 Valganciclovir HCl TABS 450 MG 2 $0 RELENZA DISKHALER AEPB 5 MG/BLISTER 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 19

21 先鋒黴素 - 治療感染的藥物 Cefaclor CAPS 250 MG, 500 MG Cefaclor SUSR 125 MG/5ML, 250 MG/5ML, 375 MG/5ML Cefaclor Monohydrate TB MG 2 $0 Cefadroxil CAPS 500 MG Cefadroxil SUSR 250 MG/5ML, 500 MG/5ML Cefadroxil TABS 1 GM Cefazolin in D5W 2 $0 Cefazolin Sodium 500 MG SOLR 1 GM, 10 GM, 20 GM, Cefdinir CAPS 300 MG Cefdinir SUSR 125 MG/5ML, 250 MG/5ML Cefepime HCl SOLR 1 GM, 2 GM SUPRAX CAPS 400 MG 2 $0 Cefixime CHEW 100 MG, 200 MG 2 $0 Cefixime SUSR 100 MG/5ML, 200 MG/5ML SUPRAX SUSR 500 MG/5ML 2 $0 Cefotaxime Sodium SOLR 1 GM, 2 GM, 500 MG Cefoxitin Sodium SOLR 1 GM, 10 GM, 2 GM Cefpodoxime Proxetil 50 MG/5ML SUSR 100 MG/5ML, Cefpodoxime Proxetil TABS 100 MG, 200 MG Cefprozil SUSR 125 MG/5ML, 250 MG/5ML Cefprozil TABS 250 MG, 500 MG TEFLARO SOLR 400 MG, 600 MG 2 $0 Ceftazidime SOLR 2 GM, 1 GM, 2 GM, 6 GM Ceftazidime SOLR 2 GM, 1 GM, 2 GM, 6 GM CEFTAZIDIME/DEXTROSE 2 $0 Ceftriaxone Sodium SOLR 1 GM, 10 GM, 2 GM, 250 MG, 500 MG Cefuroxime Axetil TABS 250 MG, 500 MG Cefuroxime Sodium 750 MG SOLR 1.5 GM, 7.5 GM, Cephalexin CAPS 250 MG, 500 MG Cephalexin SUSR 125 MG/5ML, 250 MG/5ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 20

22 紅黴素 / 巨環類抗生素 - 治療感染的藥物 AZITHROMYCIN PACK 1 GM Azithromycin SOLR 500 MG Azithromycin SUSR 100 MG/5ML, 200 MG/5ML Azithromycin TABS 250 MG, 500 MG, 600 MG Clarithromycin SUSR 125 MG/5ML, 250 MG/5ML Clarithromycin TABS 250 MG, 500 MG Clarithromycin TB MG Erythromycin Base CPEP 250 MG Erythromycin Base TABS 250 MG, 500 MG Erythromycin Base TBEC 250 MG, 333 MG, 500 MG 2 $0 Erythromycin Ethylsuccinate TABS 400 MG Erythromycin Lactobionate SOLR 500 MG 2 $0 Erythromycin Stearate TABS 250 MG DIFICID TABS 200 MG 2 $0 氟化苯酚酮 - 治療感染的藥物 Ciprofloxacin SOLN 200 MG/20ML, 400 MG/40ML Ciprofloxacin SUSR 250 MG/5ML, 500 MG/5ML Ciprofloxacin HCl TABS 100 MG, 250 MG, 500 MG, 750 MG Ciprofloxacin in D5W SOLN Ciprofloxacin in D5W SOLN Ciprofloxacin-Ciprofloxacin HCl Levofloxacin SOLN 25 MG/ML Levofloxacin TABS 250 MG, 500 MG, 750 MG Levofloxacin in D5W 盤尼西林 - 治療感染的藥物 Amoxicillin CAPS 250 MG, 500 MG Amoxicillin CHEW 125 MG, 250 MG Amoxicillin SUSR 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML Amoxicillin TABS 500 MG, 875 MG Amoxicillin & Pot Clavulanate TB12 Ampicillin CAPS 250 MG, 500 MG Ampicillin SUSR 125 MG/5ML, 250 MG/5ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 21

23 Ampicillin & Sulbactam Sodium Ampicillin Sodium SOLR 1 GM, 10 GM, 125 MG, 2 GM, 250 MG, 500 MG Dicloxacillin Sodium CAPS 250 MG, 500 MG Nafcillin Sodium SOLR 1 GM Nafcillin Sodium SOLR 10 GM, 2 GM 2 $0 Oxacillin Sodium SOLR 1 GM, 2 GM Oxacillin Sodium SOLR 1 GM, 2 GM Oxacillin Sodium SOLR 10 GM 2 $0 BICILLIN L-A SUSP UNIT/2ML, UNIT/4ML, UNIT/ML 2 $0 PENICILLIN G POTASSIUM IN 2 $0 Penicillin G Potassium UNIT SOLR UNIT, Penicillin G Procaine SUSP UNIT/ML 2 $0 Penicillin G Sodium SOLR UNIT Penicillin V Potassium 250 MG/5ML SOLR 125 MG/5ML, Penicillin V Potassium TABS 250 MG, 500 MG Piperacillin Sodium-Tazobactam Sodium 四環素 - 治療感染的藥物 Doxycycline (Monohydrate) CAPS 100 MG, 50 MG Doxycycline (Monohydrate) 50 MG, 75 MG TABS 100 MG, 150 MG, Doxycycline Hyclate CAPS 100 MG, 50 MG Doxycycline Hyclate SOLR 100 MG, 100 MG Doxycycline Hyclate SOLR 100 MG, 100 MG Doxycycline Hyclate TABS 100 MG, 20 MG Minocycline HCl CAPS 100 MG, 50 MG, 75 MG 抗腫瘤劑 - 治療癌症的藥物 烷化基藥劑 HEXALEN CAPS 50 MG 2 $0 TREANDA SOLN 180 MG/2ML, 45 MG/0.5ML 2 $0 NM, B/D TREANDA SOLR 100 MG, 25 MG 2 $0 NM, B/D BUSULFEX SOLN 6 MG/ML 2 $0 B/D BICNU SOLR 100 MG 2 $0 B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 22

24 LEUKERAN TABS 2 MG 2 $0 CYCLOPHOSPHAMIDE CAPS 25 MG, 50 MG 2 $0 B/D Cyclophosphamide SOLR 1 GM, 500 MG 2 $0 B/D Cyclophosphamide SOLR 2 GM B/D Dacarbazine SOLR 200 MG B/D EMCYT CAPS 140 MG 2 $0 Ifosfamide SOLN 1 GM/20ML, 3 GM/60ML B/D Ifosfamide SOLR 1 GM B/D Ifosfamide SOLR 3 GM, 3 GM 2 $0 B/D IFOSFAMIDE SOLR 3 GM, 3 GM 2 $0 B/D LOMUSTINE CAPS 10 MG, 100 MG, 40 MG MUSTARGEN SOLR 10 MG 2 $0 B/D Melphalan HCl SOLR 50 MG 2 $0 B/D 蒽環黴素 Daunorubicin HCl INJ 5 MG/ML B/D Doxorubicin HCl SOLN 2 MG/ML B/D Doxorubicin HCl SOLR 50 MG B/D Doxorubicin HCl Liposomal INJ 2 MG/ML 2 $0 B/D Epirubicin HCl 50 MG/25ML Idarubicin HCl 5 MG/5ML 抗生素 SOLN 200 MG/100ML, SOLN 10 MG/10ML, 20 MG/20ML, B/D 2 $0 B/D Bleomycin Sulfate SOLR 15 UNIT, 30 UNIT B/D Mitomycin SOLR 20 MG, 40 MG, 5 MG B/D 抗代謝物 Azacitidine SUSR 100 MG 2 $0 NM, B/D Cladribine SOLN 1 MG/ML 2 $0 B/D Cytarabine SOLN 20 MG/ML B/D Fludarabine Phosphate SOLN 50 MG/2ML B/D Fludarabine Phosphate SOLR 50 MG B/D Fluorouracil SOLN 1 GM/20ML, 2.5 GM/50ML, 5 GM/100ML, 500 MG/10ML GEMCITABINE SOLN 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML B/D 2 $0 B/D Gemcitabine HCl SOLR 1 GM, 2 GM, 200 MG 2 $0 B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 23

25 PURIXAN SUSP 2000 MG/100ML 2 $0 Mercaptopurine TABS 50 MG Methotrexate Sodium 25 MG/ ML SOLN 1 GM/40ML, B/D Methotrexate Sodium SOLR 1 GM B/D ALIMTA SOLR 100 MG, 500 MG 2 $0 B/D NIPENT SOLR 10 MG 2 $0 B/D TABLOID TABS 40 MG 2 $0 抗有絲分裂 紫杉烷類 Docetaxel CONC 140 MG/7ML, 20 MG/ML, 80 MG/4ML DOCETAXEL CONC 140 MG/7ML, 20 MG/ML, 80 MG/4ML 2 $0 B/D 2 $0 B/D DOCETAXEL SOLN 200 MG/20ML, 80 MG/8ML 2 $0 B/D Paclitaxel CONC 100 MG/16.7ML, 150 MG/25ML, 30 MG/5ML, 300 MG/50ML B/D ABRAXANE 2 $0 B/D 抗有絲分裂 長春花生物鹼類 Vinblastine Sulfate SOLN 1 MG/ML 2 $0 B/D Vincristine Sulfate SOLN 1 MG/ML B/D Vinorelbine Tartrate SOLN 10 MG/ML, 50 MG/5ML B/D 生物反應調節 KADCYLA SOLR 100 MG, 160 MG 2 $0 NM, B/D PROLEUKIN SOLR UNIT 2 $0 NM, B/D BELEODAQ SOLR 500 MG 2 $0 NM, PA AVASTIN SOLN 100 MG/4ML, 400 MG/16ML 2 $0 NM, B/D, LA VELCADE SOLR 3.5 MG 2 $0 NM, B/D YERVOY SOLN 200 MG/40ML, 50 MG/10ML 2 $0 NM, PA LYNPARZA CAPS 50 MG 2 $0 NM, PA, LA IBRANCE CAPS 100 MG, 125 MG, 75 MG 2 $0 NM, PA, LA FARYDAK CAPS 10 MG, 15 MG, 20 MG 2 $0 NM, PA, LA KEYTRUDA SOLN 100 MG/4ML 2 $0 NM, PA KEYTRUDA SOLR 50 MG 2 $0 NM, PA RITUXAN CONC 10 MG/ML 2 $0 NM, PA, LA ISTODAX SOLR 10 MG 2 $0 NM, B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 24

26 HERCEPTIN SOLR 440 MG 2 $0 NM, B/D ERIVEDGE CAPS 150 MG 2 $0 NM, PA, LA ZOLINZA CAPS 100 MG 2 $0 NM, PA 賀爾蒙抗腫瘤劑 ZYTIGA TABS 250 MG 2 $0 NM, PA, LA Anastrozole TABS 1 MG Bicalutamide TABS 50 MG XTANDI CAPS 40 MG 2 $0 NM, PA, LA Exemestane TABS 25 MG Flutamide CAPS 125 MG FASLODEX SOLN 250 MG/5ML 2 $0 B/D Letrozole TABS 2.5 MG Leuprolide Acetate KIT 1 MG/0.2ML NM, PA LUPRON DEPOT KIT 3.75 MG 2 $0 NM, PA LUPRON DEPOT KIT MG 2 $0 NM, PA LUPRON DEPOT-PED 7.5 MG KIT MG, 15 MG, 2 $0 NM, PA Leuprolide Acetate (CPP) (3 Month) KIT MG 2 $0 NM, PA LUPRON DEPOT-PED KIT 30 MG 2 $0 NM, PA DEPO-PROVERA SUSP 400 MG/ML 2 $0 B/D Megestrol Acetate SUSP 40 MG/ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Megestrol Acetate TABS 20 MG, 40 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) MEGACE ES SUSP 625 MG/5ML 2 $0 PA LYSODREN TABS 500 MG 2 $0 NILANDRON TABS 150 MG 2 $0 SOLTAMOX SOLN 10 MG/5ML 2 $0 Tamoxifen Citrate TABS 10 MG, 20 MG FARESTON TABS 60 MG 2 $0 TRELSTAR MIXJECT SUSR MG, 3.75 MG 2 $0 NM, PA 激酶抑制劑 GILOTRIF TABS 20 MG, 30 MG, 40 MG 2 $0 NM, PA, LA INLYTA TABS 1 MG, 5 MG 2 $0 NM, PA, LA BOSULIF TABS 100 MG, 500 MG 2 $0 NM, PA COMETRIQ 2 $0 NM, PA, LA NSLIJHealthPlans.com/FIDALiveWell 頁碼 25

27 其他 COMETRIQ KIT 20 MG 2 $0 NM, PA, LA ZYKADIA CAPS 150 MG 2 $0 NM, PA, LA XALKORI CAPS 200 MG, 250 MG 2 $0 NM, PA, LA TAFINLAR CAPS 50 MG, 75 MG 2 $0 NM, PA, LA SPRYCEL TABS 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG 2 $0 NM, PA TARCEVA TABS 100 MG, 150 MG, 25 MG 2 $0 NM, PA, LA AFINITOR TABS 10 MG, 2.5 MG, 5 MG, 7.5 MG 2 $0 NM, PA AFINITOR DISPERZ TBSO 2 MG, 3 MG, 5 MG 2 $0 NM, PA IMBRUVICA CAPS 140 MG 2 $0 NM, PA, LA ZYDELIG TABS 100 MG, 150 MG 2 $0 NM, PA, LA GLEEVEC TABS 100 MG, 400 MG 2 $0 NM, PA TYKERB TABS 250 MG 2 $0 NM, PA, LA LENVIMA 14MG DAILY DOSE 2 $0 NM, PA, LA LENVIMA 24MG DAILY DOSE 2 $0 NM, PA, LA LENVIMA 10MG DAILY DOSE CPPK 10 MG 2 $0 NM, PA, LA LENVIMA 20MG DAILY DOSE CPPK 10 MG 2 $0 NM, PA, LA TASIGNA CAPS 150 MG, 200 MG 2 $0 NM, PA VOTRIENT TABS 200 MG 2 $0 NM, PA, LA ICLUSIG TABS 15 MG, 45 MG 2 $0 NM, PA, LA STIVARGA TABS 40 MG 2 $0 NM, PA, LA JAKAFI TABS 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 2 $0 NM, PA, LA NEXAVAR TABS 200 MG 2 $0 NM, PA, LA SUTENT CAPS 12.5 MG, 25 MG, 37.5 MG, 50 MG 2 $0 NM, PA MEKINIST TABS.5 MG, 2 MG 2 $0 NM, PA, LA CAPRELSA TABS 100 MG, 300 MG 2 $0 NM, PA, LA ZELBORAF TABS 240 MG 2 $0 NM, PA, LA TRISENOX SOLN 10 MG/10ML 2 $0 B/D TARGRETIN CAPS 75 MG 2 $0 NM, PA Hydroxyurea CAPS 500 MG DROXIA CAPS 200 MG, 300 MG, 400 MG 2 $0 Mitoxantrone HCl CONC 2 MG/ML NM, B/D SYNRIBO SOLR 3.5 MG 2 $0 NM, PA SYLATRON KIT 200 MCG, 300 MCG, 600 MCG 2 $0 NM, PA NSLIJHealthPlans.com/FIDALiveWell 頁碼 26

28 POMALYST CAPS 1 MG, 2 MG, 3 MG, 4 MG 2 $0 NM, PA, LA MATULANE CAPS 50 MG 2 $0 LA Tretinoin (Chemotherapy) CAPS 10 MG 2 $0 鉑基藥劑 Carboplatin SOLN 150 MG/15ML, 450 MG/45ML, 50 MG/5ML, 600 MG/60ML B/D Cisplatin SOLN 100 MG/100ML, 200 MG/200ML, B/D 50 MG/50ML Oxaliplatin SOLN 100 MG/20ML, 50 MG/10ML 2 $0 B/D Oxaliplatin SOLR 100 MG, 50 MG 2 $0 B/D 保護劑 Amifostine Crystalline SOLR 500 MG 2 $0 B/D Dexrazoxane SOLR 250 MG 2 $0 B/D Leucovorin Calcium 350 MG, 50 MG, 500 MG SOLR 100 MG, 200 MG, Leucovorin Calcium TABS 10 MG, 15 MG, 25 MG, 5 MG B/D Levoleucovorin Calcium SOLN 175 MG/17.5ML 2 $0 NM, B/D FUSILEV SOLR 50 MG 2 $0 NM, B/D Mesna SOLN 100 MG/ML B/D MESNEX TABS 400 MG 2 $0 ELITEK SOLR 1.5 MG, 7.5 MG 2 $0 B/D 拓璞異構酵素抑制劑 Etoposide SOLN 1 GM/50ML, 500 MG/25ML B/D Irinotecan HCl SOLN 100 MG/5ML, 40 MG/2ML, 500 MG/25ML B/D Topotecan HCl SOLR 4 MG 2 $0 B/D 心血管藥 - 治療心臟和循環系統的藥物 血管收縮素轉換酶抑制綜合劑 - 治療高血壓的藥物 Amlodipine Besylate-Benazepril HCl CAPS Amlodipine Besylate-Benazepril HCl CAPS QL:30 顆膠囊 / 30 天 Benazepril & Hydrochlorothiazide Captopril & Hydrochlorothiazide Enalapril Maleate & Hydrochlorothiazide Fosinopril Sodium & Hydrochlorothiazide Lisinopril & Hydrochlorothiazide NSLIJHealthPlans.com/FIDALiveWell 頁碼 27

29 Moexipril-Hydrochlorothiazide Quinapril-Hydrochlorothiazide 血管收縮素轉換酶抑制劑 - 治療高血壓的藥物 Benazepril HCl TABS 10 MG, 20 MG, 40 MG, 5 MG Captopril TABS 100 MG, 12.5 MG, 25 MG, 50 MG Enalapril Maleate TABS 10 MG, 2.5 MG, 20 MG, 5 MG Fosinopril Sodium TABS 10 MG, 20 MG, 40 MG Lisinopril TABS 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG Moexipril HCl TABS 15 MG, 7.5 MG Perindopril Erbumine TABS 2 MG, 4 MG, 8 MG Quinapril HCl TABS 10 MG, 20 MG, 40 MG, 5 MG Ramipril CAPS 1.25 MG, 10 MG, 2.5 MG, 5 MG Trandolapril TABS 1 MG, 2 MG, 4 MG 醛固酮受體拮抗劑 - 治療高血壓的藥物 Eplerenone TABS 25 MG, 50 MG Spironolactone TABS 100 MG, 25 MG, 50 MG 甲型交感神經接受體阻斷劑 - 治療高血壓的藥物 Doxazosin Mesylate TABS 1 MG, 2 MG, 4 MG QL:30 錠 / 30 天 Doxazosin Mesylate TABS 8 MG Prazosin HCl CAPS 1 MG, 2 MG, 5 MG Terazosin HCl CAPS 1 MG, 10 MG, 2 MG, 5 MG 血管張力素 II 型受體拮抗綜合劑 - 治療高血壓的藥物 AZOR TABS 2 $0 AZOR TABS 2 $0 QL:30 錠 / 30 天 Amlodipine Besylate-Valsartan TABS Amlodipine Besylate-Valsartan TABS QL:30 錠 / 30 天 Amlodipine-Valsartan-Hydrochlorothiazide TABS Amlodipine-Valsartan-Hydrochlorothiazide TABS QL:30 錠 / 30 天 Amlodipine-Valsartan-Hydrochlorothiazide TABS QL:60 錠 / 30 天 Irbesartan-Hydrochlorothiazide Losartan Potassium & Hydrochlorothiazide TRIBENZOR TABS 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 28

30 TRIBENZOR TABS 2 $0 QL:30 錠 / 30 天 BENICAR HCT 2 $0 Valsartan-Hydrochlorothiazide 血管張力素 II 型受體拮抗劑 - 治療高血壓的藥物 Irbesartan TABS 150 MG, 300 MG, 75 MG Losartan Potassium TABS 100 MG, 25 MG, 50 MG BENICAR TABS 20 MG, 40 MG, 5 MG 2 $0 Valsartan TABS 160 MG, 320 MG, 40 MG, 80 MG 抗心律失常劑 - 控制心律的藥物 Amiodarone HCl SOLN 50 MG/ML, 900 MG/18ML Amiodarone HCl TABS 100 MG, 200 MG, 400 MG Disopyramide Phosphate CAPS 100 MG, 150 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) NORPACE CR CP MG, 150 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) TIKOSYN CAPS 125 MCG, 250 MCG, 500 MCG 2 $0 NM MULTAQ TABS 400 MG 2 $0 Flecainide Acetate TABS 100 MG, 150 MG, 50 MG Mexiletine HCl CAPS 150 MG, 200 MG, 250 MG Propafenone HCl CP MG, 325 MG, 425 MG Propafenone HCl TABS 150 MG, 225 MG, 300 MG Quinidine Gluconate TBCR 324 MG Quinidine Sulfate TABS 200 MG, 300 MG Sotalol HCl Sotalol HCl (AFIB/AFL) 80 MG TABS 120 MG, 160 MG, 240 MG, 80 MG TABS 120 MG, 160 MG, 抗脂 還原酶抑制劑 - 治療高血脂的藥物 Atorvastatin Calcium TABS 10 MG, 20 MG, 40 MG, 80 MG QL:30 錠 / 30 天 Lovastatin TABS 10 MG QL:30 錠 / 30 天 Lovastatin TABS 20 MG QL:120 錠 / 30 天 Lovastatin TABS 40 MG QL:60 錠 / 30 天 Pravastatin Sodium TABS 10 MG, 20 MG, 40 MG, 80 MG QL:30 錠 / 30 天 CRESTOR TABS 10 MG, 20 MG, 40 MG, 5 MG 2 $0 QL:30 錠 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 29

31 Simvastatin 80 MG 抗脂 其他 - 治療高血脂的藥物 TABS 10 MG, 20 MG, 40 MG, 5 MG, Cholestyramine PACK 4 GM Cholestyramine POWD 4 GM/DOSE Cholestyramine Light PACK 4 GM Cholestyramine Light POWD 4 GM/DOSE Choline Fenofibrate CPDR 135 MG, 45 MG WELCHOL PACK 3.75 GM 2 $0 WELCHOL TABS 625 MG 2 $0 Colestipol HCl GRAN 5 GM Colestipol HCl PACK 5 GM Colestipol HCl TABS 1 GM ZETIA TABS 10 MG 2 $0 Fenofibrate TABS 145 MG, 160 MG, 48 MG, 54 MG Fenofibrate Micronized 67 MG CAPS 134 MG, 200 MG, QL:30 錠 / 30 天 Gemfibrozil TABS 600 MG Icosapent Ethyl CAPS 1 GM 2 $0 JUXTAPID CAPS 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG 2 $0 NM, PA, LA KYNAMRO SOSY 200 MG/ML 2 $0 NM, PA Niacin (Antihyperlipidemic) TABS 500 MG Niacin (Antihyperlipidemic) TBCR 1000 MG, 750 MG Niacin (Antihyperlipidemic) TBCR 500 MG QL:90 錠 / 30 天 Omega-3-acid Ethyl Esters 乙型交感神經接受體阻斷劑 / 綜合利尿劑 - 治療高血壓和心臟疾病的藥物 Atenolol & Chlorthalidone Bisoprolol & Hydrochlorothiazide Metoprolol & Hydrochlorothiazide Propranolol & Hydrochlorothiazide 乙型交感神經接受體阻斷劑 - 治療高血壓和心臟疾病的藥物 Acebutolol HCl CAPS 200 MG, 400 MG Atenolol TABS 100 MG, 25 MG, 50 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 30

32 Bisoprolol Fumarate TABS 10 MG, 5 MG Carvedilol 6.25 MG TABS 12.5 MG, 25 MG, MG, Labetalol HCl TABS 100 MG, 200 MG, 300 MG Metoprolol Succinate TB MG QL:45 錠 / 30 天 Metoprolol Succinate TB MG Metoprolol Succinate TB24 25 MG, 50 MG QL:60 錠 / 30 天 Metoprolol Tartrate SOLN 1 MG/ML Metoprolol Tartrate TABS 100 MG, 25 MG, 50 MG Nadolol TABS 20 MG, 40 MG, 80 MG BYSTOLIC TABS 10 MG, 2.5 MG, 20 MG, 5 MG 2 $0 Pindolol TABS 10 MG, 5 MG Propranolol HCl 80 MG Propranolol HCl 40 MG/5ML Propranolol HCl 60 MG, 80 MG CP MG, 160 MG, 60 MG, SOLN 1 MG/ML, 20 MG/5ML, TABS 10 MG, 20 MG, 40 MG, Timolol Maleate TABS 10 MG, 20 MG, 5 MG 鈣離子通道阻斷劑 - 治療高血壓和心臟疾病的藥物 Amlodipine Besylate TABS 10 MG Amlodipine Besylate TABS 2.5 MG, 5 MG QL:45 錠 / 30 天 Diltiazem HCl CP MG, 60 MG, 90 MG Diltiazem HCl CP MG, 180 MG, 240 MG Diltiazem HCl SOLN 125 MG/25ML, 25 MG/5ML, 50 MG/10ML Diltiazem HCl TABS 120 MG, 30 MG, 60 MG, 90 MG Diltiazem HCl Coated Beads CP MG, 180 MG, 240 MG, 300 MG, 360 MG Diltiazem HCl Extended Release Beads CP MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG Felodipine TB24 10 MG Felodipine TB MG QL:30 錠 / 30 天 Felodipine TB24 5 MG QL:60 錠 / 30 天 Isradipine CAPS 2.5 MG, 5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 31

33 Nicardipine HCl CAPS 20 MG, 30 MG Nifedipine TB24 30 MG QL:30 錠 / 30 天 Nifedipine TB24 30 MG QL:60 錠 / 30 天 Nifedipine TB24 60 MG, 90 MG Nimodipine CAPS 30 MG 2 $0 NYMALIZE SOLN 60 MG/20ML 2 $0 Verapamil HCl CP MG, 120 MG, 180 MG, 200 MG, 240 MG, 300 MG VERAPAMIL HCL SR CP MG Verapamil HCl SOLN 2.5 MG/ML Verapamil HCl TABS 120 MG, 40 MG, 80 MG Verapamil HCl TBCR 120 MG, 180 MG, 240 MG 洋地黃苷類 - 治療心臟疾病的藥物 DIGOXIN SOLN.05 MG/ML PA PA ( 若年滿 65 歲以上 ) Digoxin SOLN.25 MG/ML Digoxin TABS.125 MG, 125 MCG QL:30 錠 / 30 天 Digoxin TABS.25 MG, 250 MCG PA PA ( 若年滿 65 歲以上 ) 直接腎素抑制劑 / 綜合劑 - 治療心臟疾病的藥物 TEKTURNA TABS 150 MG 2 $0 QL:30 錠 / 30 天 TEKTURNA TABS 300 MG 2 $0 TEKTURNA HCT TABS 2 $0 TEKTURNA HCT TABS 2 $0 QL:30 錠 / 30 天 TEKTURNA HCT TABS 2 $0 QL:60 錠 / 30 天 利尿劑 - 治療心臟疾病的藥物 Acetazolamide CP MG Acetazolamide TABS 125 MG, 250 MG Amiloride & Hydrochlorothiazide Amiloride HCl TABS 5 MG Bumetanide SOLN.25 MG/ML Bumetanide TABS.5 MG, 1 MG, 2 MG Chlorothiazide TABS 250 MG, 500 MG Chlorthalidone TABS 25 MG, 50 MG Furosemide SOLN 10 MG/ML, 10 MG/ML, 8 MG/ML, 10 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 32

34 其他 Furosemide SOLN 10 MG/ML, 10 MG/ML, 8 MG/ML, 10 MG/ML FUROSEMIDE SOLN 10 MG/ML, 10 MG/ML, 8 MG/ML, 10 MG/ML Furosemide TABS 20 MG, 40 MG, 80 MG Hydrochlorothiazide CAPS 12.5 MG Hydrochlorothiazide TABS 12.5 MG, 25 MG, 50 MG Indapamide TABS 1.25 MG, 2.5 MG Methazolamide TABS 25 MG, 50 MG Methyclothiazide TABS 5 MG Metolazone TABS 10 MG, 2.5 MG, 5 MG Spironolactone & Hydrochlorothiazide Torsemide SOLN 50 MG/5ML Torsemide TABS 10 MG, 100 MG, 20 MG, 5 MG Triamterene & Hydrochlorothiazide CAPS Clonidine HCl.3 MG/24HR PTWK.1 MG/24HR,.2 MG/24HR, Clonidine HCl TABS.1 MG,.2 MG,.3 MG Hydralazine HCl SOLN 20 MG/ML Hydralazine HCl 50 MG TABS 10 MG, 100 MG, 25 MG, DEMSER CAPS 250 MG 2 $0 Midodrine HCl TABS 10 MG, 2.5 MG, 5 MG Minoxidil TABS 10 MG, 2.5 MG RANEXA TB MG, 500 MG 2 $0 硝酸酯 - 治療心臟疾病的藥物 Isosorbide Dinitrate 5 MG TABS 10 MG, 20 MG, 30 MG, Isosorbide Dinitrate TBCR 40 MG Isosorbide Mononitrate TABS 10 MG, 20 MG Isosorbide Mononitrate TB MG, 30 MG, 60 MG Nitroglycerin OINT 2% 2 $0 Nitroglycerin PT24.1 MG/HR,.2 MG/HR,.4 MG/HR,.6 MG/HR NITRO-DUR PT24.3 MG/HR,.8 MG/HR 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 33

35 NITROSTAT SUBL.3 MG,.4 MG,.6 MG 2 $0 肺動脈高壓藥 - 治療肺高血壓的藥物 LETAIRIS TABS 10 MG, 5 MG 2 $0 NM, PA, QL: 30 錠 / 30 天, LA TRACLEER TABS 125 MG 2 $0 NM, PA, QL: 60 錠 / 30 天, LA TRACLEER TABS 62.5 MG 2 $0 NM, PA, QL: 120 錠 / 30 天, LA Macitentan TABS 10 MG 2 $0 NM, PA, QL: 30 錠 / 30 天, LA ADEMPAS 2.5 MG TABS.5 MG, 1 MG, 1.5 MG, 2 MG, 2 $0 NM, PA, QL: 90 錠 / 30 天, LA REVATIO SUSR 10 MG/ML 2 $0 NM, PA, QL: 224 毫升 / 30 天 Sildenafil Citrate (Pulmonary Hypertension) TABS 20 MG REMODULIN SOLN 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML 中樞神經系統藥物 - 治療神經系統失調的藥物 抗焦慮藥 - 治療焦慮的藥物 2 $0 NM, PA, QL:90 錠 / 30 天 NM, B/D, LA Alprazolam TABS.25 MG QL:480 錠 / 30 天 Alprazolam TABS.5 MG QL:240 錠 / 30 天 Alprazolam TABS 1 MG QL:120 錠 / 30 天 Alprazolam TABS 2 MG QL:150 錠 / 30 天 Buspirone HCl TABS 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG Fluvoxamine Maleate TABS 100 MG Fluvoxamine Maleate TABS 25 MG, 50 MG QL:45 錠 / 30 天 Lorazepam CONC 2 MG/ML QL:150 毫升 / 30 天 Lorazepam SOLN 2 MG/ML, 4 MG/ML Lorazepam TABS.5 MG, 1 MG, 2 MG QL:150 錠 / 30 天 抗痙攣藥 - 治療癲癇發作的藥物 Carbamazepine CHEW 100 MG Carbamazepine CP MG, 200 MG, 300 MG Carbamazepine SUSP 100 MG/5ML TEGRETOL SUSP 100 MG/5ML 2 $0 Carbamazepine TABS 200 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 34

36 TEGRETOL TABS 200 MG 2 $0 TEGRETOL-XR TB MG, 200 MG, 400 MG 2 $0 Carbamazepine TB MG, 400 MG ONFI SUSP 2.5 MG/ML 2 $0 PA ONFI TABS 10 MG, 20 MG 2 $0 PA Clonazepam TABS.5 MG QL:240 錠 / 30 天 Clonazepam TABS 1 MG QL:120 錠 / 30 天 Clonazepam TABS 2 MG QL:300 錠 / 30 天 Clonazepam TBDP.125 MG QL:960 錠 / 30 天 Clonazepam TBDP.25 MG QL:480 錠 / 30 天 Clonazepam TBDP.5 MG QL:240 錠 / 30 天 Clonazepam TBDP 1 MG QL:120 錠 / 30 天 Clonazepam TBDP 2 MG QL:300 錠 / 30 天 Clorazepate Dipotassium TABS 15 MG PA, QL:180 錠 / 30 天 Clorazepate Dipotassium TABS 3.75 MG, 7.5 MG PA, QL:120 錠 / 30 天 Diazepam CONC 5 MG/ML PA, QL:240 毫升 / 30 天 Diazepam SOLN 1 MG/ML PA, QL:1200 毫升 / 30 天 Diazepam SOLN 5 MG/ML Diazepam TABS 10 MG, 2 MG, 5 MG PA, QL:120 錠 / 30 天 DIAZEPAM GEL 10 MG, 2.5 MG, 20 MG Divalproex Sodium CPSP 125 MG Divalproex Sodium TB MG, 500 MG Divalproex Sodium TBEC 125 MG, 250 MG, 500 MG APTIOM TABS 200 MG 2 $0 QL:180 錠 / 30 天 APTIOM TABS 400 MG 2 $0 QL:90 錠 / 30 天 APTIOM TABS 600 MG 2 $0 QL:60 錠 / 30 天 APTIOM TABS 800 MG 2 $0 QL:30 錠 / 30 天 Ethosuximide CAPS 250 MG Ethosuximide SOLN 250 MG/5ML PEGANONE TABS 250 MG 2 $0 POTIGA TABS 200 MG 2 $0 QL:180 錠 / 30 天 POTIGA TABS 300 MG, 400 MG 2 $0 QL:90 錠 / 30 天 POTIGA TABS 50 MG 2 $0 Felbamate SUSP 600 MG/5ML 2 $0 Felbamate TABS 400 MG, 600 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 35

37 Gabapentin CAPS 100 MG QL:1080 顆膠囊 / 30 天 Gabapentin CAPS 300 MG QL:360 顆膠囊 / 30 天 Gabapentin CAPS 400 MG QL:270 顆膠囊 / 30 天 Gabapentin SOLN 250 MG/5ML QL:2160 毫升 / 30 天 Gabapentin TABS 600 MG QL:180 錠 / 30 天 Gabapentin TABS 800 MG QL:120 錠 / 30 天 VIMPAT SOLN 10 MG/ML 2 $0 QL:1200 毫升 / 30 天 VIMPAT SOLN 200 MG/20ML 2 $0 VIMPAT TABS 100 MG, 150 MG, 200 MG 2 $0 QL:60 錠 / 30 天 VIMPAT TABS 50 MG 2 $0 QL:180 錠 / 30 天 Lamotrigine CHEW 25 MG, 5 MG Lamotrigine TABS 100 MG, 150 MG, 200 MG, 25 MG Lamotrigine TB MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG Levetiracetam SOLN 100 MG/ML, 500 MG/5ML Levetiracetam TABS 1000 MG, 250 MG, 500 MG, 750 MG Levetiracetam TB MG, 750 MG LEVETIRACETAM 2 $0 CELONTIN CAPS 300 MG 2 $0 Oxcarbazepine SUSP 300 MG/5ML Oxcarbazepine TABS 150 MG, 300 MG, 600 MG FYCOMPA TABS 10 MG, 12 MG, 8 MG 2 $0 PA, QL:30 錠 / 30 天 FYCOMPA TABS 2 MG 2 $0 PA, QL:180 錠 / 30 天 FYCOMPA TABS 4 MG 2 $0 PA, QL:90 錠 / 30 天 FYCOMPA TABS 6 MG 2 $0 PA, QL:60 錠 / 30 天 Phenobarbital ELIX 20 MG/5ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Phenobarbital TABS 100 MG, 15 MG, 16.2 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG Phenobarbital Sodium 65 MG/ML PHENOBARBITAL SODIUM 65 MG/ML SOLN 130 MG/ML, SOLN 130 MG/ML, Phenytoin CHEW 50 MG Phenytoin CHEW 50 MG 2 $0 2 $0 PA PA ( 若年滿 65 歲以上 ) 2 $0 PA PA ( 若年滿 65 歲以上 ) 2 $0 PA PA ( 若年滿 65 歲以上 ) NSLIJHealthPlans.com/FIDALiveWell 頁碼 36

38 Phenytoin SUSP 125 MG/5ML DILANTIN-125 SUSP 125 MG/5ML 2 $0 Phenytoin Sodium SOLN 50 MG/ML Phenytoin Sodium Extended CAPS 100 MG, 200 MG, 30 MG, 300 MG Phenytoin Sodium Extended CAPS 100 MG, 200 MG, 300 MG LYRICA CAPS 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 2 $0 2 $0 QL:120 顆膠囊 / 30 天 LYRICA CAPS 200 MG 2 $0 QL:90 顆膠囊 / 30 天 LYRICA CAPS 225 MG, 300 MG 2 $0 QL:60 顆膠囊 / 30 天 LYRICA SOLN 20 MG/ML 2 $0 QL:946 毫升 / 30 天 Primidone TABS 250 MG, 50 MG BANZEL SUSP 40 MG/ML 2 $0 PA BANZEL TABS 200 MG, 400 MG 2 $0 PA GABITRIL TABS 12 MG, 16 MG 2 $0 Tiagabine HCl TABS 2 MG, 4 MG Topiramate CPSP 15 MG, 25 MG Topiramate TABS 100 MG, 200 MG, 25 MG, 50 MG Valproate Sodium SOLN 500 MG/5ML Valproate Sodium SYRP 250 MG/5ML Valproic Acid CAPS 250 MG SABRIL PACK 500 MG 2 $0 NM, PA, QL:180 封包 / 30 天, LA SABRIL TABS 500 MG 2 $0 NM, PA, QL:180 錠 / 30 天, LA Zonisamide CAPS 100 MG, 25 MG, 50 MG 抗癡呆劑 - 治療癡呆症和記憶力衰退的藥物 Donepezil Hydrochloride TABS 10 MG, 23 MG Donepezil Hydrochloride TABS 5 MG QL:30 錠 / 30 天 Donepezil Hydrochloride TBDP 10 MG Donepezil Hydrochloride TBDP 5 MG QL:30 錠 / 30 天 Galantamine Hydrobromide CP24 16 MG, 8 MG QL:30 顆膠囊 / 30 天 Galantamine Hydrobromide CP24 24 MG Galantamine Hydrobromide SOLN 4 MG/ML Galantamine Hydrobromide TABS 12 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 37

39 Galantamine Hydrobromide TABS 4 MG QL:180 錠 / 30 天 Galantamine Hydrobromide TABS 8 MG QL:90 錠 / 30 天 NAMENDA XR TITRATION PACK 2 $0 PA, PA 若 < 30 歲 NAMENDA XR CP24 14 MG, 21 MG, 28 MG, 7 MG 2 $0 PA, PA 若 < 30 歲 NAMENDA SOLN 10 MG/5ML 2 $0 PA, PA 若 < 30 歲 Memantine HCl TABS 10 MG, 5 MG PA, PA 若 < 30 歲 NAMENDA TABS 10 MG, 5 MG 2 $0 PA, PA 若 < 30 歲 EXELON 9.5 MG/24HR PT MG/24HR, 4.6 MG/24HR, Rivastigmine Tartrate CAPS 1.5 MG, 3 MG, 4.5 MG, 6 MG 抗憂鬱劑 - 治療憂鬱的藥物 Amitriptyline HCl TABS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 2 $0 QL:30 片貼布 / 30 天 Amoxapine TABS 100 MG, 150 MG, 25 MG, 50 MG Bupropion HCl TABS 100 MG, 75 MG Bupropion HCl TB MG, 150 MG, 200 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Bupropion HCl TB MG QL:90 錠 / 30 天 Bupropion HCl TB MG QL:30 錠 / 30 天 Citalopram Hydrobromide SOLN 10 MG/5ML Citalopram Hydrobromide TABS 10 MG, 20 MG QL:45 錠 / 30 天 Citalopram Hydrobromide TABS 40 MG QL:30 錠 / 30 天 Clomipramine HCl CAPS 25 MG, 50 MG, 75 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Desipramine HCl TABS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG Desvenlafaxine Succinate TB MG, 50 MG 2 $0 QL:30 錠 / 30 天 PRISTIQ TB24 25 MG 2 $0 QL:30 錠 / 30 天 Doxepin HCl CAPS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Doxepin HCl CONC 10 MG/ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Duloxetine HCl CPEP 20 MG, 30 MG, 60 MG QL:60 顆膠囊 / 30 天 Escitalopram Oxalate SOLN 5 MG/5ML QL:600 毫升 / 30 天 Escitalopram Oxalate TABS 10 MG, 5 MG QL:45 錠 / 30 天 Escitalopram Oxalate TABS 20 MG QL:60 錠 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 38

40 Fluoxetine HCl CAPS 10 MG QL:30 顆膠囊 / 30 天 Fluoxetine HCl CAPS 20 MG QL:120 顆膠囊 / 30 天 Fluoxetine HCl CAPS 40 MG Fluoxetine HCl SOLN 20 MG/5ML Fluoxetine HCl TABS 10 MG QL:45 錠 / 30 天 Fluoxetine HCl TABS 20 MG Imipramine HCl TABS 10 MG, 25 MG, 50 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) MARPLAN TABS 10 MG 2 $0 QL:180 錠 / 30 天 Levomilnacipran HCl 2 $0 Levomilnacipran HCl CP MG, 80 MG 2 $0 QL:30 顆膠囊 / 30 天 Levomilnacipran HCl CP24 20 MG 2 $0 QL:180 顆膠囊 / 30 天 Levomilnacipran HCl CP24 40 MG 2 $0 QL:90 顆膠囊 / 30 天 Maprotiline HCl TABS 25 MG, 50 MG, 75 MG Mirtazapine TABS 15 MG, 7.5 MG QL:45 錠 / 30 天 Mirtazapine TABS 30 MG, 45 MG Mirtazapine TBDP 15 MG QL:30 錠 / 30 天 Mirtazapine TBDP 30 MG, 45 MG Nefazodone HCl 250 MG, 50 MG TABS 100 MG, 150 MG, 200 MG, Nortriptyline HCl CAPS 10 MG, 25 MG, 50 MG, 75 MG Nortriptyline HCl SOLN 10 MG/5ML Paroxetine HCl SUSP 10 MG/5ML 2 $0 QL:900 毫升 / 30 天 Paroxetine HCl TABS 10 MG, 20 MG, 40 MG QL:45 錠 / 30 天 Paroxetine HCl TABS 30 MG QL:60 錠 / 30 天 Phenelzine Sulfate TABS 15 MG Protriptyline HCl TABS 10 MG, 5 MG Selegiline 9 MG/24HR PT24 12 MG/24HR, 6 MG/24HR, Sertraline HCl CONC 20 MG/ML Sertraline HCl TABS 100 MG 2 $0 PA, QL:30 片貼布 / 30 天 Sertraline HCl TABS 25 MG, 50 MG QL:45 錠 / 30 天 Tranylcypromine Sulfate TABS 10 MG Trazodone HCl TABS 100 MG, 150 MG, 50 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 39

41 Trimipramine Maleate CAPS 100 MG 2 $0 PA, QL:60 顆膠囊 / 30 天,PA ( 若年滿 65 歲 以上 ) Trimipramine Maleate CAPS 25 MG 2 $0 PA, QL:240 顆膠囊 / 30 天,PA ( 若年滿 65 歲 以上 ) Trimipramine Maleate CAPS 50 MG 2 $0 PA, QL:120 顆膠囊 / 30 天,PA ( 若年滿 65 歲 以上 ) Venlafaxine HCl CP MG QL:60 顆膠囊 / 30 天 Venlafaxine HCl CP MG, 75 MG QL:30 顆膠囊 / 30 天 Venlafaxine HCl 50 MG, 75 MG TABS 100 MG, 25 MG, 37.5 MG, Vilazodone HCl 2 $0 Vilazodone HCl TABS 10 MG, 20 MG, 40 MG 2 $0 QL:30 錠 / 30 天 Vortioxetine HBr TABS 10 MG 2 $0 QL:60 錠 / 30 天 Vortioxetine HBr TABS 20 MG 2 $0 QL:30 錠 / 30 天 Vortioxetine HBr TABS 5 MG 2 $0 QL:120 錠 / 30 天 抗帕金森藥物 - 治療帕金森氏症的藥物 Amantadine HCl CAPS 100 MG Amantadine HCl SYRP 50 MG/5ML Amantadine HCl TABS 100 MG APOKYN SOLN 10 MG/ML 2 $0 NM, PA, LA BENZTROPINE MESYLATE SOLN 1 MG/ML Benztropine Mesylate TABS.5 MG, 1 MG, 2 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Bromocriptine Mesylate CAPS 5 MG Bromocriptine Mesylate TABS 2.5 MG Carbidopa-Levodopa TABS CARBIDOPA/LEVODOPA/ENTACA ENTACAPONE TABS 200 MG Pramipexole Dihydrochloride TABS.125 MG,.25 MG,.5 MG,.75 MG, 1 MG, 1.5 MG AZILECT TABS.5 MG, 1 MG 2 $0 Ropinirole Hydrochloride TABS.25 MG,.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG NEUPRO PT24 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 40

42 Selegiline HCl CAPS 5 MG Selegiline HCl TABS 5 MG Trihexyphenidyl HCl ELIX.4 MG/ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Trihexyphenidyl HCl TABS 2 MG, 5 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) 抗精神病藥劑 - 治療精神病的藥物 Aripiprazole SUSR 300 MG, 400 MG 2 $0 QL:1 針注射 / 28 天 ABILIFY MAINTENA SUSR 300 MG, 400 MG 2 $0 QL:1 針注射 / 28 天 Aripiprazole TABS 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG 2 $0 QL:30 錠 / 30 天 ABILIFY DISCMELT TBDP 10 MG 2 $0 QL:60 錠 / 30 天 Asenapine Maleate SUBL 10 MG 2 $0 QL:60 錠 / 30 天 SAPHRIS SUBL 2.5 MG 2 $0 QL:240 錠 / 30 天 Asenapine Maleate SUBL 5 MG 2 $0 QL:120 錠 / 30 天 Chlorpromazine HCl SOLN 25 MG/ML 2 $0 Chlorpromazine HCl 200 MG, 25 MG, 50 MG TABS 10 MG, 100 MG, VERSACLOZ SUSP 50 MG/ML 2 $0 PA, QL:600 毫升 / 30 天 Clozapine TABS 100 MG QL:270 錠 / 30 天 Clozapine TABS 200 MG QL:135 錠 / 30 天 Clozapine TABS 25 MG, 50 MG Clozapine TBDP 100 MG PA, QL:270 錠 / 30 天 Clozapine TBDP 12.5 MG, 25 MG PA CLOZAPINE ODT TBDP 150 MG 2 $0 PA, QL:180 錠 / 30 天 FAZACLO TBDP 150 MG 2 $0 PA, QL:180 錠 / 30 天 CLOZAPINE ODT TBDP 200 MG 2 $0 PA, QL:135 錠 / 30 天 FAZACLO TBDP 200 MG 2 $0 PA, QL:135 錠 / 30 天 Fluphenazine Decanoate SOLN 25 MG/ML Fluphenazine HCl CONC 5 MG/ML Fluphenazine HCl ELIX 2.5 MG/5ML Fluphenazine HCl SOLN 2.5 MG/ML Fluphenazine HCl TABS 1 MG, 10 MG, 2.5 MG, 5 MG Haloperidol TABS.5 MG, 1 MG, 10 MG, 2 MG, 20 MG, 5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 41

43 Haloperidol Decanoate 50 MG/ML SOLN 100 MG/ML, Haloperidol Lactate CONC 2 MG/ML Haloperidol Lactate SOLN 5 MG/ML Iloperidone 2 $0 ST Iloperidone TABS 1 MG, 10 MG, 12 MG, 2 2 $0 ST, QL:60 錠 / 30 天 MG, 4 MG, 6 MG, 8 MG Loxapine Succinate CAPS 10 MG, 25 MG, 5 MG, 50 MG LATUDA TABS 120 MG, 40 MG 2 $0 QL:30 錠 / 30 天 LATUDA TABS 20 MG 2 $0 QL:240 錠 / 30 天 LATUDA TABS 60 MG, 80 MG 2 $0 QL:60 錠 / 30 天 Olanzapine SOLR 10 MG QL:3 支安瓶 / 1 天 Olanzapine TABS 10 MG, 15 MG, 20 MG QL:60 錠 / 30 天 Olanzapine TABS 2.5 MG, 5 MG, 7.5 MG QL:30 錠 / 30 天 Olanzapine TBDP 10 MG, 15 MG, 20 MG QL:60 錠 / 30 天 Olanzapine TBDP 5 MG QL:30 錠 / 30 天 ZYPREXA RELPREVV SUSR 210 MG, 300 MG 2 $0 PA, QL:2 支安瓶 / 28 天 ZYPREXA RELPREVV SUSR 405 MG 2 $0 PA, QL:1 支安瓶 / 28 天 Paliperidone TB MG, 3 MG, 9 MG 2 $0 QL:30 錠 / 30 天 Paliperidone TB24 6 MG 2 $0 QL:60 錠 / 30 天 Paliperidone Palmitate SUSP 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML Perphenazine TABS 16 MG, 2 MG, 4 MG, 8 MG 2 $0 QL:1 針注射 / 28 天 ORAP TABS 1 MG, 2 MG 2 $0 Quetiapine Fumarate TABS 100 MG, 200 MG, QL:90 錠 / 30 天 25 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR TB MG, 200 MG 2 $0 QL:30 錠 / 30 天 SEROQUEL XR TB MG, 400 MG 2 $0 QL:60 錠 / 30 天 SEROQUEL XR TB24 50 MG 2 $0 QL:120 錠 / 30 天 Risperidone SOLN 1 MG/ML QL:240 毫升 / 30 天 Risperidone TABS.25 MG,.5 MG QL:90 錠 / 30 天 Risperidone TABS 1 MG, 2 MG, 3 MG QL:60 錠 / 30 天 Risperidone TABS 4 MG QL:120 錠 / 30 天 Risperidone TBDP.25 MG,.5 MG QL:90 錠 / 30 天 Risperidone TBDP 1 MG, 2 MG, 3 MG QL:60 錠 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 42

44 Risperidone TBDP 4 MG QL:120 錠 / 30 天 Risperidone Microspheres SUSR 12.5 MG, 25 MG, 37.5 MG, 50 MG Thioridazine HCl TABS 10 MG, 100 MG, 25 MG, 50 MG Thiothixene CAPS 1 MG, 10 MG, 2 MG, 5 MG Trifluoperazine HCl 5 MG TABS 1 MG, 10 MG, 2 MG, 2 $0 QL:2 針注射 / 28 天 2 $0 PA PA ( 若年滿 65 歲以上 ) Ziprasidone HCl CAPS 20 MG, 40 MG QL:60 顆膠囊 / 30 天 Ziprasidone HCl CAPS 60 MG, 80 MG QL:90 顆膠囊 / 30 天 GEODON SOLR 20 MG 2 $0 QL:6 毫升 / 3 天 注意力不足過動症 - 治療注意力失調 (ADHD) 症的藥物 Amphetamine-Dextroamphetamine CP24 QL:30 顆膠囊 / 30 天 Amphetamine-Dextroamphetamine CP24 QL:90 顆膠囊 / 30 天 Amphetamine-Dextroamphetamine TABS QL:120 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:144 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:180 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:240 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:360 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:60 錠 / 30 天 Amphetamine-Dextroamphetamine TABS QL:90 錠 / 30 天 STRATTERA CAPS 10 MG, 18 MG, 25 MG 2 $0 QL:120 顆膠囊 / 30 天 STRATTERA CAPS 100 MG, 60 MG, 80 MG 2 $0 QL:30 顆膠囊 / 30 天 STRATTERA CAPS 40 MG 2 $0 QL:60 顆膠囊 / 30 天 Guanfacine HCl (ADHD) TB24 1 MG, 2 MG, 3 MG, 4 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Methylphenidate HCl SOLN 10 MG/5ML QL:900 毫升 / 30 天 Methylphenidate HCl SOLN 5 MG/5ML QL:1800 毫升 / 30 天 Methylphenidate HCl TABS 10 MG, 5 MG QL:180 錠 / 30 天 Methylphenidate HCl TABS 20 MG QL:90 錠 / 30 天 Methylphenidate HCl TBCR 10 MG, 20 MG QL:90 錠 / 30 天 安眠藥 - 治療失眠的藥物 SILENOR TABS 3 MG 2 $0 QL:60 錠 / 30 天 SILENOR TABS 6 MG 2 $0 QL:30 錠 / 30 天 ROZEREM TABS 8 MG 2 $0 QL:30 錠 / 30 天 HETLIOZ CAPS 20 MG 2 $0 NM, PA, LA NSLIJHealthPlans.com/FIDALiveWell 頁碼 43

45 Temazepam CAPS 15 MG PA, QL:60 顆膠囊 / 30 天, 年滿 65 歲每曆 年 90 天限制 Temazepam CAPS 7.5 MG PA, QL:30 顆膠囊 / 30 天, 年滿 65 歲每曆 年 90 天限制 Zolpidem Tartrate TABS 10 MG, 5 MG 2 $0 PA, QL:30 顆錠劑 / 30 天, 年滿 65 歲每曆 年 90 天限制 偏頭痛 - 治療嚴重頭痛的藥物 其他 Dihydroergotamine Mesylate SOLN 1 MG/ML RELPAX TABS 20 MG, 40 MG 2 $0 QL:12 錠 / 30 天 Naratriptan HCl TABS 1 MG, 2.5 MG QL:9 錠 / 30 天 Rizatriptan Benzoate TABS 10 MG, 5 MG QL:18 錠 / 30 天 Rizatriptan Benzoate TBDP 10 MG, 5 MG QL:18 錠 / 30 天 SUMATRIPTAN SOLN 20 MG/ACT QL:12 罐吸入劑 / 30 天 SUMATRIPTAN SOLN 5 MG/ACT QL:24 罐吸入劑 / 30 天 Sumatriptan Succinate SOAJ 6 MG/0.5ML, QL:12 針注射 / 30 天 4 MG/0.5ML SUMATRIPTAN SUCCINATE SOAJ 6 MG/0.5ML, QL:12 針注射 / 30 天 4 MG/0.5ML SUMATRIPTAN SUCCINATE REF SOCT 4 MG/0.5ML, 6 MG/0.5ML QL:12 針注射 / 30 天 Sumatriptan Succinate SOLN 6 MG/0.5ML QL:6 毫升 / 30 天 Sumatriptan Succinate SOSY 6 MG/0.5ML QL:12 針注射 / 30 天 Sumatriptan Succinate 50 MG TABS 100 MG, 25 MG, QL:9 錠 / 30 天 Zolmitriptan TABS 2.5 MG, 5 MG QL:12 錠 / 30 天 Zolmitriptan TBDP 2.5 MG, 5 MG QL:12 錠 / 30 天 NUEDEXTA 2 $0 PA LITHIUM SOLN 8 MEQ/5ML 2 $0 Lithium Carbonate 600 MG CAPS 150 MG, 300 MG, Lithium Carbonate TABS 300 MG Lithium Carbonate TBCR 300 MG, 450 MG Pyridostigmine Bromide TABS 60 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 44

46 Riluzole TABS 50 MG XENAZINE TABS 12.5 MG 2 $0 NM, PA, QL:240 錠 / 30 天, LA XENAZINE TABS 25 MG 2 $0 NM, PA, QL:120 錠 / 30 天, LA 多發性硬化劑 - 治療多發性硬化症的藥物 AMPYRA TB12 10 MG 2 $0 NM, PA, LA GILENYA CAPS.5 MG 2 $0 NM, PA, QL:28 顆膠囊 / 28 天 Glatiramer Acetate SOSY 20 MG/ML 2 $0 NM, PA, QL:30 針劑 / 30 天 COPAXONE SOSY 40 MG/ML 2 $0 NM, PA, QL:12 針劑 / 28 天 BETASERON KIT.3 MG 2 $0 NM, PA, QL:14 針劑 / 28 天 TYSABRI CONC 300 MG/15ML 2 $0 NM, PA, LA 肌肉骨骼治療劑 - 治療肌肉痙攣的藥物 Baclofen TABS 10 MG, 20 MG Dantrolene Sodium CAPS 100 MG, 25 MG, 50 MG Tizanidine HCl TABS 2 MG, 4 MG 嗜睡症 / 猝倒症 - 治療睡眠障礙的藥物 NUVIGIL TABS 150 MG 2 $0 PA, QL:60 錠 / 30 天 Armodafinil TABS 200 MG 2 $0 PA, QL:30 錠 / 30 天 NUVIGIL TABS 250 MG 2 $0 PA, QL:30 錠 / 30 天 NUVIGIL TABS 50 MG 2 $0 PA, QL:150 錠 / 30 天 XYREM SOLN 500 MG/ML 2 $0 PA, QL:540 毫升 / 30 天, LA 精神治療 - 其他 Acamprosate Calcium TBEC 333 MG Buprenorphine HCl SUBL 2 MG, 8 MG PA Buprenorphine HCl-Naloxone HCl Dihydrate PA, QL:120 錠 / 30 天 SUBOXONE 2 $0 PA, QL:120 舌下片 / 30 天 SUBOXONE 2 $0 PA, QL:60 舌下片 / 30 天 Bupropion HCl (Smoking Deterrent) TB MG Diphenhydramine HCl (Sleep) CAPS 50 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 45

47 Diphenhydramine-Acetaminophen (sleep) 3 $0 NM, * Disulfiram TABS 250 MG, 500 MG Doxylamine Succinate (Sleep) TABS 25 MG 3 $0 NM, * Ibuprofen-Diphenhydramine Citrate 3 $0 NM, * Naloxone HCl SOLN.4 MG/ML, 1 MG/ML Naltrexone HCl TABS 50 MG NICOTINE TRANSDERMAL SYST 3 $0 NM, * NICOTROL INHALER INHA 10 MG 2 $0 Nicotine 7 MG/24HR PT24 14 MG/24HR, 21 MG/24HR, 3 $0 NM, * NICOTROL NS SOLN 10 MG/ML 2 $0 Nicotine Polacrilex GUM 2 MG, 4 MG 3 $0 NM, * NICOTINE LOZG 2 MG 3 $0 NM, * Nicotine Polacrilex LOZG 2 MG, 4 MG, 4 MG 3 $0 NM, * NICOTINE POLACRILEX LOZG 2 MG, 4 MG, 4 MG 3 $0 NM, * CHANTIX STARTING MONTH PA 2 $0 PA CHANTIX TABS.5 MG, 1 MG 2 $0 PA CHANTIX CONTINUING MONTH TABS 1 MG 2 $0 PA 內分泌和新陳代謝 - 治療糖尿病和調節賀爾蒙的藥物 雄激素 - 調節男性賀爾蒙的藥物 Oxandrolone TABS 10 MG 2 $0 PA Oxandrolone TABS 2.5 MG PA ANDRODERM PT24 2 MG/24HR, 4 MG/24HR 2 $0 PA, QL:30 片貼布 / 30 天 AXIRON SOLN 30 MG/ACT 2 $0 PA, QL:440 毫升 / 30 天 Testosterone Cypionate 200 MG/ML SOLN 100 MG/ML, PA Testosterone Enanthate SOLN 200 MG/ML PA 抗糖尿病血管注射劑 - 治療糖尿病的藥物 2 $0 TRULICITY SOPN.75 MG/0.5ML, 1.5 MG/0.5ML 2 $0 QL:4 支注射筆 / 28 天 BYDUREON PEN 2 MG 2 $0 QL:4 支注射筆 / 28 天 BYETTA SOPN 10 MCG/0.04ML, 5 MCG/0.02ML 2 $0 QL:1 支注射筆 / 30 天 BYDUREON SUSR 2 MG 2 $0 QL:4 支安瓶 / 28 天 NOVOLOG PENFILL SOCT 100 UNIT/ML 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 46

48 NOVOLOG SOLN 100 UNIT/ML 2 $0 NOVOLOG FLEXPEN SOPN 100 UNIT/ML 2 $0 NOVOLOG MIX 70/30 2 $0 NOVOLOG MIX 70/30 PREFILL 2 $0 LEVEMIR SOLN 100 UNIT/ML 2 $0 LEVEMIR FLEXTOUCH SOPN 100 UNIT/ML 2 $0 LANTUS SOLN 100 UNIT/ML 2 $0 LANTUS SOLOSTAR SOPN 100 UNIT/ML 2 $0 TOUJEO SOLOSTAR SOPN 300 UNIT/ML 2 $0 NOVOLIN N SUSP 100 UNIT/ML 2 $0 未給付 RELION NOVOLIN 70/30 2 $0 未給付 RELION NOVOLIN R SOLN 100 UNIT/ML 2 $0 未給付 RELION HUMULIN R U-500 CONCENTR SOLN 500 UNIT/ML 2 $0 B/D VICTOZA SOPN 18 MG/3ML 2 $0 QL:3 支注射筆 / 30 天 SYMLINPEN 60 SOPN 1500 MCG/1.5ML 2 $0 PA, QL:8 支注射筆 / 30 天 SYMLINPEN 120 SOPN 2700 MCG/2.7ML 2 $0 PA, QL:4 支注射筆 / 30 天 抗糖尿病口服劑 - 治療糖尿病的藥物 Acarbose TABS 100 MG, 25 MG, 50 MG INVOKANA TABS 100 MG 2 $0 QL:90 錠 / 30 天 INVOKANA TABS 300 MG 2 $0 QL:30 錠 / 30 天 INVOKAMET TABS 2 $0 QL:120 錠 / 30 天 INVOKAMET TABS 2 $0 QL:60 錠 / 30 天 FARXIGA TABS 10 MG 2 $0 QL:30 錠 / 30 天 FARXIGA TABS 5 MG 2 $0 QL:60 錠 / 30 天 Glimepiride TABS 1 MG QL:240 錠 / 30 天 Glimepiride TABS 2 MG QL:120 錠 / 30 天 Glimepiride TABS 4 MG QL:60 錠 / 30 天 Glipizide TABS 10 MG QL:120 錠 / 30 天 Glipizide TABS 5 MG QL:240 錠 / 30 天 Glipizide TB24 10 MG QL:60 錠 / 30 天 Glipizide TB MG QL:240 錠 / 30 天 Glipizide TB24 5 MG QL:120 錠 / 30 天 Glipizide-Metformin HCl TABS QL:120 錠 / 30 天 Glipizide-Metformin HCl TABS QL:240 錠 / 30 天 TRADJENTA TABS 5 MG 2 $0 QL:30 錠 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 47

49 JENTADUETO 2 $0 QL:60 錠 / 30 天 Metformin HCl TABS 1000 MG QL:75 錠 / 30 天 Metformin HCl TABS 500 MG QL:150 錠 / 30 天 Metformin HCl TABS 850 MG QL:90 錠 / 30 天 Metformin HCl TB MG QL:120 錠 / 30 天 Metformin HCl TB MG QL:60 錠 / 30 天 Nateglinide TABS 120 MG, 60 MG QL:90 錠 / 30 天 Pioglitazone HCl TABS 15 MG, 30 MG, 45 MG QL:30 錠 / 30 天 Repaglinide TABS.5 MG, 1 MG QL:120 錠 / 30 天 Repaglinide TABS 2 MG QL:240 錠 / 30 天 JANUVIA TABS 100 MG, 25 MG, 50 MG 2 $0 QL:30 錠 / 30 天 JANUMET 2 $0 QL:60 錠 / 30 天 JANUMET XR TB24 2 $0 QL:30 錠 / 30 天 JANUMET XR TB24 2 $0 QL:60 錠 / 30 天 雙磷酸鹽類 - 治療骨質流失的藥物 Alendronate Sodium TABS 10 MG, 40 MG, 5 MG Alendronate Sodium TABS 35 MG, 70 MG QL:4 錠 / 28 天 Ibandronate Sodium TABS 150 MG B/D, QL:1 錠 / 30 天 Pamidronate Disodium SOLN 30 MG/10ML, 6 MG/ ML, 90 MG/10ML B/D Zoledronic Acid CONC 4 MG/5ML NM, B/D Zoledronic Acid SOLN 5 MG/100ML NM, B/D 鈣質受體促效劑 SENSIPAR TABS 30 MG, 90 MG 2 $0 NM, QL:120 錠 / 30 天 SENSIPAR TABS 60 MG 2 $0 NM, QL:60 錠 / 30 天 螯合劑 EXJADE TBSO 125 MG, 250 MG, 500 MG 2 $0 NM, PA, LA FERRIPROX TABS 500 MG 2 $0 NM, PA, LA DEPEN TITRATABS TABS 250 MG 2 $0 Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate SUSP 15 GM/60ML CHEMET CAPS 100 MG 2 $0 SYPRINE CAPS 250 MG 2 $0 避孕劑 - 用於節育的藥物 Desogestrel & Ethinyl Estradiol NSLIJHealthPlans.com/FIDALiveWell 頁碼 48

50 SOLIA Desogestrel-Ethinyl Estradiol (Biphasicl) Desogestrel-Ethinyl Estradiol (Triphasicl) Drospirenone-Ethinyl Estradiol GIANVI OCELLA Ethynodiol Diacet & Eth Estrad NUVARING 2 $0 Levonorgestrel & Eth Estradiol Levonorgestrel (Emergency OC) TABS.75 MG, 1.5 MG Levonorgestrel (Emergency OC) TABS 1.5 MG 3 $0 NM, * Levonorgestrel-Eth Estradiol (Triphasic) Levonorgestrel-Ethinyl Estradiol (91-Day) JOLESSA Medroxyprogesterone Acetate (Contraceptive) SUSP 150 MG/ML Norelgestromin-Ethinyl Estradiol MICROGESTIN FE MICROGESTIN FE 1.5/30 Norethin Acet & Estrad-Fe TABS Norethin Acet & Estrad-Fe TABS Norethindrone & Eth Estradiol NECON 1/50-28 Norethindrone (Contraceptive) TABS.35 MG JOLIVETTE TABS 0.35 MG NORA-BE TABS 0.35 MG Norethindrone Acet & Eth Estra MICROGESTIN 1.5/30 MICROGESTIN 1/20 Norethindrone Acetate-Ethinyl Estradiol-Fe Norethindrone-Eth Estradiol (Biphasicl) 2 $0 Norethindrone-Eth Estradiol (Triphasicl) LEENA NECON 7/7/7 Norgestimate-Ethinyl Estradiol NSLIJHealthPlans.com/FIDALiveWell 頁碼 49

51 MONONESSA Norgestimate-Ethinyl Estradiol (Triphasicl) TRINESSA Norgestrel & Ethinyl Estradiol Ulipristal Acetate TABS 30 MG 2 $0 子宮內膜異位 Danazol CAPS 100 MG, 200 MG, 50 MG SYNAREL SOLN 2 MG/ML 2 $0 酶替代 - 治療缺酶的藥物 FABRAZYME SOLR 35 MG, 5 MG 2 $0 NM, PA, LA LUMIZYME SOLR 50 MG 2 $0 NM, PA, LA MYOZYME SOLR 50 MG 2 $0 NM, PA, LA CYSTADANE 2 $0 NM, LA CARBAGLU TABS 200 MG 2 $0 NM, PA, LA CYSTAGON CAPS 150 MG, 50 MG 2 $0 NM, PA, LA CERDELGA CAPS 84 MG 2 $0 NM, PA NAGLAZYME SOLN 1 MG/ML 2 $0 NM, PA, LA RAVICTI LIQD 1.1 GM/ML 2 $0 NM, PA Imiglucerase SOLR 200 UNIT 2 $0 NM, PA, LA CEREZYME SOLR 400 UNIT 2 $0 NM, PA, LA ALDURAZYME SOLN 2.9 MG/5ML 2 $0 NM, PA, LA Levocarnitine (Metabolic Modifiers) SOLN 1 B/D GM/10ML, 200 MG/ML Levocarnitine (Metabolic Modifiers) TABS 330 MG B/D ZAVESCA CAPS 100 MG 2 $0 NM, PA, LA ORFADIN CAPS 10 MG, 2 MG, 5 MG 2 $0 NM, PA, LA ADAGEN SOLN 250 UNIT/ML 2 $0 NM, PA, LA KUVAN PACK 100 MG, 500 MG 2 $0 NM, PA, LA KUVAN TBSO 100 MG 2 $0 NM, PA, LA Sodium Phenylbutyrate POWD 3 GM/TSP 2 $0 NM 雌激素 - 調節女性賀爾蒙的藥物 Estradiol PTWK.025 MG/24HR,.05 MG/24HR, 2 $0 PA PA.06 MG/24HR,.075 MG/24HR,.1 MG/24HR, 37.5 MCG/24HR ( 若年滿 65 歲以上 ) Estradiol TABS.5 MG, 1 MG, 2 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) NSLIJHealthPlans.com/FIDALiveWell 頁碼 50

52 Estradiol Vaginal CREA.1 MG/GM 2 $0 VAGIFEM TABS 10 MCG 2 $0 DELESTROGEN OIL 10 MG/ML 2 $0 Estradiol Valerate OIL 20 MG/ML, 40 MG/ML Norethindrone Acetate-Ethinyl Estradiol 2 $0 PA PA ( 若年滿 65 歲以上 ) 糖皮質激素 - 治療發炎的藥物 Cortisone Acetate TABS 25 MG Dexamethasone CONC 1 MG/ML Dexamethasone ELIX.5 MG/5ML Dexamethasone SOLN.5 MG/5ML Dexamethasone TABS.5 MG,.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 MG Dexamethasone Sodium Phosphate SOLN 10 MG/ ML, 100 MG/10ML, 120 MG/30ML, 20 MG/5ML Fludrocortisone Acetate TABS.1 MG Hydrocortisone TABS 10 MG, 20 MG, 5 MG Hydrocortisone Sod Succinate SOLR 100 MG Hydrocortisone Sod Succinate SOLR 250 MG 2 $0 Methylprednisolone TABS 16 MG, 32 MG, 4 MG, 8 MG B/D Methylprednisolone Acetate SUSP 40 MG/ML, 80 MG/ML B/D Methylprednisolone Sod Succ SOLR 125 MG, 1 B/D GM, 40 MG Methylprednisolone Sod Succ SOLR 125 MG, 1 B/D GM, 40 MG Prednisolone SOLN 15 MG/5ML B/D Prednisolone Sodium Phosphate 25 MG/5ML, 5 MG/5ML SOLN 15 MG/5ML, B/D Prednisone CONC 5 MG/ML 2 $0 B/D Prednisone SOLN 5 MG/5ML B/D Prednisone TABS 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50 MG 葡萄糖分泌劑 - 治療低血糖的藥物 B/D PROGLYCEM SUSP 50 MG/ML 2 $0 GLUCAGON EMERGENCY KIT KIT 1 MG 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 51

53 GLUCAGEN HYPOKIT SOLR 1 MG 2 $0 KORLYM TABS 300 MG 2 $0 NM, PA, LA 人體成長激素 - 調節腦垂體激素的藥物 其他 NORDITROPIN FLEXPRO SOLN 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML NORDITROPIN NORDIFLEX PEN 30 MG/3ML SOLN 2 $0 NM, PA 2 $0 NM, PA Cabergoline TABS.5 MG Calcitonin (Salmon) SOLN 200 UNIT/ACT FORTICAL SOLN 200 UNIT/ACT 2 $0 MIACALCIN SOLN 200 UNIT/ML 2 $0 B/D XGEVA SOLN 120 MG/1.7ML 2 $0 NM, PA PROLIA SOLN 60 MG/ML 2 $0 NM, QL:1 針劑 / 180 天 SOMATULINE DEPOT SOLN 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML 2 $0 NM, PA INCRELEX SOLN 40 MG/4ML 2 $0 NM, PA, LA Methylergonovine Maleate TABS.2 MG SANDOSTATIN LAR DEPOT 30 MG KIT 10 MG, 20 MG, 2 $0 NM, PA Octreotide Acetate SOLN 100 MCG/ML, 50 MCG/ ML NM, PA Octreotide Acetate SOLN 1000 MCG/ML, 200 MCG/ML, 500 MCG/ML 2 $0 NM, PA SIGNIFOR SOLN.3 MG/ML,.6 MG/ML,.9 MG/ ML 2 $0 NM, PA, LA SOMAVERT SOLR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG Raloxifene HCl TABS 60 MG 副甲狀腺素 - 調節副甲狀腺濃度的藥物 2 $0 NM, PA, LA NATPARA CART 100 MCG, 75 MCG 2 $0 NM, PA Parathyroid Hormone (Recombinant) 25 MCG, 50 MCG CART 2 $0 NM, PA FORTEO SOLN 600 MCG/2.4ML 2 $0 NM, PA, QL:1 支注射筆 / 28 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 52

54 磷結合劑 - 調節鈣磷濃度的藥物 Calcium Acetate (Phosphate Binder) CAPS 667 MG Calcium Acetate (Phosphate Binder) TABS 667 MG RENVELA PACK.8 GM, 2.4 GM 2 $0 RENVELA TABS 800 MG 2 $0 黃體激素 - 調節女性荷爾蒙的藥物 Medroxyprogesterone Acetate TABS 10 MG, 2.5 MG, 5 MG Norethindrone Acetate TABS 5 MG 甲狀腺劑 - 調節甲狀腺濃度的藥物 Levothyroxine Sodium TABS 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG SYNTHROID TABS 100 MCG, 112 MCG, 2 $0 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG LEVOXYL TABS 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID TABS 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG Liothyronine Sodium TABS 25 MCG, 5 MCG, 50 MCG Methimazole TABS 10 MG, 5 MG Propylthiouracil TABS 50 MG 垂體後葉荷爾蒙 - 調節腦垂體激素的藥物 Desmopressin Acetate SOLN 4 MCG/ML Desmopressin Acetate TABS.1 MG,.2 MG DESMOPRESSIN ACETATE SOLN.01% Desmopressin Acetate Spray SOLN.01% Desmopressin Acetate Spray Refrigerated SOLN.01% 腸胃藥 - 治療腸胃功能失調的藥物抗酸劑 Alum & Mag Hydrox-Simethicone, 3 $0 NM, * MAG-AL 3 $0 NM, * ALUMINUM HYDROXIDE SUSP 320 MG/5ML 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 53

55 GAVISCON EXTRA STRENGTH R 3 $0 NM, * Aluminum Hydroxide-Mag Carb, 3 $0 NM, * Aluminum Hydroxide-Mag Trisil 3 $0 NM, * GAVISCON 3 $0 NM, * Calcium Carbonate (Antacid) CHEW 1000 MG, 3 $0 NM, * 400 MG, 420 MG, 500 MG, 750 MG Calcium Carbonate-Mag Hydrox 3 $0 NM, * Calcium Carbonate-Simethicone 3 $0 NM, * MAGNESIUM OXIDE CAPS 400 MG 3 $0 NM, * Magnesium Oxide TABS 250 MG, 400 MG, 420 MG 3 $0 NM, * SODIUM BICARBONATE 3 $0 NM, * 治療腹瀉 Bismuth Subsalicylate CHEW 262 MG 3 $0 NM, * Bismuth Subsalicylate SUSP 262 MG/15ML, 3 $0 NM, * 525 MG/15ML Bismuth Subsalicylate TABS 262 MG 3 $0 NM, * Lactobacillus, 3 $0 NM, * Lactobacillus Rhamnosus (GG) CAPS 10 B CELL 3 $0 NM, * Loperamide HCl LIQD 1 MG/5ML 3 $0 NM, * Loperamide HCl SUSP 1 MG/7.5ML 3 $0 NM, * Loperamide HCl TABS 2 MG 3 $0 NM, * RA PROBIOTIC COMPLEX 3 $0 NM, * RISA-BID PROBIOTIC 3 $0 NM, * FLORASTOR KIDS PACK 250 MG 3 $0 NM, * 止吐藥 - 治療噁心和嘔吐的藥物 EMEND 2 $0 B/D EMEND CAPS 125 MG, 40 MG, 80 MG 2 $0 B/D Dimenhydrinate TABS 50 MG 3 $0 NM, * Dronabinol CAPS 10 MG 2 $0 B/D, QL:60 顆膠囊 / 30 天 Dronabinol CAPS 2.5 MG, 5 MG B/D, QL:60 顆膠囊 / 30 天 Granisetron HCl SOLN.1 MG/ML, 1 MG/ML Granisetron HCl TABS 1 MG B/D Meclizine HCl CHEW 25 MG 3 $0 NM, * Meclizine HCl TABS 12.5 MG, 25 MG Meclizine HCl TABS 25 MG 3 $0 NM, * Metoclopramide HCl SOLN 5 MG/5ML, 5 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 54

56 Metoclopramide HCl TABS 10 MG, 5 MG Ondansetron TBDP 4 MG, 8 MG B/D Ondansetron HCl SOLN 4 MG/2ML, 40 MG/20ML Ondansetron HCl SOLN 4 MG/5ML B/D Ondansetron HCl TABS 24 MG, 4 MG, 8 MG B/D Prochlorperazine SUPP 25 MG Prochlorperazine Edisylate SOLN 5 MG/ML Prochlorperazine Maleate TABS 10 MG, 5 MG Promethazine HCl SOLN 25 MG/ML, 50 MG/ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Promethazine HCl SUPP 12.5 MG, 25 MG, 50 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Promethazine HCl SYRP 6.25 MG/5ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Promethazine HCl TABS 12.5 MG, 25 MG, 50 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) TRANSDERM-SCOP PT72 1 MG/3DAYS 2 $0 PA, QL:10 個貼片 / 30 天,PA ( 若年滿 65 歲以上 ) 解痙藥 - 治療胃痙攣的藥物 Dicyclomine HCl CAPS 10 MG Dicyclomine HCl SOLN 10 MG/5ML Dicyclomine HCl TABS 20 MG CUVPOSA SOLN 1 MG/5ML 2 $0 Glycopyrrolate SOLN 4 MG/20ML Glycopyrrolate TABS 1 MG, 2 MG H2- 受體拮抗劑 - 治療潰瘍和胃酸的藥物 PEPCID AC CHEW 10 MG 3 $0 NM, * Famotidine 40 MG/4ML SOLN 20 MG/2ML, 200 MG/20ML, Famotidine SUSR 40 MG/5ML Famotidine TABS 10 MG, 20 MG 3 $0 NM, * Famotidine TABS 20 MG, 40 MG Famotidine in NaCl AXID AR TABS 75 MG 3 $0 NM, * Ranitidine HCl SOLN 150 MG/6ML, 50 MG/2ML Ranitidine HCl SYRP 15 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 55

57 Ranitidine HCl TABS 150 MG, 300 MG Ranitidine HCl TABS 150 MG, 75 MG 3 $0 NM, * 腸胃炎 瀉藥 Balsalazide Disodium CAPS 750 MG Budesonide CP24 3 MG 2 $0 UCERIS TB24 9 MG 2 $0 Hydrocortisone (Intrarectal) ENEM 100 MG/60ML HYDROCORTISONE ENEM 100 MG/60ML Mesalamine CP GM 2 $0 DELZICOL CPDR 400 MG 2 $0 Mesalamine ENEM 4 GM CANASA SUPP 1000 MG 2 $0 ASACOL HD TBEC 800 MG 2 $0 Mesalamine w/ Cleanser KIT 4 GM DIPENTUM CAPS 250 MG 2 $0 Sulfasalazine TABS 500 MG Sulfasalazine TBEC 500 MG Benzocaine-Docusate Sodium 3 $0 NM, * FLEET BISACODYL ENEM 10 MG/30ML 3 $0 NM, * Bisacodyl SUPP 10 MG 3 $0 NM, * Bisacodyl TBEC 5 MG 3 $0 NM, * Bisacodyl-PEG 3350-Pot Chloride-Sod Bicarb-Sod Chloride EQUALACTIN CHEW 625 MG 3 $0 NM, * Calcium Polycarbophil TABS 625 MG 3 $0 NM, * Corn Dextrin 3 $0 NM, * Docusate Calcium CAPS 240 MG 3 $0 NM, * Docusate Sodium CAPS 100 MG, 50 MG 3 $0 NM, * Docusate Sodium ENEM 283 MG 3 $0 NM, * PEDIA-LAX LIQD 50 MG/15ML 3 $0 NM, * Docusate Sodium LIQD 50 MG/5ML 3 $0 NM, * Docusate Sodium SYRP 60 MG/15ML 3 $0 NM, * Docusate Sodium TABS 100 MG 3 $0 NM, * Fiber 3 $0 NM, * FIBER 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 56

58 NUTRISOURCE FIBER, 3 $0 NM, * Lactulose SOLN 10 GM/15ML Lactulose (Encephalopathy) SOLN 10 GM/15ML Magnesium Citrate SOLN GM/30ML 3 $0 NM, * Magnesium Hydroxide SUSP 1200 MG/15ML 3 $0 NM, * MILK OF MAGNESIA CONCENTR 2400 MG/10ML SUSP 3 $0 NM, * Magnesium Oxide (Laxative) TABS 500 MG 3 $0 NM, * Magnesium Sulfate (Laxative) 3 $0 NM, * Methylcellulose (Laxative) 3 $0 NM, * Methylcellulose (Laxative) TABS 500 MG 3 $0 NM, * RELISTOR SOLN 12 MG/0.6ML, 8 MG/0.4ML 2 $0 PA Mineral Oil, 3 $0 NM, * MINERAL OIL, 3 $0 NM, * PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic Acid 2 $0 PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate GOLYTELY 2 $0 PEG 3350/ELECTROLYTES PEG-3350/ELECTROLYTES PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride NULYTELY/FLAVOR PACKS 2 $0 Polyethylene Glycol 3350, METAMUCIL 3 $0 NM, * Psyllium CAPS 520 MG 3 $0 NM, * KONSYL PACK 100%, 28.3% 3 $0 NM, * METAMUCIL SMOOTH TEXTURE PACK 28% 3 $0 NM, * HYDROCIL INSTANT PACK 95% 3 $0 NM, * Psyllium POWD 100%, 28.3%, 30%, 30.9%, 33%, 48.57%, 49%, 58.6%, 68%, 95% 3 $0 NM, * KONSYL-D POWD 52.3% 3 $0 NM, * KONSYL POWD 60.3%, 71.67% 3 $0 NM, * METAMUCIL MULTIHEALTH FIB POWD 63% 3 $0 NM, * SENNA SYRP 176 MG/5ML 3 $0 NM, * Sennosides CAPS 8.6 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 57

59 其他 Sennosides SYRP 8.8 MG/5ML 3 $0 NM, * Sennosides TABS 15 MG, 17.2 MG, 25 MG, 8.6 MG 3 $0 NM, * Sennosides-Docusate Sodium 3 $0 NM, * SENNA PROMPT 3 $0 NM, * Sodium Phosphates 3 $0 NM, * SUPREP BOWEL PREP 2 $0 Wheat Dextrin-Calcium 3 $0 NM, * Alosetron HCl TABS.5 MG, 1 MG 2 $0 PA Cromolyn Sodium (Mastocytosis) CONC 100 MG/5ML 2 $0 Diphenoxylate w/ Atropine LINZESS CAPS 145 MCG 2 $0 QL:60 顆膠囊 / 30 天 LINZESS CAPS 290 MCG 2 $0 QL:30 顆膠囊 / 30 天 Loperamide HCl CAPS 2 MG AMITIZA CAPS 24 MCG, 8 MCG 2 $0 QL:60 顆膠囊 / 30 天 Misoprostol TABS 100 MCG, 200 MCG MOVANTIK TABS 12.5 MG 2 $0 QL:60 錠 / 30 天 MOVANTIK TABS 25 MG 2 $0 QL:30 錠 / 30 天 XIFAXAN TABS 550 MG 2 $0 PA SUCRAID SOLN 8500 UNIT/ML 2 $0 LA Sucralfate TABS 1 GM GATTEX KIT 5 MG 2 $0 NM, PA, LA Ursodiol CAPS 300 MG Ursodiol TABS 250 MG, 500 MG 胰腺酶 CREON 2 $0 ZENPEP 2 $0 氫離子幫浦抑制劑 - 治療潰瘍和胃酸的藥物 DEXILANT CPDR 30 MG, 60 MG 2 $0 QL:30 顆膠囊 / 30 天 Esomeprazole Magnesium CPDR 20 MG, 40 MG 2 $0 QL:30 顆膠囊 / 30 天 NEXIUM PACK 10 MG, 20 MG, 40 MG 2 $0 QL:30 封包 / 30 天 NEXIUM PACK 2.5 MG, 5 MG 2 $0 Esomeprazole Sodium SOLR 20 MG, 40 MG Famotidine-Calcium Carbonate-Magnesium Hydroxide 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 58

60 Lansoprazole CPDR 15 MG 3 $0 NM, * Omeprazole CPDR 10 MG, 40 MG QL:30 顆膠囊 / 30 天 Omeprazole CPDR 20 MG QL:60 顆膠囊 / 30 天 OMEPRAZOLE TBEC 20 MG 3 $0 NM, * PRILOSEC OTC TBEC 20 MG 3 $0 NM, * Omeprazole-Sodium Bicarbonate 3 $0 NM, * Pantoprazole Sodium TBEC 20 MG, 40 MG QL:30 錠 / 30 天 泌尿生殖藥物 - 治療生殖器和尿道疾病的藥物 良性攝護腺肥大藥物 - 治療攝護腺肥大的藥物 其他 Alfuzosin HCl TB24 10 MG QL:30 錠 / 30 天 AVODART CAPS.5 MG 2 $0 QL:30 顆膠囊 / 30 天 JALYN 2 $0 QL:30 顆膠囊 / 30 天 Finasteride TABS 5 MG Tamsulosin HCl CAPS.4 MG Bethanechol Chloride TABS 10 MG, 25 MG, 5 MG, 50 MG ELMIRON CAPS 100 MG 2 $0 POTASSIUM CITRATE ER 540 MG 泌尿抗痙攣 - 治療尿失禁的藥物 TBCR 1080 MG, TOVIAZ TB24 4 MG, 8 MG 2 $0 QL:30 錠 / 30 天 Mirabegron TB24 25 MG 2 $0 QL:60 錠 / 30 天 Mirabegron TB24 50 MG 2 $0 QL:30 錠 / 30 天 Oxybutynin Chloride SYRP 5 MG/5ML Oxybutynin Chloride TABS 5 MG Oxybutynin Chloride TB24 10 MG, 15 MG QL:60 錠 / 30 天 Oxybutynin Chloride TB24 5 MG QL:30 錠 / 30 天 VESICARE TABS 10 MG, 5 MG 2 $0 QL:30 錠 / 30 天 Tolterodine Tartrate CP24 2 MG, 4 MG QL:30 顆膠囊 / 30 天 Tolterodine Tartrate TABS 1 MG, 2 MG Trospium Chloride TABS 20 MG QL:60 錠 / 30 天 陰道抗感染 Clindamycin Phosphate Vaginal CREA 2% Clotrimazole Vaginal CREA 1%, 2% 3 $0 NM, * Metronidazole Vaginal GEL.75% NSLIJHealthPlans.com/FIDALiveWell 頁碼 59

61 VANDAZOLE GEL.75% Miconazole Nitrate Vaginal 3 $0 NM, * Miconazole Nitrate Vaginal CREA 2%, 4% 3 $0 NM, * Miconazole Nitrate Vaginal SUPP 100 MG 3 $0 NM, * Povidone-Iodine Vaginal SOLN.3% 3 $0 NM, * Terconazole Vaginal CREA.4%,.8% ZAZOLE CREA.8% Terconazole Vaginal SUPP 80 MG Tioconazole Vaginal OINT 6.5% 3 $0 NM, * 血液 - 治療血液疾病的藥物 抗凝血劑 - 血液稀釋劑 ELIQUIS TABS 2.5 MG, 5 MG 2 $0 PRADAXA CAPS 150 MG, 75 MG 2 $0 Enoxaparin Sodium SOLN 100 MG/ML, 2 $0 120 MG/0.8ML, 150 MG/ML Enoxaparin Sodium SOLN 30 MG/0.3ML, 300 MG/3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML Fondaparinux Sodium SOLN 10 MG/0.8ML, 2 $0 5 MG/0.4ML, 7.5 MG/0.6ML Fondaparinux Sodium SOLN 2.5 MG/0.5ML HEPARIN SODIUM/NACL 0.45% 2 $0 HEPARIN SODIUM/D5W 2 $0 Heparin Sodium (Porcine) SOLN 1000 UNIT/ML, UNIT/ML, UNIT/ML, 5000 UNIT/ML HEPARIN SODIUM 2500 UNIT/ML SOLN 2000 UNIT/ML, B/D 2 $0 B/D XARELTO STARTER PACK 2 $0 XARELTO TABS 10 MG, 15 MG, 20 MG 2 $0 Warfarin Sodium TABS 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG COUMADIN TABS 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG 造血生長因子 PROCRIT SOLN UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ML 2 $0 2 $0 NM, PA NSLIJHealthPlans.com/FIDALiveWell 頁碼 60

62 鐵質 NEUPOGEN SOLN 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML 2 $0 NM, PA NEUMEGA SOLR 5 MG 2 $0 NM MOZOBIL SOLN 24 MG/1.2ML 2 $0 NM, PA LEUKINE SOLR 250 MCG 2 $0 NM, PA GRANIX SOSY 300 MCG/0.5ML, 480 MCG/0.8ML 2 $0 NM, PA IRON CHEWS PEDIATRIC CHEW 15 MG 3 $0 NM, * Carbonyl Iron SUSP 15 MG/1.25ML 3 $0 NM, * VITAMIN B12/FOLIC ACID 3 $0 NM, * INTEGRA 3 $0 NM, * FERRIMIN 150 TABS 150 MG 3 $0 NM, * Ferrous Fumarate TABS 325 MG, 29 MG, 90 MG 3 $0 NM, * FERROUS FUMARATE TABS 325 MG, 29 MG, 3 $0 NM, * 90 MG Ferrous Gluconate TABS 240 MG, 324 MG, 225 MG, 3 $0 NM, * 324 MG FERROUS GLUCONATE TABS 240 MG, 324 MG, 225 MG, 324 MG 3 $0 NM, * IRON TABS 256 MG 3 $0 NM, * Ferrous Sulfate ELIX 220 MG/5ML 3 $0 NM, * FERROUS SULFATE LIQD 220 MG/5ML 3 $0 NM, * Ferrous Sulfate SOLN 15 MG/ML 3 $0 NM, * FERROUS SULFATE SYRP 300 MG/5ML 3 $0 NM, * Ferrous Sulfate TABS 27 MG, 325 MG 3 $0 NM, * IRON TABS 90 MG 3 $0 NM, * Ferrous Sulfate TBCR 45 MG, 47.5 MG, 50 MG, 140 MG FERROUS SULFATE TBCR 45 MG, 47.5 MG, 50 MG, 140 MG 3 $0 NM, * 3 $0 NM, * Ferrous Sulfate TBEC 325 MG, 324 MG 3 $0 NM, * FERROUS SULFATE TBEC 325 MG, 324 MG 3 $0 NM, * Ferrous Sulfate Dried TABS 200 MG 3 $0 NM, * SLOW RELEASE IRON TBCR 140 MG 3 $0 NM, * SM SLOW RELEASE IRON TBCR 143 MG 3 $0 NM, * Ferrous Sulfate Dried TBCR 160 MG, 45 MG 3 $0 NM, * FOLITAB $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 61

63 其他 FOLGARD 3 $0 NM, * Folic Acid-Vitamin B6-Vitamin B12 3 $0 NM, * MYKIDZ IRON 10 SUSP 15 MG/1.5ML 3 $0 NM, * FERRETTS IPS SOLN 40 MG/15ML 3 $0 NM, * Iron-Vitamin C 3 $0 NM, * Iron-Vitamin C-Vitamin B12-Folic Acid 3 $0 NM, * Polysaccharide Iron Complex CAPS 150 MG, 3 $0 NM, * 200 MG PROFE CAPS 180 MG 3 $0 NM, * IRON UP LIQD 15 MG/0.5ML 3 $0 NM, * NOVAFERRUM PEDIATRIC DROP 15 MG/ML LIQD 3 $0 NM, * NOVAFERRUM $0 NM, * Anagrelide HCl CAPS.5 MG, 1 MG CINRYZE SOLR 500 UNIT 2 $0 NM, PA, LA Cilostazol TABS 100 MG, 50 MG PROMACTA TABS 12.5 MG 2 $0 NM, PA, QL:360 錠 / 30 天, LA PROMACTA TABS 25 MG 2 $0 NM, PA, QL:180 錠 / 30 天, LA PROMACTA TABS 50 MG 2 $0 NM, PA, QL:90 錠 / 30 天, LA PROMACTA TABS 75 MG 2 $0 NM, PA, QL:60 錠 / 30 天, LA FIRAZYR SOLN 30 MG/3ML 2 $0 NM, PA Pentoxifylline TBCR 400 MG Tranexamic Acid SOLN 100 MG/ML Tranexamic Acid TABS 650 MG 血小板凝聚抑制劑 AGGRENOX 2 $0 ASPIRIN/DIPYRIDAMOLE Clopidogrel Bisulfate TABS 75 MG EFFIENT TABS 10 MG, 5 MG 2 $0 Ticagrelor TABS 90 MG 2 $0 ZONTIVITY TABS 2.08 MG 2 $0 免疫調節劑 - 治療免疫系統失調的藥物 NSLIJHealthPlans.com/FIDALiveWell 頁碼 62

64 疾病緩和抗風濕藥物 (DMARDS) - 治療類風濕關節炎的藥物 HUMIRA PEN PNKT 40 MG/0.8ML 2 $0 NM, PA HUMIRA PEN-CROHNS DISEASE 40 MG/0.8ML PNKT HUMIRA PEN-PSORIASIS STAR PNKT 40 MG/0.8ML HUMIRA PSKT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML 2 $0 NM, PA 2 $0 NM, PA 2 $0 NM, PA CIMZIA KIT 200 MG, 200 MG/ML 2 $0 NM, PA CIMZIA STARTER KIT KIT 200 MG/ML 2 $0 NM, PA Hydroxychloroquine Sulfate TABS 200 MG REMICADE SOLR 100 MG 2 $0 NM, PA Leflunomide TABS 10 MG, 20 MG Methotrexate Sodium TABS 2.5 MG 免疫血球素 GAMASTAN S/D 2 $0 NM, B/D FLEBOGAMMA DIF SOLN.5 GM/10ML, 10%, 2 $0 NM, PA 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML FLEBOGAMMA SOLN.5 GM/10ML, 5% 2 $0 NM, PA OCTAGAM SOLN 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML 2 $0 NM, PA Immune Globulin (Human) IV SOLN 10 GM/100ML 2 $0 NM, PA PRIVIGEN SOLN 10 GM/100ML, 20 2 $0 NM, PA GM/200ML, 40 GM/400ML, 5 GM/50ML GAMMAPLEX SOLN 10 GM/200ML, 2 $0 NM, PA 2.5 GM/50ML, 5 GM/100ML BIVIGAM SOLN 5 GM/50ML 2 $0 NM, PA GAMMAGARD S/D IGA LESS TH SOLR 10 2 $0 NM, PA GM, 5 GM CARIMUNE NANOFILTERED SOLR 12 GM 2 $0 NM, PA GAMMAGARD S/D SOLR 2.5 GM 2 $0 NM, PA GAMMAGARD LIQUID SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML 2 $0 NM, PA NSLIJHealthPlans.com/FIDALiveWell 頁碼 63

65 GAMUNEX-C SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML GAMMAKED SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML 免疫調節劑 2 $0 NM, PA 2 $0 NM, PA INTRON A SOLN 10 MU/ML, UNIT/ML 2 $0 NM, B/D INTRON A W/DILUENT SOLR 10 MU 2 $0 NM, B/D INTRON A SOLR 18 MU, 50 MU 2 $0 NM, B/D ACTIMMUNE SOLN UNIT/0.5ML 2 $0 NM, PA, LA REVLIMID CAPS 10 MG, 15 MG, 2.5 MG, 20 MG, 2 $0 NM, PA, LA 25 MG, 5 MG ARCALYST SOLR 220 MG 2 $0 NM, PA THALOMID CAPS 100 MG, 150 MG, 200 MG, 50 MG 抑制免疫力藥劑 2 $0 NM, PA Azathioprine TABS 50 MG B/D NULOJIX SOLR 250 MG 2 $0 B/D BENLYSTA SOLR 120 MG, 400 MG 2 $0 NM, PA Cyclosporine CAPS 100 MG, 25 MG B/D SANDIMMUNE SOLN 100 MG/ML 2 $0 B/D Cyclosporine SOLN 50 MG/ML B/D NEORAL CAPS 100 MG, 25 MG 2 $0 B/D Cyclosporine Modified (For Microemulsion) CAPS B/D 100 MG, 25 MG, 50 MG Cyclosporine Modified (For Microemulsion) SOLN 100 MG/ML B/D NEORAL SOLN 100 MG/ML 2 $0 B/D ZORTRESS TABS.25 MG,.5 MG,.75 MG 2 $0 B/D Mycophenolate Mofetil CAPS 250 MG B/D Mycophenolate Mofetil SUSR 200 MG/ML 2 $0 B/D Mycophenolate Mofetil TABS 500 MG B/D Mycophenolate Sodium TBEC 180 MG B/D Mycophenolate Sodium TBEC 360 MG 2 $0 B/D Sirolimus SOLN 1 MG/ML 2 $0 B/D Sirolimus TABS.5 MG, 1 MG B/D SIROLIMUS TABS 2 MG 2 $0 B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 64

66 疫苗 Tacrolimus CAPS.5 MG, 1 MG B/D PROGRAF CAPS.5 MG, 1 MG, 5 MG 2 $0 B/D Tacrolimus CAPS 5 MG 2 $0 B/D BCG VACCINE 2 $0 KINRIX 2 $0 QUADRACEL 2 $0 DAPTACEL 2 $0 INFANRIX 2 $0 DIPHTHERIA/TETANUS TOXOID 2 $0 B/D ACTHIB 2 $0 HIBERIX SOLR 10 MCG 2 $0 PEDVAX HIB SUSP 7.5 MCG/0.5ML 2 $0 COMVAX 2 $0 TWINRIX 2 $0 HAVRIX SUSP 1440 ELU/ML, 720 ELU/0.5ML 2 $0 VAQTA SUSP 25 UNIT/0.5ML, 50 UNIT/ML 2 $0 ENGERIX-B SUSP 10 MCG/0.5ML, 20 MCG/ML 2 $0 B/D RECOMBIVAX HB SUSP 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML 2 $0 B/D GARDASIL 9, 2 $0 CERVARIX 2 $0 GARDASIL 2 $0 IXIARO 2 $0 M-M-R II 2 $0 PROQUAD 2 $0 MENVEO 2 $0 MENACTRA 2 $0 TRUMENBA 2 $0 MENOMUNE-A/C/Y/W $0 BEXSERO 2 $0 SYNAGIS SOLN 100 MG/ML, 50 MG/0.5ML 2 $0 NM IPOL INACTIVATED IPV 2 $0 RABAVERT 2 $0 IMOVAX RABIES (H.D.C.V.) INJ 2.5 UNIT/ML 2 $0 ROTARIX 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 65

67 ROTATEQ 2 $0 ADACEL 2 $0 BOOSTRIX 2 $0 TENIVAC 2 $0 B/D TETANUS/DIPHTHERIA TOXOID 2 $0 B/D Typhoid VI Polysaccharide Vaccine SOLN 25 MCG/ 0.5ML 2 $0 TYPHIM VI SOLN 25 MCG/0.5ML 2 $0 VARIVAX INJ 1350 PFU/0.5ML 2 $0 YF-VAX 2 $0 ZOSTAVAX SOLR UNT/0.65ML 2 $0 QL: 終生 1 安瓶 營養 / 補給品 - 維他命和補給品 電解質 MAGNESIUM SULFATE 80 MG/ML SOLN 40 MG/ML, 2 $0 Magnesium Sulfate SOLN 50%, 50% MAGNESIUM SULFATE SOLN 50%, 50% MAGNESIUM SULFATE IN D5W 2 $0 Oral Electrolytes 3 $0 NM, * TPN ELECTROLYTES 2 $0 B/D Potassium Chloride CPCR 10 MEQ, 8 MEQ POTASSIUM CHLORIDE LIQD 10%, 20% Potassium Chloride PACK 20 MEQ KLOR-CON 10 TBCR 10 MEQ POTASSIUM CHLORIDE ER TBCR 10 MEQ, 20 MEQ Potassium Chloride TBCR 8 MEQ KLOR-CON 8 TBCR 8 MEQ Potassium Chloride Microencapsulated Crystals CR TBCR 10 MEQ, 15 MEQ, 20 MEQ SODIUM CHLORIDE SOLN 2.5 MEQ/ML IV 營養素 AMINOSYN 7%/ELECTROLYTES 2 $0 B/D AMINOSYN 8.5%/ELECTROLYTE 2 $0 B/D AMINOSYN II 8.5%/ELECTROL 2 $0 B/D NSLIJHealthPlans.com/FIDALiveWell 頁碼 66

68 AMINOSYN M 2 $0 B/D PROCALAMINE 2 $0 B/D Amino Acid Infusion B/D Amino Acid Infusion 2 $0 B/D AMINOSYN 2 $0 B/D AMINOSYN II 2 $0 B/D AMINOSYN-HBC 2 $0 B/D AMINOSYN-PF 2 $0 B/D AMINOSYN-PF 7% 2 $0 B/D AMINOSYN-RF 2 $0 B/D FREAMINE HBC 6.9% 2 $0 B/D FREAMINE III 2 $0 B/D HEPATAMINE 2 $0 B/D NEPHRAMINE 2 $0 B/D PROSOL 2 $0 B/D TRAVASOL 2 $0 B/D TROPHAMINE 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 1 2 $0 B/D CLINIMIX 5%/DEXTROSE 15% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 2 2 $0 B/D CLINIMIX 5%/DEXTROSE 20% 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 2 2 $0 B/D CLINIMIX 5%/DEXTROSE 25% 2 $0 B/D CLINIMIX 2.75%/DEXTROSE 5 2 $0 B/D CLINIMIX 4.25%/DEXTROSE 5 2 $0 B/D NUTRILIPID EMUL 20 GM/100ML 2 $0 B/D INTRALIPID EMUL 20 GM/100ML, 30 GM/100ML 2 $0 B/D IV 注射液 DEXTROSE 10% FLEX CONTAIN SOLN 10% DEXTROSE 5% SOLN 5% DEXTROSE 50% SOLN 50% DEXTROSE 70% SOLN 70% LACTATED RINGERS DEXTROSE DEXTROSE 10%/NACL 0.2% 2 $0 DEXTROSE 10%/NACL 0.45% NSLIJHealthPlans.com/FIDALiveWell 頁碼 67

69 DEXTROSE 2.5%/SODIUM CHLO DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% PLASMA-LYTE $0 DEXTROSE 5% /ELECTROLYTE 2 $0 PLASMA-LYTE-56/D5W 2 $0 PLASMA-LYTE A 2 $0 IONOSOL-B/DEXTROSE 5% 2 $0 NORMOSOL-M IN D5W IONOSOL-MB/DEXTROSE 5% 2 $0 ISOLYTE-P/DEXTROSE 5% 2 $0 NORMOSOL-R 2 $0 NORMOSOL-R IN D5W 2 $0 ISOLYTE-S 2 $0 LACTATED RINGERS VIAFLEX Potassium Chloride SOLN 2 MEQ/ML,.4 MEQ/ML, 10 MEQ/100ML, 10 MEQ/50ML, 20 MEQ/100ML, 40 MEQ/100ML POTASSIUM CHLORIDE SOLN 2 MEQ/ML,.4 MEQ/ML, 10 MEQ/100ML, 10 MEQ/50ML, 20 MEQ/100ML, 40 MEQ/100ML DEXTROSE 5%/POTASSIUM CHL POTASSIUM CHLORIDE 0.3%/D KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% 2 $0 KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.22% Potassium Chloride in NaCl NSLIJHealthPlans.com/FIDALiveWell 頁碼 68

70 POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.3% RINGERS INJECTION SODIUM CHLORIDE 0.45% VIA SOLN.45% SODIUM CHLORIDE SOLN.9%, 3%, 5% 礦物質 Bone Meal w/ Vitamin D 3 $0 NM, * CHELATED CALCIUM TABS 200 MG 3 $0 NM, * Calcium TABS 500 MG 3 $0 NM, * CALCIUM GUMMIES 3 $0 NM, * CITRACAL CALCIUM GUMMIES 3 $0 NM, * EQL CHILDRENS CALCIUM GUM 3 $0 NM, * CALCI-MIX CAPS 1250 MG 3 $0 NM, * CALCIUM CARBONATE CHEW 260 MG 3 $0 NM, * CALCIUM CARBONATE POWD 800 MG/2GM 3 $0 NM, * Calcium Carbonate SUSP 1250 MG/5ML 3 $0 NM, * Calcium Carbonate TABS 1250 MG, 600 MG 3 $0 NM, * CALCIUM D 3 $0 NM, * CAL-QUICK 3 $0 NM, * CALTRATE 600+D SOFT CHEWS 3 $0 NM, * EQL CALCIUM/VITAMIN D 3 $0 NM, * LIQUID CALCIUM WITH D3 MA 3 $0 NM, * OSTEO-PORETICAL 3 $0 NM, * Calcium Carbonate-Cholecalciferol,, 3 $0 NM, * Calcium Carbonate-Ergocalciferol 3 $0 NM, * RA OYSTER SHELL CALCIUM/V 3 $0 NM, * MAGNEBIND $0 NM, * LOCALNESIUM-C 3 $0 NM, * Calcium Carbonate-Vitamin D,, 3 $0 NM, * Calcium Carbonate-Vitamin D w/ Minerals, 3 $0 NM, * CALCIUM CITRATE GRAN 760 MG/3.5GM 3 $0 NM, * CVS CALCIUM CITRATE TABS 200 MG 3 $0 NM, * CALCIUM CITRATE TABS 250 MG 3 $0 NM, * CALCIUM CITRATE MALATE/VI 3 $0 NM, * Calcium Citrate-Vitamin D 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 69

71 CALCET CREAMY BITES 3 $0 NM, * CAL-CITRATE PLUS VITAMIN 3 $0 NM, * CALCIUM CITRATE W/D 3 $0 NM, * UPCAL D 3 $0 NM, * ADVANCED CALCIUM FORMULA 3 $0 NM, * CALCIONATE SYRP 1.8 GM/5ML 3 $0 NM, * Calcium Gluconate TABS 500 MG, 50 MG, 500 MG 3 $0 NM, * CALCIUM GLUCONATE TABS 500 MG, 50 MG, 500 MG 3 $0 NM, * Calcium Lactate TABS 650 MG, 100 MG, 648 MG 3 $0 NM, * CALCIUM LACTATE 648 MG TABS 650 MG, 100 MG, 3 $0 NM, * Calcium w/ Magnesium 3 $0 NM, * CAL/MAG 3 $0 NM, * CALCIUM & MAGNESIUM 3 $0 NM, * CALMAG THINS 3 $0 NM, * LOCALNESIUM 3 $0 NM, * CALCIUM/C/D 3 $0 NM, * Calcium w/ Vitamins D & K 3 $0 NM, * RA CALCIUM/BORON 3 $0 NM, * CALCET PETITES 3 $0 NM, * PARVA-CAL 3 $0 NM, * Calcium-Magnesium w/ Vitamin D 3 $0 NM, * CALCIUM $0 NM, * CALCIUM/MAGNESIUM/VITAMIN 3 $0 NM, * CORAL CALCIUM 3 $0 NM, * Calcium-Magnesium-Zinc 3 $0 NM, * CALCIUM/MAGNESIUM/ZINC 3 $0 NM, * BONE DENSITY 3 $0 NM, * CITRACAL PLUS HEART HEALT 3 $0 NM, * SM CORAL CALCIUM TABS 1000 MG 3 $0 NM, * Coral Calcium-Magnesium w/ Vitamin D 3 $0 NM, * CORAL CALCIUM 3 $0 NM, * CORAL CALCIUM PLUS 3 $0 NM, * MAGNESIUM ELEMENTAL CAPS 300 MG 3 $0 NM, * Magnesium TABS 200 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 70

72 MAGNESIUM ELEMENTAL TABS 30 MG 3 $0 NM, * MAGINEX TBEC 615 MG 3 $0 NM, * Magnesium Chloride TBCR 64 MG 3 $0 NM, * Magnesium Chloride-Calcium 3 $0 NM, * SLOW-MAG 3 $0 NM, * MAGNESIUM CITRATE TABS 100 MG 3 $0 NM, * MAG-TAB SR TBCR 84 MG 3 $0 NM, * MAGNESIUM CAPS 400 MG 3 $0 NM, * Magnesium Oxide (Mg Supplement) CAPS 500 MG 3 $0 NM, * Magnesium Oxide (Mg Supplement) TABS 250 MG, 400 MG, 500 MG 3 $0 NM, * Oyster Shell TABS 500 MG 3 $0 NM, * PHOS-NAK POWDER CONCENTRA 3 $0 NM, * Selenium TABS 100 MCG 3 $0 NM, * SELENIUM TBCR 200 MCG 3 $0 NM, * 維他命 Ascorbic Acid 3 $0 NM, * ASCORBIC ACID 3 $0 NM, * Ascorbic Acid CHEW 100 MG, 250 MG 3 $0 NM, * CVS VITAMIN C CHEW 1000 MG 3 $0 NM, * Ascorbic Acid LOZG 60 MG 3 $0 NM, * Ascorbic Acid SYRP 500 MG/5ML 3 $0 NM, * Ascorbic Acid TABS 100 MG, 250 MG, 500 MG 3 $0 NM, * Ascorbic Acid TBCR 1000 MG, 500 MG 3 $0 NM, * ACEROLA C 500 WAFR 500 MG 3 $0 NM, * B Complex w/ C 3 $0 NM, * B-Complex Vitamins 3 $0 NM, * B-Complex w/ C & Calcium 3 $0 NM, * B-Complex w/ C & E + Zn 3 $0 NM, * B-Complex w/ C & Folic Acid 3 $0 NM, * NEPHRONEX 3 $0 NM, * DIALYVITE 800/ZINC 15 3 $0 NM, * B-Complex w/ Minerals 3 $0 NM, * Beta Carotene CAPS 15 MG, UNIT 3 $0 NM, * LUMITENE CAPS 30 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 71

73 Biotin CAPS 5 MG 3 $0 NM, * Biotin TABS 300 MCG 3 $0 NM, * Calcitriol CAPS.25 MCG,.5 MCG B/D Calcitriol SOLN 1 MCG/ML B/D VITAMIN C 3 $0 NM, * Calcium Ascorbate TABS 500 MG 3 $0 NM, * Calcium Pantothenate TABS 500 MG 3 $0 NM, * Cholecalciferol CAPS 1000 UNIT, UNIT, 2000 UNIT, 400 UNIT, 5000 UNIT, UNIT SM VITAMIN D3 MAXIMUM STR 4000 UNIT CAPS 3 $0 NM, * 3 $0 NM, * Cholecalciferol CHEW 1000 UNIT, 400 UNIT 3 $0 NM, * VITAMIN D3 LIQD 1200 UNIT/15ML 3 $0 NM, * Cholecalciferol LIQD 400 UNIT/ML, 5000 UNIT/ ML 3 $0 NM, * Cholecalciferol TABS 1000 UNIT, 2000 UNIT, 400 UNIT, 5000 UNIT 3 $0 NM, * VITAMIN D3 TABS 3000 UNIT 3 $0 NM, * THERA-D 4000 TABS 4000 UNIT 3 $0 NM, * DIALYVITE VITAMIN D3 MAX TABS 3 $0 NM, * UNIT Cod Liver Oil 3 $0 NM, * Cyanocobalamin LIQD 1000 MCG/15ML 3 $0 NM, * Cyanocobalamin SOLN 1000 MCG/ML 3 $0 NM, * NASCOBAL SOLN 500 MCG/0.1ML 3 $0 NM, * Cyanocobalamin SUBL 1000 MCG, 2500 MCG 3 $0 NM, * Cyanocobalamin 500 MCG TABS 2000 MCG, 250 MCG, 3 $0 NM, * Cyanocobalamin TBCR 2000 MCG 3 $0 NM, * Cyanocobalamin TBDP 1500 MCG 3 $0 NM, * B-12 DOTS TBDP 500 MCG 3 $0 NM, * Ergocalciferol CAPS UNIT 3 $0 NM, * VITAMIN D2 TABS 2000 UNIT, 400 UNIT 3 $0 NM, * FOLIC ACID CAPS 20 MG 3 $0 NM, * Folic Acid SOLN 5 MG/ML 3 $0 NM, * Folic Acid TABS 1 MG, 400 MCG, 800 MCG, 1 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 72

74 FOLIC ACID 1 MG TABS 1 MG, 400 MCG, 800 MCG, 3 $0 NM, * Hydroxocobalamin SOLN 1000 MCG/ML 3 $0 NM, * Iron w/ Vitamins 3 $0 NM, * B-12 QUICK DISSOLVE TBDP 5000 MCG 3 $0 NM, * THERA/BETA-CAROTENE 3 $0 NM, * Multiple Vitamins w/ Iron 3 $0 NM, * ANTIOXIDANT FORMULA SG 3 $0 NM, * CENTRUM SILVER 3 $0 NM, * ELDERTONIC 3 $0 NM, * Multiple Vitamins w/ Minerals,,, 3 $0 NM, * Niacin CPCR 250 MG, 500 MG 3 $0 NM, * Niacin TABS 100 MG, 50 MG, 500 MG 3 $0 NM, * NIACIN TR TBCR 1000 MG 3 $0 NM, * Niacin TBCR 250 MG, 500 MG, 750 MG 3 $0 NM, * Niacinamide TABS 100 MG, 500 MG 3 $0 NM, * Paricalcitol CAPS 1 MCG, 2 MCG, 4 MCG B/D Pediatric Multiple Vitamin w/ C 3 $0 NM, * Pediatric Multiple Vitamin w/ C & FA 3 $0 NM, * Pediatric Multiple Vitamin w/ Extra C & FA 3 $0 NM, * VITALETS 3 $0 NM, * ZOO FRIENDS COMPLETE 3 $0 NM, * Pediatric Multiple Vitamin w/ Minerals & C, 3 $0 NM, * Pediatric Multiple Vitamins 3 $0 NM, * EQL CHILDRENS MULTIVITAMI 3 $0 NM, * HONEY BEARS W/IRON AND ZI 3 $0 NM, * MULTI-DELYN/IRON 3 $0 NM, * SCOOBY-DOO ONE A DAY 3 $0 NM, * Pediatric Multiple Vitamins w/ Iron, 3 $0 NM, * HONEY BEARS 3 $0 NM, * MYKIDZ IRON 3 $0 NM, * Pediatric Vitamins ADC 3 $0 NM, * TRI-VI-SOL 3 $0 NM, * Phytonadione SOLN 1 MG/0.5ML, 10 MG/ML 3 $0 NM, * Phytonadione TABS 100 MCG 3 $0 NM, * MEPHYTON TABS 5 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 73

75 KPN PRENATAL 3 $0 NM, * PRENATAL 3 $0 NM, * CLASSIC PRENATAL 3 $0 NM, * PERRY PRENATAL 3 $0 NM, * PRENATAL 3 $0 NM, * THERANATAL CORE NUTRITION 3 $0 NM, * MISSION PRENATAL 3 $0 NM, * MISSION PRENATAL HP 3 $0 NM, * EZFE FORTE 3 $0 NM, * B-NATAL LOZG 25 MG 3 $0 NM, * B-NATAL LPOP 25 MG 3 $0 NM, * Pyridoxine HCl SOLN 100 MG/ML 3 $0 NM, * Pyridoxine HCl TABS 100 MG, 200 MG, 25 MG, 3 $0 NM, * 50 MG Pyridoxine HCl TBCR 200 MG 3 $0 NM, * CYTO B2 POWD 343 MG/GM 3 $0 NM, * Riboflavin TABS 25 MG, 50 MG 3 $0 NM, * Specialty Vitamins Products 3 $0 NM, * ICAPS LUTEIN/ZEAXANTHIN F 3 $0 NM, * Thiamine HCl SOLN 100 MG/ML 3 $0 NM, * Thiamine HCl TABS 100 MG, 50 MG 3 $0 NM, * Thiamine Mononitrate TABS 100 MG 3 $0 NM, * AQUA-E 3 $0 NM, * VITAMIN A PALMITATE TABS UNIT 3 $0 NM, * Vitamin E CAPS 100 UNIT, 1000 UNIT, 200 UNIT 3 $0 NM, * Vitamin E OIL 100 UNT/0.25ML 3 $0 NM, * Vitamin E SOLN 15 UNIT/0.3ML 3 $0 NM, * VITAMIN E TABS 100 UNIT 3 $0 NM, * Vitamin Mixture, 3 $0 NM, * Vitamins A & D 3 $0 NM, * 眼科 - 治療眼疾的藥物 抗感染 / 抗發炎 - 治療感染和發炎的藥物 Bacitracin-Poly-Neomycin-HC ZYLET 2 $0 Neomycin-Polymy-Dexameth OINT Neomycin-Polymyxin-HC (Ophth) NSLIJHealthPlans.com/FIDALiveWell 頁碼 74

76 Sulfacetamide Sod-Prednisolone Sulfacetamide Sod-Prednisolone 2 $0 Tobramycin-Dexamethasone TOBRADEX 2 $0 TOBRADEX ST 2 $0 抗感染 - 治療感染的藥物 Bacitracin (Ophthalmic) OINT 500 UNIT/GM Bacitracin-Polymyxin B (Ophth) BESIVANCE SUSP.6% 2 $0 CILOXAN OINT.3% 2 $0 Ciprofloxacin HCl (Ophth) SOLN.3% Erythromycin (Ophth) OINT 5 MG/GM ZIRGAN GEL.15% 2 $0 Gatifloxacin (Ophth) SOLN.5% Gentamicin Sulfate (Ophth) OINT.3% Gentamicin Sulfate (Ophth) SOLN.3% MOXEZA SOLN.5% 2 $0 VIGAMOX SOLN.5% 2 $0 NATACYN SUSP 5% 2 $0 Neomycin-Bacitracin Zn-Polymyxin Neomycin-Polymyxin-Gramicidin Ofloxacin (Ophth) SOLN.3% Polymyxin B-Trimethoprim Sulfacetamide Sodium (Ophth) OINT 10% Sulfacetamide Sodium (Ophth) SOLN 10% TOBREX OINT.3% 2 $0 Tobramycin (Ophth) SOLN.3% Trifluridine SOLN 1% 消炎藥 - 治療發炎的藥物 Bromfenac Sodium (Ophth) SOLN.09% BROMFENAC SOLN.09% MAXIDEX SUSP.1% 2 $0 Dexamethasone Sodium Phosphate (Ophth) SOLN.1% Diclofenac Sodium (Ophth) SOLN.1% DUREZOL EMUL.05% 2 $0 NSLIJHealthPlans.com/FIDALiveWell 頁碼 75

77 FLUOROMETHOLONE SUSP.1% Flurbiprofen Sodium SOLN.03% Ketorolac Tromethamine (Ophth) SOLN.4%,.5% LOTEMAX GEL.5% 2 $0 LOTEMAX OINT.5% 2 $0 ALREX SUSP.2% 2 $0 LOTEMAX SUSP.5% 2 $0 ILEVRO SUSP.3% 2 $0 PREDNISOLONE ACETATE SUSP 1% Prednisolone Sodium Phosphate (Ophth) SOLN 1% 2 $0 抗過敏 - 治療過敏的藥物 LASTACAFT SOLN.25% 2 $0 Azelastine HCl (Ophth) SOLN.05% BEPREVE SOLN 1.5% 2 $0 Cromolyn Sodium (Ophth) SOLN 4% Ketotifen Fumarate (Ophth) SOLN.025% 3 $0 NM, * TGT EYE ALLERGY RELIEF 3 $0 NM, * Naphazoline-Glycerin 3 $0 NM, * PATADAY SOLN.2% 2 $0 PAZEO SOLN.7% 2 $0 VISINE-LR SOLN.025% 3 $0 NM, * Tetrahydrozoline HCl (Ophth) SOLN.05% 3 $0 NM, * Tetrahydrozoline w/ Zinc Sulfate 3 $0 NM, * 抗青光眼 - 治療青光眼的藥物 Betaxolol HCl (Ophth) SOLN.5% BETOPTIC-S SUSP.25% 2 $0 LUMIGAN SOLN.01% 2 $0 ALPHAGAN P SOLN.1% 2 $0 Brimonidine Tartrate SOLN.2%,.15% BRIMONIDINE TARTRATE SOLN.2%,.15% COMBIGAN 2 $0 AZOPT SUSP 1% 2 $0 SIMBRINZA 2 $0 Carteolol HCl (Ophth) SOLN 1% Dorzolamide HCl SOLN 2% Dorzolamide HCl-Timolol Maleate NSLIJHealthPlans.com/FIDALiveWell 頁碼 76

78 其他 PHOSPHOLINE IODIDE SOLR.125% 2 $0 Latanoprost SOLN.005% Levobunolol HCl SOLN.5%,.25% LEVOBUNOLOL HCL SOLN.5%,.25% Metipranolol SOLN.3% PILOCARPINE HCL SOLN 1%, 2%, 4% TIMOLOL MALEATE OPHTHALMI SOLG.2%,.5% Timolol Maleate (Ophth) SOLN.25%,.5% ISTALOL SOLN.5% 2 $0 TRAVATAN Z SOLN.004% 2 $0 TEARS AGAIN NIGHT & DAY 3 $0 NM, * Artificial Tear Ointment 3 $0 NM, * PROLENSA SOLN.07% 2 $0 Carboxymethylcellulose Sodium (Ophth) GEL 1% 3 $0 NM, * STERILE LUBRICANT DROPS LIQD.7% 3 $0 NM, * THERATEARS SOLN.25% 3 $0 NM, * Carboxymethylcellulose Sodium (Ophth) SOLN.5% 3 $0 NM, * REFRESH CELLUVISC SOLN 1% 3 $0 NM, * Carboxymethylcellulose-Glycerin 3 $0 NM, * REFRESH OPTIVE ADVANCED 3 $0 NM, * RESTASIS EMUL.05% 2 $0 QL:64 支安瓶 / 30 天 Glycerin-Hypromellose-Polyethylene Glycol $0 NM, * Hypromellose (Gonioscopic) SOLN 2.5% 3 $0 NM, * SYSTANE OVERNIGHT THERAPY GEL.3% 3 $0 NM, * Hypromellose (Ophth) SOLN.3%,.4% 3 $0 NM, * ISOPTO TEARS SOLN.5% 3 $0 NM, * RETAINE MGD 3 $0 NM, * Naphazoline HCl SOLN.1% Ophthalmic Irrigation Solution 3 $0 NM, * HYPOTEARS 3 $0 NM, * Polyethylene Glycol-Propylene Glycol (Ophth) 3 $0 NM, * Polyvinyl Alcohol SOLN 1.4% 3 $0 NM, * Polyvinyl Alcohol-Povidone (Ophth) 3 $0 NM, * FRESHKOTE 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 77

79 Proparacaine HCl SOLN.5% SYSTANE BALANCE RESTORATI SOLN.6% 3 $0 NM, * Propylene Glycol-Glycerin 3 $0 NM, * SOOTHE 3 $0 NM, * Sodium Chloride Hypertonic OINT 5% 3 $0 NM, * MURO 128 SOLN 2% 3 $0 NM, * Sodium Chloride Hypertonic SOLN 5% 3 $0 NM, * ENUCLENE SOLN.25% 3 $0 NM, * White Petrolatum-Mineral Oil 3 $0 NM, * 呼吸道 - 治療呼吸障礙的藥物 反副交感神經生理作用 / 乙型促效綜合劑 - 治療慢性肺部阻塞的藥物 Ipratropium-Albuterol B/D COMBIVENT RESPIMAT 2 $0 QL:2 罐吸入劑 / 30 天 ANORO ELLIPTA 2 $0 QL:60 罐吸入劑 / 30 天 反副交感神經生理作用 - 治療慢性肺部阻塞的藥物 Ipratropium Bromide SOLN.02% B/D Ipratropium Bromide (Nasal) SOLN.03%,.06% ATROVENT HFA AERS 17 MCG/ACT 2 $0 QL:2 罐吸入劑 / 30 天 Umeclidinium Bromide AEPB 62.5 MCG/INH 2 $0 QL:1 罐吸入劑 / 30 天 抗組胺劑 - 治療過敏的藥物 Azelastine HCl SOLN.1%,.15% ASTEPRO SOLN.15% 2 $0 J-TAN PD LIQD 1 MG/ML 3 $0 NM, * Cetirizine HCl CHEW 10 MG, 5 MG 3 $0 NM, * Cetirizine HCl SOLN 5 MG/5ML 3 $0 NM, * Cetirizine HCl SYRP 1 MG/ML Cetirizine HCl TABS 10 MG, 5 MG 3 $0 NM, * ED CHLORPED LIQD 2 MG/ML 3 $0 NM, * Chlorpheniramine Maleate SYRP 2 MG/5ML 3 $0 NM, * Chlorpheniramine Maleate TBCR 12 MG 3 $0 NM, * ALA-HIST IR TABS 2 MG 3 $0 NM, * Diphenhydramine HCl CAPS 25 MG, 50 MG 3 $0 NM, * Diphenhydramine HCl CHEW 12.5 MG 3 $0 NM, * Diphenhydramine HCl LIQD 12.5 MG/5ML 3 $0 NM, * Diphenhydramine HCl SOLN 50 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 78

80 TRIAMINIC COUGH & RUNNY N STRP 12.5 MG 3 $0 NM, * Diphenhydramine HCl TABS 25 MG 3 $0 NM, * Diphenhydramine HCl TBDP 12.5 MG 3 $0 NM, * Fexofenadine HCl SUSP 30 MG/5ML 3 $0 NM, * Fexofenadine HCl TABS 180 MG, 60 MG 3 $0 NM, * ALLEGRA ALLERGY CHILDRENS TABS 30 MG 3 $0 NM, * Hydroxyzine HCl SOLN 10 MG/5ML, 25 MG/ML, 50 MG/ML 2 $0 PA PA ( 若年滿 65 歲以上 ) Hydroxyzine HCl TABS 10 MG, 25 MG, 50 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) Hydroxyzine Pamoate 50 MG CAPS 100 MG, 25 MG, Levocetirizine Dihydrochloride SOLN 2.5 MG/5ML Levocetirizine Dihydrochloride TABS 5 MG 2 $0 PA PA ( 若年滿 65 歲以上 ) CLARITIN CHEW 5 MG 3 $0 NM, * Loratadine SYRP 5 MG/5ML 3 $0 NM, * Loratadine TABS 10 MG 3 $0 NM, * CLARITIN REDITABS TBDP 5 MG 3 $0 NM, * Olopatadine HCl (Nasal) SOLN.6% 乙型促效劑 - 治療氣喘和慢性肺部阻塞的藥物 Albuterol Sulfate AERS 108 MCG/ACT 2 $0 QL:2 罐吸入劑 / 30 天 Albuterol Sulfate 1.25 MG/3ML NEBU.083%,.5%,.63 MG/3ML, B/D Albuterol Sulfate SYRP 2 MG/5ML Albuterol Sulfate TABS 2 MG, 4 MG Albuterol Sulfate TB12 4 MG, 8 MG PERFOROMIST NEBU 20 MCG/2ML 2 $0 B/D Levalbuterol HCl NEBU 1.25 MG/0.5ML B/D XOPENEX HFA AERO 45 MCG/ACT 2 $0 QL:2 罐吸入劑 / 30 天 SEREVENT DISKUS AEPB 50 MCG/DOSE 2 $0 QL:60 罐吸入劑 / 30 天 Terbutaline Sulfate SOLN 1 MG/ML 2 $0 Terbutaline Sulfate TABS 2.5 MG, 5 MG 咳嗽和感冒 Acetaminophen w/ DM 3 $0 NM, * Benzonatate CAPS 100 MG, 150 MG, 200 MG 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 79

81 BROHIST D 3 $0 NM, * Brompheniramine & Phenyleph 3 $0 NM, * Brompheniramine & Pseudoeph 3 $0 NM, * J-TAN D PD 3 $0 NM, * LODRANE D 3 $0 NM, * VICKS VAPORUB 3 $0 NM, * Cetirizine-Pseudoephedrine 3 $0 NM, * CHLO TUSS EX 3 $0 NM, * STAHIST AD 3 $0 NM, * ED CHLORPED D 3 $0 NM, * PHENAGIL 3 $0 NM, * Chlorpheniramine & Phenylephrine 3 $0 NM, * Chlorpheniramine & Pseudoeph 3 $0 NM, * LOHIST-D 3 $0 NM, * DIMETAPP LONG ACTING COUGH 3 $0 NM, * ROBITUSSIN CHILDRENS COUGH 3 $0 NM, * Chlorpheniramine-DM 3 $0 NM, * CONTAC COLD/FLU MAXIMUM S 3 $0 NM, * NOREL AD 3 $0 NM, * Chlorpheniramine-Phenylephrine-Acetaminophen 3 $0 NM, * ADVIL ALLERGY & CONGESTION 3 $0 NM, * ADVIL ALLERGY SINUS 3 $0 NM, * Cromolyn Sodium (Nasal) AERS 5.2 MG/ACT 3 $0 NM, * CONEX COLD/ALLERGY 3 $0 NM, * ALA-HIST PE 3 $0 NM, * COMPLETE SINUS RELIEF 3 $0 NM, * DELTUSS DP 3 $0 NM, * RESCON 3 $0 NM, * RYMED 3 $0 NM, * Dextromethorphan HBr CAPS 15 MG 3 $0 NM, * Dextromethorphan HBr LIQD 15 MG/5ML, 3 $0 NM, * 7.5 MG/5ML Dextromethorphan HBr SYRP 7.5 MG/5ML 3 $0 NM, * Dextromethorphan Polistirex LQCR 30 MG/5ML 3 $0 NM, * BIOSPEC DMX 3 $0 NM, * MUCINEX COUGH FOR KIDS 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 80

82 SCOT-TUSSIN SENIOR 3 $0 NM, * Dextromethorphan-Guaifenesin 3 $0 NM, * Dextromethorphan-Phenylephrine-Acetaminophen 3 $0 NM, * Diphenhydramine-Acetaminophen 3 $0 NM, * TRIAMINIC NIGHT TIME COLD 3 $0 NM, * Diphenhydramine-Phenylephrine 3 $0 NM, * ROBITUSSIN PEAK COLD NIGH 3 $0 NM, * Diphenhydramine-Phenylephrine-Acetaminophen 3 $0 NM, * Doxylamine-Phenylephrine-Acetaminophen 3 $0 NM, * Fexofenadine-Pseudoephedrine 3 $0 NM, * Guaifenesin LIQD 100 MG/5ML, 200 MG/5ML 3 $0 NM, * MUCINEX FOR KIDS PACK 100 MG 3 $0 NM, * Guaifenesin TABS 200 MG, 400 MG 3 $0 NM, * MUCINEX MAXIMUM STRENGTH 1200 MG TB12 3 $0 NM, * Guaifenesin TB MG 3 $0 NM, * Guaifenesin-Codeine 3 $0 NM, * Loratadine & Pseudoephedrine 3 $0 NM, * Oxymetazoline HCl SOLN.05% 3 $0 NM, * Phenylephrine HCl SOLN.25% 3 $0 NM, * Phenylephrine HCl (Oral) TABS 10 MG 3 $0 NM, * Phenylephrine w/ Acetaminophen 3 $0 NM, * ROBITUSSIN CHILDRENS COUG 3 $0 NM, * Phenylephrine w/ DM-GG 3 $0 NM, * Phenylephrine-Acetaminophen-Guaifenesin 3 $0 NM, * Phenylephrine-Brompheniramine-DM 3 $0 NM, * Phenylephrine-Chlorphen-DM 3 $0 NM, * Phenylephrine-Chlorpheniramine-DM w/ APAP 3 $0 NM, * Phenylephrine-DM 3 $0 NM, * Phenylephrine-DM-GG w/ APAP 3 $0 NM, * Phenylephrine-Doxylamine-Dextromethorphan- Acetaminophen 3 $0 NM, * J-MAX 3 $0 NM, * Phenylephrine-Guaifenesin 3 $0 NM, * PRO-CHLO 3 $0 NM, * CODITUSS DM 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 81

83 Pseudoephed-Bromphen-DM 3 $0 NM, * Pseudoephed-Doxyl-DM w/apap 3 $0 NM, * Pseudoephedrine HCl LIQD 15 MG/5ML 3 $0 NM, * NASAL DECONGESTANT LIQD 30 MG/5ML 3 $0 NM, * Pseudoephedrine HCl SYRP 30 MG/5ML 3 $0 NM, * Pseudoephedrine HCl TABA 30 MG 3 $0 NM, * Pseudoephedrine HCl TABS 60 MG 3 $0 NM, * Pseudoephedrine HCl TB MG 3 $0 NM, * TUSNEL 3 $0 NM, * TUSNEL PEDIATRIC 3 $0 NM, * TUSNEL-DM PEDIATRIC 3 $0 NM, * Pseudoephedrine w/ DM-GG 3 $0 NM, * NEXAFED SINUS PRESSURE + 3 $0 NM, * Pseudoephedrine-Chlorphen-DM 3 $0 NM, * RESCON DM 3 $0 NM, * M-END DMX 3 $0 NM, * Pseudoephedrine-Dexchlorpheniramine-Chlophedianol 3 $0 NM, * DURAFLU 3 $0 NM, * Pseudoephedrine-Guaifenesin 3 $0 NM, * MUCINEX D 3 $0 NM, * RESPAIRE-30 3 $0 NM, * TUSNEL PEDIATRIC 3 $0 NM, * ADVIL COLD & SINUS 3 $0 NM, * Pyrilamine Maleate-Phenylephrine HCl Tannate 3 $0 NM, * Pyrilamine-Phenylephrine 3 $0 NM, * Saline 3 $0 NM, * CVS NASAL MIST AERS.9% 3 $0 NM, * RHINARIS GEL.2% 3 $0 NM, * RHINARIS SOLN.2% 3 $0 NM, * AYR NASAL DROPS SOLN.65% 3 $0 NM, * PRETZ 3 $0 NM, * NASOPEN PE 3 $0 NM, * Triprolidine & Pseudoephedrine 3 $0 NM, * 白三棱受體拮抗劑 - 治療氣喘和過敏的藥物 Montelukast Sodium CHEW 4 MG, 5 MG Montelukast Sodium PACK 4 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 82

84 Montelukast Sodium TABS 10 MG Zafirlukast TABS 10 MG, 20 MG 肥大細胞穩定劑 - 治療過敏的藥物 其他 Cromolyn Sodium NEBU 20 MG/2ML B/D Acetylcysteine SOLN 10%, 20% B/D PROLASTIN-C SOLR 1000 毫克 2 $0 NM, PA, LA ZEMAIRA SOLR 1000 毫克 2 $0 NM, PA, LA ARALAST NP SOLR 1000 MG, 400 MG, 500 MG, 2 $0 NM, PA, LA 800 MG PULMOZYME SOLN 1 MG/ML 2 $0 NM, B/D AUVI-Q SOAJ.15 MG/0.15ML,.3 MG/0.3ML 2 $0 EPIPEN-JR 2-PAK SOAJ.15 MG/0.3ML 2 $0 EPIPEN 2-PAK SOAJ.3 MG/0.3ML 2 $0 KALYDECO PACK 50 MG, 75 MG 2 $0 NM, PA KALYDECO TABS 150 MG 2 $0 NM, PA ORKAMBI 2 $0 NM, PA OFEV CAPS 100 MG, 150 MG 2 $0 NM, PA XOLAIR SOLR 150 毫克 2 $0 NM, PA, LA ESBRIET CAPS 267 MG 2 $0 NM, PA DALIRESP TABS 500 MCG 2 $0 鼻道類固醇 - 治療過敏的藥物 Flunisolide (Nasal) SOLN.025% QL:2 瓶 / 30 天 Fluticasone Propionate (Nasal) SUSP 50 MCG/ACT QL:1 瓶 / 30 天 類固醇吸入劑 - 治療氣喘的藥物 PULMICORT FLEXHALER AEPB 180 MCG/ACT, 90 MCG/ACT Budesonide (Inhalation).5 MG/2ML Fluticasone Furoate (Inhalation) 100 MCG/ACT, 200 MCG/ACT SUSP.25 MG/2ML, AEPB FLOVENT DISKUS AEPB 100 MCG/BLIST, 50 MCG/BLIST 2 $0 QL:2 罐吸入劑 / 30 天 B/D 2 $0 QL:30 罐吸入劑 / 30 天 2 $0 QL:120 罐吸入劑 / 30 天 FLOVENT DISKUS AEPB 250 MCG/BLIST 2 $0 QL:240 罐吸入劑 / 30 天 FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT 2 $0 QL:2 罐吸入劑 / 30 天 NSLIJHealthPlans.com/FIDALiveWell 頁碼 83

85 類固醇 / 乙型促效綜合劑 - 治療氣喘和慢性肺部阻塞的藥物 SYMBICORT 2 $0 QL:1 罐吸入劑 / 30 天 Fluticasone Furoate-Vilanterol 2 $0 QL:60 罐吸入劑 / 30 天 BREO ELLIPTA 2 $0 QL:60 罐吸入劑 / 30 天 ADVAIR DISKUS 2 $0 QL:60 罐吸入劑 / 30 天 ADVAIR HFA 2 $0 QL:1 罐吸入劑 / 30 天 黃嘌呤 - 治療慢性肺部阻塞的藥物 Aminophylline SOLN 25 MG/ML Theophylline 2 $0 Theophylline CP MG, 300 MG, 400 MG 2 $0 Theophylline ELIX 80 MG/15ML 2 $0 Theophylline SOLN 80 MG/15ML Theophylline 450 MG TB MG, 200 MG, 300 MG, Theophylline TB MG, 600 MG 局部藥 - 治療耳科和皮膚科疾病的藥物 皮膚病 痤瘡 Adapalene CREA.1% Adapalene GEL.1% Benzoyl Peroxide-Erythromycin Clindamycin Phosphate (Topical) GEL 1% Clindamycin Phosphate (Topical) LOTN 1% Clindamycin Phosphate (Topical) SOLN 1% Clindamycin Phosphate (Topical) SWAB 1% Erythromycin (Acne Aid) GEL 2% Erythromycin (Acne Aid) PADS 2% Erythromycin (Acne Aid) SOLN 2% Isotretinoin CAPS 30 MG, 10 MG, 20 MG, 30 MG, 40 MG Isotretinoin CAPS 30 MG, 10 MG, 20 MG, 30 MG, 40 MG Sulfacetamide Sodium (Acne) SUSP 10% AVITA CREA.025% Tretinoin CREA.025%,.05%,.1% NSLIJHealthPlans.com/FIDALiveWell 頁碼 84

86 AVITA GEL.025% Tretinoin GEL.025%,.01% TRETINOIN GEL.025%,.01% 皮膚病 抗生素 Bacitracin (Topical) OINT 500 UNIT/GM 3 $0 NM, * Bacitracin Zinc OINT 500 UNIT/GM 3 $0 NM, * Bacitracin-Polymyxin B 3 $0 NM, * Benzoyl Peroxide BAR 10% 3 $0 NM, * Benzoyl Peroxide GEL 10%, 5%, 2.5% 3 $0 NM, * BENZOYL PEROXIDE GEL 10%, 5%, 2.5% 3 $0 NM, * Benzoyl Peroxide LIQD 10%, 5% 3 $0 NM, * PANOXYL-4 CREAMY WASH LIQD 4% 3 $0 NM, * ACNE MEDICATION LOTN 10% 3 $0 NM, * ACNE MEDICATION 5 LOTN 5% 3 $0 NM, * Benzoyl Peroxide LOTN 6% 3 $0 NM, * Gentamicin Sulfate (Topical) CREA.1% Gentamicin Sulfate (Topical) OINT.1% SULFAMYLON CREA 85 MG/GM 2 $0 SULFAMYLON PACK 5% 2 $0 Mupirocin OINT 2% Neomycin-Bacitracin-Polymyxin 3 $0 NM, * SILVER SULFADIAZINE CREA 1% SSD CREA 1% 皮膚病 抗真菌 LOTRIMIN ULTRA CREA 1% 3 $0 NM, * Castellani Paint LIQD 1.5% 3 $0 NM, * Ciclopirox GEL.77% Ciclopirox SHAM 1% Ciclopirox Olamine CREA.77% Ciclopirox Olamine SUSP.77% Clotrimazole (Topical) CREA 1% Clotrimazole (Topical) SOLN 1% Clotrimazole (Topical) SOLN 1% 3 $0 NM, * Econazole Nitrate CREA 1% GENTIAN VIOLET SOLN 1%, 2% 3 $0 NM, * Hydrocortisone (Topical) CREA 1% 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 85

87 Ketoconazole (Topical) CREA 2% Miconazole Nitrate (Topical) AERO 2% 3 $0 NM, * Miconazole Nitrate (Topical) CREA 2% 3 $0 NM, * FUNGOID TINCTURE KIT 2% 3 $0 NM, * Miconazole Nitrate (Topical) OINT 2% 3 $0 NM, * Miconazole Nitrate (Topical) POWD 2% 3 $0 NM, * FUNGOID TINCTURE SOLN 2% 3 $0 NM, * Nystatin (Topical) CREA UNIT/GM Nystatin (Topical) OINT UNIT/GM Nystatin (Topical) POWD UNIT/GM LAMISIL ADVANCED GEL 1% 3 $0 NM, * Terbinafine HCl (Topical) CREA 1% 3 $0 NM, * Tolnaftate AERO 1% 3 $0 NM, * Tolnaftate AERP 1% 3 $0 NM, * Tolnaftate CREA 1% 3 $0 NM, * Tolnaftate POWD 1% 3 $0 NM, * Tolnaftate SOLN 1% 3 $0 NM, * Zinc Oxide (Topical) OINT 40% 3 $0 NM, * 皮膚病 止癢 PRUDOXIN CREA 5% Hydrocortisone (Rectal) CREA 2.5%, 1%, 2.5% Hydrocortisone (Rectal) CREA 2.5%, 1%, 2.5% 皮膚病 治牛皮癣 Acitretin CAPS 10 MG, 17.5 MG, 25 MG 2 $0 PA Calcipotriene CREA.005% Calcipotriene OINT.005% Calcipotriene SOLN.005% 8-MOP CAPS 10 MG 2 $0 TAZORAC CREA.05%,.1% 2 $0 PA 皮膚病 抗皮脂漏劑 Ketoconazole (Topical) SHAM 2% Selenium Sulfide LOTN 2.5% 皮膚病 皮質類固醇 Alclometasone Dipropionate CREA.05% Alclometasone Dipropionate OINT.05% Betamethasone Dipropionate (Topical) CREA.05% NSLIJHealthPlans.com/FIDALiveWell 頁碼 86

88 Betamethasone Dipropionate (Topical) LOTN.05% Betamethasone Dipropionate (Topical) OINT.05% Betamethasone Dipropionate Augmented CREA.05% Betamethasone Dipropionate Augmented GEL.05% Betamethasone Dipropionate Augmented LOTN.05% Betamethasone Dipropionate Augmented OINT.05% Betamethasone Valerate CREA.1% Betamethasone Valerate LOTN.1% Betamethasone Valerate OINT.1% Clobetasol Propionate CREA.05% Clobetasol Propionate GEL.05% Clobetasol Propionate OINT.05% Clobetasol Propionate SOLN.05% Clobetasol Propionate Emollient Base CREA.05% DESONIDE CREA.05% Desonide LOTN.05% Desonide OINT.05% Desoximetasone CREA.05%,.25% Desoximetasone GEL.05% Desoximetasone OINT.25%,.05% DESOXIMETASONE OINT.25%,.05% Diflorasone Diacetate CREA.05% Diflorasone Diacetate OINT.05% Fluocinolone Acetonide CREA.01%,.025% Fluocinolone Acetonide OIL.01% Fluocinolone Acetonide OINT.025% Fluocinolone Acetonide SOLN.01% Fluocinonide CREA.05% Fluocinonide GEL.05% Fluocinonide OINT.05% Fluocinonide SOLN.05% Fluocinonide Emulsified Base CREA.05% Fluticasone Propionate CREA.05% NSLIJHealthPlans.com/FIDALiveWell 頁碼 87

89 Fluticasone Propionate OINT.005% Halobetasol Propionate CREA.05% Halobetasol Propionate OINT.05% Hydrocortisone (Topical) CREA.5% 3 $0 NM, * Hydrocortisone (Topical) CREA 1%, 2.5% Hydrocortisone (Topical) GEL 1% 3 $0 NM, * Hydrocortisone (Topical) LOTN 1% 3 $0 NM, * Hydrocortisone (Topical) LOTN 2.5% Hydrocortisone (Topical) OINT.5%, 1% 3 $0 NM, * Hydrocortisone (Topical) OINT 1%, 2.5% Hydrocortisone (Topical) SOLN 2.5% 2 $0 CVS HDYROCORTISONE ACETAT CREA.5% 3 $0 NM, * Hydrocortisone Acetate-Aloe Vera 3 $0 NM, * Hydrocortisone Butyrate CREA.1% Hydrocortisone Butyrate OINT.1% Hydrocortisone Butyrate SOLN.1% Hydrocortisone Valerate CREA.2% Hydrocortisone Valerate OINT.2% Hydrocortisone-Aloe Vera 3 $0 NM, * Mometasone Furoate CREA.1% Mometasone Furoate OINT.1% Mometasone Furoate SOLN.1% Triamcinolone Acetonide (Topical) CREA.025%,.1%,.5% Triamcinolone Acetonide (Topical) LOTN.025%,.1% Triamcinolone Acetonide (Topical) OINT.025%,.1%,.5% 皮膚病 局部麻醉藥 Lidocaine OINT 5% Lidocaine PTCH 5% PA, QL:3 片貼布 / 1 天 Lidocaine HCl GEL 2% Lidocaine HCl SOLN 4% Lidocaine-Prilocaine B/D 皮膚病 其他皮膚病和黏膜疾病 Acyclovir Topical OINT 5% NSLIJHealthPlans.com/FIDALiveWell 頁碼 88

90 PANRETIN GEL.1% 2 $0 TARGRETIN GEL 1% 2 $0 NM, PA RA CALAMINE 3 $0 NM, * VOLTAREN GEL 1% 2 $0 ABREVA CREA 10% 3 $0 NM, * Fluorouracil (Topical) CREA 5% Fluorouracil (Topical) SOLN 2%, 5% Imiquimod CREA 5% Lactic Acid (Ammonium Lactate) CREA 12% Lactic Acid (Ammonium Lactate) LOTN 12% VALCHLOR GEL.016% 2 $0 NM, PA, LA RISAMINE 3 $0 NM, * Metronidazole (Topical) CREA.75% Metronidazole (Topical) GEL.75% Metronidazole (Topical) LOTN.75% SENSI-CARE PROTECTIVE BAR 3 $0 NM, * ELIDEL CREA 1% 2 $0 PA Podofilox SOLN.5% Tacrolimus (Topical) OINT.03%,.1% PA Zinc Oxide (Topical) CREA 10% 3 $0 NM, * DESITIN CREA 13% 3 $0 NM, * SECURA EXTRA PROTECTIVE CREA 30.6% 3 $0 NM, * TRIPLE PASTE OINT 12.8% 3 $0 NM, * BOUDREAUXS BUTT PASTE OINT 16% 3 $0 NM, * Zinc Oxide (Topical) OINT 20% 3 $0 NM, * MEXSANA POWD 10.8% 3 $0 NM, * ZINC OXIDE PSTE 25% 3 $0 NM, * 皮膚病 殺疥蟲藥和滅蝨藥 EURAX CREA 10% 2 $0 EURAX LOTN 10% 2 $0 Malathion LOTN.5% Permethrin CREA 5% Permethrin LIQD 1% 3 $0 NM, * Permethrin LOTN 1% 3 $0 NM, * Permethrin & Pyrethrins-Piperonyl Butoxide 3 $0 NM, * PYRETHINS/PIPERONYL BUTO 3 $0 NM, * NSLIJHealthPlans.com/FIDALiveWell 頁碼 89

91 RID ESSENTIAL LICE ELIMIN 3 $0 NM, * Pyrethrins-Piperonyl Butoxide, 3 $0 NM, * 皮膚病 傷口護理劑 Acetic Acid SOLN.25% REGRANEX GEL.01% 2 $0 PA SANTYL OINT 250 UNIT/GM 2 $0 SODIUM CHLORIDE 0.9% SOLN.9% STERILE WATER IRRIGATION 口腔 / 喉科 / 牙科 Cevimeline HCl CAPS 30 MG Chlorhexidine Gluconate (Mouth-Throat) SOLN.12% Clotrimazole TROC 10 MG Lidocaine HCl (Mouth-Throat) SOLN 2% Nystatin (Mouth-Throat) SUSP UNIT/ML PILOCARPINE HYDROCHLORIDE TABS 5 MG Pilocarpine HCl (Oral) TABS 7.5 MG Triamcinolone Acetonide (Mouth) PSTE.1% OTIC - 治療耳科疾病的藥物 Acetic Acid (Otic) SOLN 2% Acetic Acid-Aluminum Acetate CIPRODEX 2 $0 Fluocinolone Acetonide (Otic) OIL.01% Neomycin-Polymyxin-HC (Otic) SOLN Ofloxacin (Otic) SOLN.3% NSLIJHealthPlans.com/FIDALiveWell 頁碼 90

92 給付藥物索引 ( 依字母順序排列 ) # 8-MOP CAPS 10 MG A Abacavir Sulfate TABS 300 MG Abacavir Sulfate-Lamivudine-Zidovudine ABELCET SUSP 5 MG/ML ABILIFY DISCMELT TBDP 10 MG ABILIFY MAINTENA SUSR 300 MG, 400 MG ABRAXANE ABREVA CREA 10% Acamprosate Calcium TBEC 333 MG Acarbose TABS 100 MG, 25 MG, 50 MG Acebutolol HCl CAPS 200 MG, 400 MG ACEPHEN SUPP 120 MG ACEROLA C 500 WAFR 500 MG ACETAMINOPHEN 8 HOUR TABS 650 MG Acetaminophen CHEW 80 MG Acetaminophen LIQD 160 MG/5ML, 500 MG/15ML Acetaminophen SOLN 160 MG/5ML, 80 MG/0.8ML Acetaminophen SUPP 325 MG, 650 MG Acetaminophen SUSP 160 MG/5ML, 80 MG/0.8ML Acetaminophen TABS 325 MG, 500 MG Acetaminophen TBCR 650 MG Acetaminophen TBDP 160 MG, 80 MG Acetaminophen w/ Codeine SOLN Acetaminophen w/ Codeine TABS Acetaminophen w/ DM Acetazolamide CP MG Acetazolamide TABS 125 MG, 250 MG Acetic Acid (Otic) SOLN 2% Acetic Acid SOLN.25% Acetic Acid-Aluminum Acetate Acetylcysteine SOLN 10%, 20% Acitretin CAPS 10 MG, 17.5 MG, 25 MG ACNE MEDICATION 5 LOTN 5% ACNE MEDICATION LOTN 10% ACTHIB ACTIMMUNE SOLN UNIT/0.5ML Acyclovir CAPS 200 MG Acyclovir Sodium SOLN 50 MG/ML Acyclovir Sodium SOLR 500 MG Acyclovir SUSP 200 MG/5ML Acyclovir TABS 400 MG, 800 MG Acyclovir Topical OINT 5% ADACEL ADAGEN SOLN 250 UNIT/ML Adapalene CREA.1% Adapalene GEL.1% Adefovir Dipivoxil TABS 10 MG ADEMPAS TABS.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG ADVAIR DISKUS ADVAIR HFA ADVANCED CALCIUM FORMULA ADVIL ALLERGY & CONGESTIO ADVIL ALLERGY SINUS ADVIL COLD & SINUS ADVIL JUNIOR STRENGTH TABS 100 MG AFINITOR DISPERZ TBSO 2 MG, 3 MG, 5 MG AFINITOR TABS 10 MG, 2.5 MG, 5 MG, 7.5 MG AGGRENOX ALA-HIST IR TABS 2 MG ALA-HIST PE ALBENZA TABS 200 MG Albuterol Sulfate AERS 108 MCG/ACT Albuterol Sulfate NEBU.083%,.5%,.63 MG/3ML, 1.25 MG/3ML Albuterol Sulfate SYRP 2 MG/5ML Albuterol Sulfate TABS 2 MG, 4 MG Albuterol Sulfate TB12 4 MG, 8 MG Alclometasone Dipropionate CREA.05% Alclometasone Dipropionate OINT.05% ALDURAZYME SOLN 2.9 MG/5ML Alendronate Sodium TABS 10 MG, 40 MG, 5 MG Alendronate Sodium TABS 35 MG, 70 MG Alfuzosin HCl TB24 10 MG ALIMTA SOLR 100 MG, 500 MG ALINIA SUSR 100 MG/5ML ALINIA TABS 500 MG ALLEGRA ALLERGY CHILDRENS TABS 30 MG Allopurinol TABS 100 MG, 300 MG Alosetron HCl TABS.5 MG, 1 MG ALPHAGAN P SOLN.1% Alprazolam TABS.25 MG Alprazolam TABS.5 MG Alprazolam TABS 1 MG Alprazolam TABS 2 MG ALREX SUSP.2% Alum & Mag Hydrox-Simethicone, ALUMINUM HYDROXIDE SUSP 320 MG/5ML Aluminum Hydroxide-Mag Carb, Aluminum Hydroxide-Mag Trisil Amantadine HCl CAPS 100 MG Amantadine HCl SYRP 50 MG/5ML Amantadine HCl TABS 100 MG AMBISOME SUSR 50 MG Amifostine Crystalline SOLR 500 MG Amikacin Sulfate SOLN 1 GM/4ML, 500 MG/2ML Amiloride & Hydrochlorothiazide Amiloride HCl TABS 5 MG Amino Acid Infusion Aminophylline SOLN 25 MG/ML Aminosalicylic Acid PACK 4 GM AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTE NSLIJHealthPlans.com/FIDALiveWell 頁碼 91

93 AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF Amiodarone HCl SOLN 50 MG/ML, 900 MG/18ML Amiodarone HCl TABS 100 MG, 200 MG, 400 MG AMITIZA CAPS 24 MCG, 8 MCG Amitriptyline HCl TABS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG Amlodipine Besylate TABS 10 MG Amlodipine Besylate TABS 2.5 MG, 5 MG Amlodipine Besylate-Benazepril HCl CAPS Amlodipine Besylate-Valsartan TABS Amlodipine-Valsartan-Hydrochlorothiazide TABS Amoxapine TABS 100 MG, 150 MG, 25 MG, 50 MG Amoxicillin & Pot Clavulanate TB Amoxicillin CAPS 250 MG, 500 MG Amoxicillin CHEW 125 MG, 250 MG Amoxicillin SUSR 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML Amoxicillin TABS 500 MG, 875 MG Amphetamine-Dextroamphetamine CP Amphetamine-Dextroamphetamine TABS Amphotericin B SOLR 50 MG Ampicillin & Sulbactam Sodium Ampicillin CAPS 250 MG, 500 MG Ampicillin Sodium SOLR 1 GM, 10 GM, 125 MG, 2 GM, 250 MG, 500 MG Ampicillin SUSR 125 MG/5ML, 250 MG/5ML AMPYRA TB12 10 MG Anagrelide HCl CAPS.5 MG, 1 MG Anastrozole TABS 1 MG ANDRODERM PT24 2 MG/24HR, 4 MG/24HR ANORO ELLIPTA ANTIOXIDANT FORMULA SG APAP 500 LIQD 500 MG/5ML APOKYN SOLN 10 MG/ML APTIOM TABS 200 MG APTIOM TABS 400 MG APTIOM TABS 600 MG APTIOM TABS 800 MG APTIVUS CAPS 250 MG APTIVUS SOLN 100 MG/ML AQUA-E ARALAST NP SOLR 1000 MG, 400 MG, 500 MG, 800 MG ARCALYST SOLR 220 MG Aripiprazole SUSR 300 MG, 400 MG Aripiprazole TABS 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG Armodafinil TABS 200 MG Artificial Tear Ointment ASACOL HD TBEC 800 MG Ascorbic Acid, Ascorbic Acid CHEW 100 MG, 250 MG Ascorbic Acid LOZG 60 MG Ascorbic Acid SYRP 500 MG/5ML Ascorbic Acid TABS 100 MG, 250 MG, 500 MG Ascorbic Acid TBCR 1000 MG, 500 MG Asenapine Maleate SUBL 10 MG Asenapine Maleate SUBL 5 MG Aspirin Buffered (Cal Carb-Mag Carb-Mag Oxide) Aspirin SUPP 300 MG, 600 MG Aspirin TABS 325 MG, 81 MG Aspirin TBEC 325 MG, 500 MG, 650 MG ASPIRIN/DIPYRIDAMOLE ASTEPRO SOLN.15% Atenolol & Chlorthalidone Atenolol TABS 100 MG, 25 MG, 50 MG Atorvastatin Calcium TABS 10 MG, 20 MG, 40 MG, 80 MG Atovaquone SUSP 750 MG/5ML Atovaquone-Proguanil HCl TABS ATRIPLA ATROVENT HFA AERS 17 MCG/ACT AUVI-Q SOAJ.15 MG/0.15ML,.3 MG/0.3ML AVASTIN SOLN 100 MG/4ML, 400 MG/16ML AVITA CREA.025% AVITA GEL.025% AVODART CAPS.5 MG AXID AR TABS 75 MG AXIRON SOLN 30 MG/ACT AYR NASAL DROPS SOLN.65% Azacitidine SUSR 100 MG AZACTAM IN ISO-OSMOTIC DE Azathioprine TABS 50 MG Azelastine HCl (Ophth) SOLN.05% Azelastine HCl SOLN.1%,.15% AZILECT TABS.5 MG, 1 MG AZITHROMYCIN PACK 1 GM Azithromycin SOLR 500 MG Azithromycin SUSR 100 MG/5ML, 200 MG/5ML Azithromycin TABS 250 MG, 500 MG, 600 MG AZOPT SUSP 1% AZOR TABS Aztreonam SOLR 1 GM, 2 GM B B Complex w/ C, B-12 DOTS TBDP 500 MCG B-12 QUICK DISSOLVE TBDP 5000 MCG B-Complex Vitamins, B-Complex w/ C & Calcium B-Complex w/ C & E + Zn B-Complex w/ C & Folic Acid B-Complex w/ Minerals B-NATAL LOZG 25 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 92

94 B-NATAL LPOP 25 MG Bacitracin (Ophthalmic) OINT 500 UNIT/GM Bacitracin (Topical) OINT 500 UNIT/GM Bacitracin Zinc OINT 500 UNIT/GM Bacitracin-Poly-Neomycin-HC Bacitracin-Polymyxin B Bacitracin-Polymyxin B (Ophth) Baclofen TABS 10 MG, 20 MG Balsalazide Disodium CAPS 750 MG BANZEL SUSP 40 MG/ML BANZEL TABS 200 MG, 400 MG BARACLUDE SOLN.05 MG/ML BCG VACCINE BELEODAQ SOLR 500 MG Benazepril & Hydrochlorothiazide Benazepril HCl TABS 10 MG, 20 MG, 40 MG, 5 MG BENICAR HCT BENICAR TABS 20 MG, 40 MG, 5 MG BENLYSTA SOLR 120 MG, 400 MG Benzocaine-Docusate Sodium Benzonatate CAPS 100 MG, 150 MG, 200 MG Benzoyl Peroxide BAR 10% Benzoyl Peroxide GEL 10%, 5%, 2.5% Benzoyl Peroxide LIQD 10%, 5% Benzoyl Peroxide LOTN 6% Benzoyl Peroxide-Erythromycin BENZTROPINE MESYLATE SOLN 1 MG/ML Benztropine Mesylate TABS.5 MG, 1 MG, 2 MG BEPREVE SOLN 1.5% BESIVANCE SUSP.6% Beta Carotene CAPS 15 MG, UNIT Betamethasone Dipropionate (Topical) CREA.05% Betamethasone Dipropionate (Topical) LOTN.05% Betamethasone Dipropionate (Topical) OINT.05% Betamethasone Dipropionate Augmented CREA.05% Betamethasone Dipropionate Augmented GEL.05% Betamethasone Dipropionate Augmented LOTN.05% Betamethasone Dipropionate Augmented OINT.05% Betamethasone Valerate CREA.1% Betamethasone Valerate LOTN.1% Betamethasone Valerate OINT.1% BETASERON KIT.3 MG Betaxolol HCl (Ophth) SOLN.5% Bethanechol Chloride TABS 10 MG, 25 MG, 5 MG, 50 MG BETOPTIC-S SUSP.25% BEXSERO Bicalutamide TABS 50 MG BICILLIN L-A SUSP UNIT/2ML, UNIT/4ML, UNIT/ML BICNU SOLR 100 MG BILTRICIDE TABS 600 MG BIOSPEC DMX Biotin CAPS 5 MG Biotin TABS 300 MCG Bisacodyl SUPP 10 MG Bisacodyl TBEC 5 MG Bisacodyl-PEG 3350-Pot Chloride-Sod Bicarb-Sod Chloride Bismuth Subsalicylate CHEW 262 MG Bismuth Subsalicylate SUSP 262 MG/15ML, 525 MG/15ML Bismuth Subsalicylate TABS 262 MG Bisoprolol & Hydrochlorothiazide Bisoprolol Fumarate TABS 10 MG, 5 MG BIVIGAM SOLN 5 GM/50ML Bleomycin Sulfate SOLR 15 UNIT, 30 UNIT BONE DENSITY Bone Meal w/ Vitamin D BOOSTRIX BOSULIF TABS 100 MG, 500 MG BOUDREAUXS BUTT PASTE OINT 16% BREO ELLIPTA Brimonidine Tartrate SOLN.2%,.15% BROHIST D Bromfenac Sodium (Ophth) SOLN.09% BROMFENAC SOLN.09% Bromocriptine Mesylate CAPS 5 MG Bromocriptine Mesylate TABS 2.5 MG Brompheniramine & Phenyleph, Brompheniramine & Pseudoeph Budesonide (Inhalation) SUSP.25 MG/2ML,.5 MG/2ML Budesonide CP24 3 MG Bumetanide SOLN.25 MG/ML Bumetanide TABS.5 MG, 1 MG, 2 MG BuprenorphineHCl SUBL 2 MG, 8 MG BuprenorphineHCl-Naloxone HCl Dihydrate Bupropion HCl (Smoking Deterrent) TB MG Bupropion HCl TABS 100 MG, 75 MG Bupropion HCl TB MG, 150 MG, 200 MG Bupropion HCl TB MG Bupropion HCl TB MG Buspirone HCl TABS 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG BUSULFEX SOLN 6 MG/ML ButorphanolTartrate SOLN 1 MG/ML, 2 MG/ML BYDUREON PEN 2 MG BYDUREON SUSR 2 MG BYETTA SOPN 10 MCG/0.04ML, 5 MCG/0.02ML BYSTOLIC TABS 10 MG, 2.5 MG, 20 MG, 5 MG C Cabergoline TABS.5 MG CAL-CITRATE PLUS VITAMIN CAL-QUICK CAL/MAG CALCET CREAMY BITES CALCET PETITES CALCI-MIX CAPS 1250 MG CALCIONATE SYRP 1.8 GM/5ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 93

95 Calcipotriene CREA.005% Calcipotriene OINT.005% Calcipotriene SOLN.005% Calcitonin (Salmon) SOLN 200 UNIT/ACT Calcitriol CAPS.25 MCG,.5 MCG Calcitriol SOLN 1 MCG/ML CALCIUM & MAGNESIUM CALCIUM D CALCIUM Calcium Acetate (Phosphate Binder) CAPS 667 MG Calcium Acetate (Phosphate Binder) TABS 667 MG Calcium Ascorbate TABS 500 MG Calcium Carbonate (Antacid) CHEW 1000 MG, 400 MG, 420 MG, 500 MG, 750 MG CALCIUM CARBONATE CHEW 260 MG CALCIUM CARBONATE POWD 800 MG/2GM Calcium Carbonate SUSP 1250 MG/5ML Calcium Carbonate TABS 1250 MG, 600 MG Calcium Carbonate-Cholecalciferol Calcium Carbonate-Ergocalciferol Calcium Carbonate-Mag Hydrox Calcium Carbonate-Simethicone Calcium Carbonate-Vitamin D Calcium Carbonate-Vitamin D w/ Minerals, CALCIUM CITRATE GRAN 760 MG/3.5GM CALCIUM CITRATE MALATE/VI CALCIUM CITRATE TABS 250 MG CALCIUM CITRATE W/D Calcium Citrate-Vitamin D Calcium Gluconate TABS 500 MG, 50 MG, 500 MG CALCIUM GUMMIES Calcium Lactate TABS 650 MG, 100 MG, 648 MG Calcium Pantothenate TABS 500 MG Calcium Polycarbophil TABS 625 MG Calcium TABS 500 MG Calcium w/ Magnesium Calcium w/ Vitamins D & K Calcium-Magnesium w/ Vitamin D Calcium-Magnesium-Zinc CALCIUM/C/D CALCIUM/MAGNESIUM/VITAMIN CALCIUM/MAGNESIUM/ZINC CALMAG THINS CALTRATE 600+D SOFT CHEWS CANASA SUPP 1000 MG CANCIDAS SOLR 50 MG, 70 MG CAPASTAT SULFATE SOLR 1 GM CAPRELSA TABS 100 MG, 300 MG Captopril & Hydrochlorothiazide Captopril TABS 100 MG, 12.5 MG, 25 MG, 50 MG CARBAGLU TABS 200 MG Carbamazepine CHEW 100 MG Carbamazepine CP MG, 200 MG, 300 MG Carbamazepine SUSP 100 MG/5ML Carbamazepine TABS 200 MG Carbamazepine TB MG, 400 MG Carbidopa-Levodopa TABS CARBIDOPA/LEVODOPA/ENTACA Carbonyl Iron SUSP 15 MG/1.25ML Carboplatin SOLN 150 MG/15ML, 450 MG/45ML, 50 MG/5ML, 600 MG/60ML Carboxymethylcellulose Sodium (Ophth) GEL 1% Carboxymethylcellulose Sodium (Ophth) SOLN.5% Carboxymethylcellulose-Glycerin CARIMUNE NANOFILTERED SOLR 12 GM Carteolol HCl (Ophth) SOLN 1% Carvedilol TABS 12.5 MG, 25 MG, MG, 6.25 MG Castellani Paint LIQD 1.5% CAYSTON SOLR 75 MG Cefaclor CAPS 250 MG, 500 MG CefaclorMonohydrate TB MG Cefaclor SUSR 125 MG/5ML, 250 MG/5ML, 375 MG/5ML Cefadroxil CAPS 500 MG Cefadroxil SUSR 250 MG/5ML, 500 MG/5ML Cefadroxil TABS 1 GM Cefazolin in D5W Cefazolin Sodium SOLR 1 GM, 10 GM, 20 GM, 500 MG Cefdinir CAPS 300 MG Cefdinir SUSR 125 MG/5ML, 250 MG/5ML Cefepime HCl SOLR 1 GM, 2 GM Cefixime CHEW 100 MG, 200 MG Cefixime SUSR 100 MG/5ML, 200 MG/5ML Cefotaxime Sodium SOLR 1 GM, 2 GM, 500 MG CefoxitinSodium SOLR 1 GM, 10 GM, 2 GM Cefpodoxime Proxetil SUSR 100 MG/5ML, 50 MG/5ML Cefpodoxime Proxetil TABS 100 MG, 200 MG Cefprozil SUSR 125 MG/5ML, 250 MG/5ML Cefprozil TABS 250 MG, 500 MG Ceftazidime SOLR 2 GM, 1 GM, 2 GM, 6 GM CEFTAZIDIME/DEXTROSE Ceftriaxone Sodium SOLR 1 GM, 10 GM, 2 GM, 250 MG, 500 MG Cefuroxime Axetil TABS 250 MG, 500 MG Cefuroxime Sodium SOLR 1.5 GM, 7.5 GM, 750 MG Celecoxib CAPS 100 MG, 200 MG, 400 MG, 50 MG CELONTIN CAPS 300 MG CENTRUM SILVER Cephalexin CAPS 250 MG, 500 MG Cephalexin SUSR 125 MG/5ML, 250 MG/5ML CERDELGA CAPS 84 MG CEREZYME SOLR 400 UNIT CERVARIX Cetirizine HCl CHEW 10 MG, 5 MG Cetirizine HCl SOLN 5 MG/5ML Cetirizine HCl SYRP 1 MG/ML Cetirizine HCl TABS 10 MG, 5 MG Cetirizine-Pseudoephedrine Cevimeline HCl CAPS 30 MG CHANTIX CONTINUING MONTH TABS 1 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 94

96 CHANTIX STARTING MONTH PA CHANTIX TABS.5 MG, 1 MG CHELATED CALCIUM TABS 200 MG CHEMET CAPS 100 MG CHLO TUSS EX Chlorhexidine Gluconate (Mouth-Throat) SOLN.12% Chloroquine Phosphate TABS 250 MG, 500 MG Chlorothiazide TABS 250 MG, 500 MG Chlorpheniramine & Phenylephrine Chlorpheniramine & Pseudoeph Chlorpheniramine Maleate SYRP 2 MG/5ML Chlorpheniramine Maleate TBCR 12 MG Chlorpheniramine-DM Chlorpheniramine-Phenylephrine-Acetaminophen Chlorpromazine HCl SOLN 25 MG/ML Chlorpromazine HCl TABS 10 MG, 100 MG, 200 MG, 25 MG, 50 MG Chlorthalidone TABS 25 MG, 50 MG Cholecalciferol CAPS 1000 UNIT, UNIT, 2000 UNIT, 400 UNIT, 5000 UNIT, UNIT Cholecalciferol CHEW 1000 UNIT, 400 UNIT Cholecalciferol LIQD 400 UNIT/ML, 5000 UNIT/ML Cholecalciferol TABS 1000 UNIT, 2000 UNIT, 400 UNIT, 5000 UNIT Cholestyramine Light PACK 4 GM Cholestyramine Light POWD 4 GM/DOSE Cholestyramine PACK 4 GM Cholestyramine POWD 4 GM/DOSE Choline Fenofibrate CPDR 135 MG, 45 MG Ciclopirox GEL.77% CiclopiroxOlamine CREA.77% CiclopiroxOlamine SUSP.77% Ciclopirox SHAM 1% Cilostazol TABS 100 MG, 50 MG CILOXAN OINT.3% CIMZIA KIT 200 MG, 200 MG/ML CIMZIA STARTER KIT KIT 200 MG/ML CINRYZE SOLR 500 UNIT CIPRODEX Ciprofloxacin HCl (Ophth) SOLN.3% Ciprofloxacin HCl TABS 100 MG, 250 MG, 500 MG, 750 MG Ciprofloxacin in D5W SOLN Ciprofloxacin SOLN 200 MG/20ML, 400 MG/40ML Ciprofloxacin SUSR 250 MG/5ML, 500 MG/5ML Ciprofloxacin-Ciprofloxacin HCl Cisplatin SOLN 100 MG/100ML, 200 MG/200ML, 50 MG/50ML Citalopram Hydrobromide SOLN 10 MG/5ML Citalopram Hydrobromide TABS 10 MG, 20 MG Citalopram Hydrobromide TABS 40 MG CITRACAL CALCIUM GUMMIES CITRACAL PLUS HEART HEALT Cladribine SOLN 1 MG/ML Clarithromycin SUSR 125 MG/5ML, 250 MG/5ML Clarithromycin TABS 250 MG, 500 MG Clarithromycin TB MG CLARITIN CHEW 5 MG CLARITIN REDITABS TBDP 5 MG CLASSIC PRENATAL Clindamycin HCl CAPS 150 MG, 300 MG, 75 MG Clindamycin Palmitate Hydrochloride SOLR 75 MG/5ML Clindamycin Phosphate (Topical) GEL 1% Clindamycin Phosphate (Topical) LOTN 1% Clindamycin Phosphate (Topical) SOLN 1% Clindamycin Phosphate (Topical) SWAB 1% Clindamycin Phosphate in D5W Clindamycin Phosphate SOLN 150 MG/ML, 300 MG/2ML, 600 MG/4ML, 900 MG/6ML, 9000 MG/60ML Clindamycin Phosphate Vaginal CREA 2% CLINIMIX 2.75%/DEXTROSE CLINIMIX 4.25%/DEXTROSE CLINIMIX 4.25%/DEXTROSE CLINIMIX 4.25%/DEXTROSE CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% Clobetasol Propionate CREA.05% Clobetasol Propionate Emollient Base CREA.05% Clobetasol Propionate GEL.05% Clobetasol Propionate OINT.05% Clobetasol Propionate SOLN.05% Clomipramine HCl CAPS 25 MG, 50 MG, 75 MG Clonazepam TABS.5 MG Clonazepam TABS 1 MG Clonazepam TABS 2 MG Clonazepam TBDP.125 MG Clonazepam TBDP.25 MG Clonazepam TBDP.5 MG Clonazepam TBDP 1 MG Clonazepam TBDP 2 MG Clonidine HCl PTWK.1 MG/24HR,.2 MG/24HR,.3 MG/24HR Clonidine HCl TABS.1 MG,.2 MG,.3 MG Clopidogrel Bisulfate TABS 75 MG Clorazepate Dipotassium TABS 15 MG Clorazepate Dipotassium TABS 3.75 MG, 7.5 MG Clotrimazole (Topical) CREA 1% Clotrimazole (Topical) SOLN 1% Clotrimazole TROC 10 MG Clotrimazole Vaginal CREA 1%, 2% CLOZAPINE ODT TBDP 150 MG CLOZAPINE ODT TBDP 200 MG Clozapine TABS 100 MG Clozapine TABS 200 MG Clozapine TABS 25 MG, 50 MG Clozapine TBDP 100 MG Clozapine TBDP 12.5 MG, 25 MG COARTEM Cod Liver Oil NSLIJHealthPlans.com/FIDALiveWell 頁碼 95

97 CODITUSS DM Colchicine w/ Probenecid COLCRYS TABS.6 MG Colestipol HCl GRAN 5 GM Colestipol HCl PACK 5 GM Colestipol HCl TABS 1 GM Colistimethate Sodium SOLR 150 MG COMBIGAN COMBIVENT RESPIMAT COMETRIQ COMETRIQ KIT 20 MG COMPLERA COMPLETE SINUS RELIEF COMVAX CONEX COLD/ALLERGY CONTAC COLD/FLU MAXIMUM S COPAXONE SOSY 40 MG/ML CORAL CALCIUM CORAL CALCIUM PLUS Coral Calcium-Magnesium w/ Vitamin D Corn Dextrin Cortisone Acetate TABS 25 MG COUMADIN TABS 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG CREON CRESTOR TABS 10 MG, 20 MG, 40 MG, 5 MG CRIXIVAN CAPS 200 MG, 400 MG Cromolyn Sodium (Mastocytosis) CONC 100 MG/5ML.. 58 Cromolyn Sodium (Nasal) AERS 5.2 MG/ACT Cromolyn Sodium (Ophth) SOLN 4% Cromolyn Sodium NEBU 20 MG/2ML CUBICIN SOLR 500 MG CUVPOSA SOLN 1 MG/5ML CVS CALCIUM CITRATE TABS 200 MG CVS HDYROCORTISONE ACETAT CREA.5% CVS NASAL MIST AERS.9% CVS VITAMIN C CHEW 1000 MG Cyanocobalamin LIQD 1000 MCG/15ML Cyanocobalamin SOLN 1000 MCG/ML Cyanocobalamin SUBL 1000 MCG, 2500 MCG Cyanocobalamin TABS 2000 MCG, 250 MCG, 500 MCG Cyanocobalamin TBCR 2000 MCG Cyanocobalamin TBDP 1500 MCG CYCLOPHOSPHAMIDE CAPS 25 MG, 50 MG Cyclophosphamide SOLR 1 GM, 500 MG Cyclophosphamide SOLR 2 GM Cycloserine CAPS 250 MG Cyclosporine CAPS 100 MG, 25 MG Cyclosporine Modified (For Microemulsion) CAPS 100 MG, 25 MG, 50 MG Cyclosporine Modified (For Microemulsion) SOLN 100 MG/ ML Cyclosporine SOLN 50 MG/ML CYSTADANE CYSTAGON CAPS 150 MG, 50 MG Cytarabine SOLN 20 MG/ML CYTO B2 POWD 343 MG/GM D Dacarbazine SOLR 200 MG DALIRESP TABS 500 MCG Danazol CAPS 100 MG, 200 MG, 50 MG Dantrolene Sodium CAPS 100 MG, 25 MG, 50 MG Dapsone TABS 100 MG, 25 MG DAPTACEL DARAPRIM TABS 25 MG Daunorubicin HCl INJ 5 MG/ML DELESTROGEN OIL 10 MG/ML DELTUSS DP DELZICOL CPDR 400 MG DEMSER CAPS 250 MG DEPEN TITRATABS TABS 250 MG DEPO-PROVERA SUSP 400 MG/ML Desipramine HCl TABS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG DESITIN CREA 13% DESMOPRESSIN ACETATE SOLN.01% Desmopressin Acetate SOLN 4 MCG/ML Desmopressin Acetate Spray Refrigerated SOLN.01% Desmopressin Acetate Spray SOLN.01% Desmopressin Acetate TABS.1 MG,.2 MG Desogestrel & Ethinyl Estradiol Desogestrel-Ethinyl Estradiol (Biphasic) Desogestrel-Ethinyl Estradiol (Triphasic) DESONIDE CREA.05% Desonide LOTN.05% Desonide OINT.05% Desoximetasone CREA.05%,.25% Desoximetasone GEL.05% Desoximetasone OINT.25%,.05% Desvenlafaxine Succinate TB MG, 50 MG Dexamethasone CONC 1 MG/ML Dexamethasone ELIX.5 MG/5ML Dexamethasone Sodium Phosphate (Ophth) SOLN.1% Dexamethasone Sodium Phosphate SOLN 10 MG/ML, 100 MG/10ML, 120 MG/30ML, 20 MG/5ML Dexamethasone SOLN.5 MG/5ML Dexamethasone TABS.5 MG,.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 MG DEXILANT CPDR 30 MG, 60 MG Dexrazoxane SOLR 250 MG Dextromethorphan HBr CAPS 15 MG Dextromethorphan HBr LIQD 15 MG/5ML, 7.5 MG/5ML Dextromethorphan HBr SYRP 7.5 MG/5ML Dextromethorphan Polistirex LQCR 30 MG/5ML Dextromethorphan-Guaifenesin Dextromethorphan-Phenylephrine-Acetaminophen DEXTROSE 10% FLEX CONTAIN SOLN 10% DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.45% NSLIJHealthPlans.com/FIDALiveWell 頁碼 96

98 DEXTROSE 2.5%/SODIUM CHLO DEXTROSE 5% /ELECTROLYTE DEXTROSE 5% SOLN 5% DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 50% SOLN 50% DEXTROSE 70% SOLN 70% DIALYVITE 800/ZINC DIALYVITE VITAMIN D3 MAX TABS UNIT Diazepam CONC 5 MG/ML DIAZEPAM GEL 10 MG, 2.5 MG, 20 MG Diazepam SOLN 1 MG/ML Diazepam SOLN 5 MG/ML Diazepam TABS 10 MG, 2 MG, 5 MG Diclofenac Potassium TABS 50 MG Diclofenac Sodium (Ophth) SOLN.1% Diclofenac Sodium TB MG Diclofenac Sodium TBEC 25 MG, 50 MG, 75 MG Dicloxacillin Sodium CAPS 250 MG, 500 MG Dicyclomine HCl CAPS 10 MG Dicyclomine HCl SOLN 10 MG/5ML Dicyclomine HCl TABS 20 MG Didanosine CPDR 125 MG, 200 MG, 250 MG, 400 MG DIFICID TABS 200 MG Diflorasone Diacetate CREA.05% Diflorasone Diacetate OINT.05% Diflunisal TABS 500 MG DIGOXIN SOLN.05 MG/ML Digoxin SOLN.25 MG/ML Digoxin TABS.125 MG, 125 MCG Digoxin TABS.25 MG, 250 MCG Dihydroergotamine Mesylate SOLN 1 MG/ML DILANTIN-125 SUSP 125 MG/5ML Diltiazem HCl Coated Beads CP MG, 180 MG, 240 MG, 300 MG, 360 MG Diltiazem HCl CP MG, 60 MG, 90 MG Diltiazem HCl CP MG, 180 MG, 240 MG Diltiazem HCl Extended Release Beads CP MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG Diltiazem HCl SOLN 125 MG/25ML, 25 MG/5ML, 50 MG/10ML Diltiazem HCl TABS 120 MG, 30 MG, 60 MG, 90 MG Dimenhydrinate TABS 50 MG DIMETAPP LONG ACTING COUG DIPENTUM CAPS 250 MG Diphenhydramine HCl (Sleep) CAPS 50 MG Diphenhydramine HCl CAPS 25 MG, 50 MG Diphenhydramine HCl CHEW 12.5 MG Diphenhydramine HCl LIQD 12.5 MG/5ML Diphenhydramine HCl SOLN 50 MG/ML Diphenhydramine HCl TABS 25 MG Diphenhydramine HCl TBDP 12.5 MG Diphenhydramine-Acetaminophen Diphenhydramine-Acetaminophen (sleep) Diphenhydramine-Phenylephrine Diphenhydramine-Phenylephrine-Acetaminophen Diphenoxylate w/ Atropine DIPHTHERIA/TETANUS TOXOID Disopyramide Phosphate CAPS 100 MG, 150 MG Disulfiram TABS 250 MG, 500 MG Divalproex Sodium CPSP 125 MG Divalproex Sodium TB MG, 500 MG Divalproex Sodium TBEC 125 MG, 250 MG, 500 MG Docetaxel CONC 140 MG/7ML, 20 MG/ML, 80 MG/4ML DOCETAXEL SOLN 200 MG/20ML, 80 MG/8ML Docusate Calcium CAPS 240 MG Docusate Sodium CAPS 100 MG, 50 MG Docusate Sodium ENEM 283 MG Docusate Sodium LIQD 50 MG/5ML Docusate Sodium SYRP 60 MG/15ML Docusate Sodium TABS 100 MG Donepezil Hydrochloride TABS 10 MG, 23 MG Donepezil Hydrochloride TABS 5 MG Donepezil Hydrochloride TBDP 10 MG Donepezil Hydrochloride TBDP 5 MG Dorzolamide HCl SOLN 2% Dorzolamide HCl-Timolol Maleate Doxazosin Mesylate TABS 1 MG, 2 MG, 4 MG Doxazosin Mesylate TABS 8 MG Doxepin HCl CAPS 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG Doxepin HCl CONC 10 MG/ML Doxorubicin HCl Liposomal INJ 2 MG/ML Doxorubicin HCl SOLN 2 MG/ML Doxorubicin HCl SOLR 50 MG Doxycycline (Monohydrate) CAPS 100 MG, 50 MG Doxycycline (Monohydrate) TABS 100 MG, 150 MG, 50 MG, 75 MG Doxycycline Hyclate CAPS 100 MG, 50 MG Doxycycline Hyclate SOLR 100 MG, 100 MG Doxycycline Hyclate TABS 100 MG, 20 MG Doxylamine Succinate (Sleep) TABS 25 MG Doxylamine-Phenylephrine-Acetaminophen Dronabinol CAPS 10 MG Dronabinol CAPS 2.5 MG, 5 MG Drospirenone-Ethinyl Estradiol DROXIA CAPS 200 MG, 300 MG, 400 MG Duloxetine HCl CPEP 20 MG, 30 MG, 60 MG DURAFLU DURAMORPH SOLN.5 MG/ML, 1 MG/ML DUREZOL EMUL.05% E Econazole Nitrate CREA 1% ED CHLORPED D NSLIJHealthPlans.com/FIDALiveWell 頁碼 97

99 ED CHLORPED LIQD 2 MG/ML EDURANT TABS 25 MG EFFIENT TABS 10 MG, 5 MG ELDERTONIC ELIDEL CREA 1% ELIQUIS TABS 2.5 MG, 5 MG ELITEK SOLR 1.5 MG, 7.5 MG ELMIRON CAPS 100 MG EMCYT CAPS 140 MG EMEND EMEND CAPS 125 MG, 40 MG, 80 MG EMTRIVA CAPS 200 MG EMTRIVA SOLN 10 MG/ML Enalapril Maleate & Hydrochlorothiazide Enalapril Maleate TABS 10 MG, 2.5 MG, 20 MG, 5 MG ENGERIX-B SUSP 10 MCG/0.5ML, 20 MCG/ML Enoxaparin Sodium SOLN 100 MG/ML, 120 MG/0.8ML, 150 MG/ML Enoxaparin Sodium SOLN 30 MG/0.3ML, 300 MG/3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80 MG/0.8ML ENTACAPONE TABS 200 MG Entecavir TABS.5 MG, 1 MG ENUCLENE SOLN.25% EPIPEN 2-PAK SOAJ.3 MG/0.3ML EPIPEN-JR 2-PAK SOAJ.15 MG/0.3ML Epirubicin HCl SOLN 200 MG/100ML, 50 MG/25ML EPIVIR HBV SOLN 5 MG/ML Eplerenone TABS 25 MG, 50 MG EPZICOM EQL CALCIUM/VITAMIN D EQL CHILDRENS CALCIUM GUM EQL CHILDRENS MULTIVITAMI EQUALACTIN CHEW 625 MG Ergocalciferol CAPS UNIT ERIVEDGE CAPS 150 MG Erythromycin (Acne Aid) GEL 2% Erythromycin (Acne Aid) PADS 2% Erythromycin (Acne Aid) SOLN 2% Erythromycin (Ophth) OINT 5 MG/GM Erythromycin Base CPEP 250 MG Erythromycin Base TABS 250 MG, 500 MG Erythromycin Base TBEC 250 MG, 333 MG, 500 MG Erythromycin Ethylsuccinate TABS 400 MG Erythromycin Lactobionate SOLR 500 MG Erythromycin Stearate TABS 250 MG ESBRIET CAPS 267 MG Escitalopram Oxalate SOLN 5 MG/5ML Escitalopram Oxalate TABS 10 MG, 5 MG Escitalopram Oxalate TABS 20 MG Esomeprazole Magnesium CPDR 20 MG, 40 MG Esomeprazole Sodium SOLR 20 MG, 40 MG Estradiol PTWK.025 MG/24HR,.05 MG/24HR,.06 MG/24HR,.075 MG/24HR,.1 MG/24HR, 37.5 MCG/24HR Estradiol TABS.5 MG, 1 MG, 2 MG Estradiol Vaginal CREA.1 MG/GM Estradiol Valerate OIL 20 MG/ML, 40 MG/ML Ethambutol HCl TABS 100 MG, 400 MG Ethosuximide CAPS 250 MG Ethosuximide SOLN 250 MG/5ML Ethynodiol Diacet & Eth Estrad Etodolac CAPS 200 MG, 300 MG Etodolac TABS 400 MG, 500 MG Etodolac TB MG, 500 MG, 600 MG Etoposide SOLN 1 GM/50ML, 500 MG/25ML EURAX CREA 10% EURAX LOTN 10% EVOTAZ EXELON PT MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR Exemestane TABS 25 MG EXJADE TBSO 125 MG, 250 MG, 500 MG EZFE FORTE F FABRAZYME SOLR 35 MG, 5 MG Famciclovir TABS 125 MG, 250 MG, 500 MG Famotidine in NaCl Famotidine SOLN 20 MG/2ML, 200 MG/20ML, 40 MG/4ML Famotidine SUSR 40 MG/5ML Famotidine TABS 10 MG, 20 MG Famotidine TABS 20 MG, 40 MG Famotidine-Calcium Carbonate-Magnesium Hydroxide FARESTON TABS 60 MG FARXIGA TABS 10 MG FARXIGA TABS 5 MG FARYDAK CAPS 10 MG, 15 MG, 20 MG FASLODEX SOLN 250 MG/5ML FAZACLO TBDP 150 MG FAZACLO TBDP 200 MG FEBROL SOLN 325 MG/5ML Felbamate SUSP 600 MG/5ML Felbamate TABS 400 MG, 600 MG Felodipine TB24 10 MG Felodipine TB MG Felodipine TB24 5 MG Fenofibrate Micronized CAPS 134 MG, 200 MG, 67 MG Fenofibrate TABS 145 MG, 160 MG, 48 MG, 54 MG Fentanyl Citrate LPOP 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG Fentanyl PT MCG/HR, 50 MCG/HR, 75 MCG/HR Fentanyl PT72 12 MCG/HR, 25 MCG/HR FENTORA TABS 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG FERRETTS IPS SOLN 40 MG/15ML FERRIMIN 150 TABS 150 MG FERRIPROX TABS 500 MG Ferrous Fumarate TABS 325 MG, 29 MG, 90 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 98

100 Ferrous Gluconate TABS 240 MG, 324 MG, 225 MG, 324 MG Ferrous Sulfate Dried TABS 200 MG Ferrous Sulfate Dried TBCR 160 MG, 45 MG Ferrous Sulfate ELIX 220 MG/5ML FERROUS SULFATE LIQD 220 MG/5ML Ferrous Sulfate SOLN 15 MG/ML FERROUS SULFATE SYRP 300 MG/5ML Ferrous Sulfate TABS 27 MG, 325 MG Ferrous Sulfate TBCR 45 MG, 47.5 MG, 50 MG, 140 MG Ferrous Sulfate TBEC 325 MG, 324 MG FEVERALL INFANTS SUPP 80 MG Fexofenadine HCl SUSP 30 MG/5ML Fexofenadine HCl TABS 180 MG, 60 MG Fexofenadine-Pseudoephedrine Fiber Finasteride TABS 5 MG FIRAZYR SOLN 30 MG/3ML FLEBOGAMMA DIF SOLN.5 GM/10ML, 10%, 10 GM/200ML, 2.5 GM/50ML, 20 GM/400ML, 5 GM/100ML FLEBOGAMMA SOLN.5 GM/10ML, 5% Flecainide Acetate TABS 100 MG, 150 MG, 50 MG FLEET BISACODYL ENEM 10 MG/30ML FLORASTOR KIDS PACK 250 MG FLOVENT DISKUS AEPB 100 MCG/BLIST, 50 MCG/BLIST FLOVENT DISKUS AEPB 250 MCG/BLIST FLOVENT HFA AERO 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT Fluconazole in Dextrose Fluconazole in NaCl Fluconazole SUSR 10 MG/ML, 40 MG/ML Fluconazole TABS 100 MG, 150 MG, 200 MG, 50 MG Flucytosine CAPS 250 MG, 500 MG Fludarabine Phosphate SOLN 50 MG/2ML Fludarabine Phosphate SOLR 50 MG Fludrocortisone Acetate TABS.1 MG Flunisolide (Nasal) SOLN.025% Fluocinolone Acetonide (Otic) OIL.01% Fluocinolone Acetonide CREA.01%,.025% Fluocinolone Acetonide OIL.01% Fluocinolone Acetonide OINT.025% Fluocinolone Acetonide SOLN.01% Fluocinonide CREA.05% Fluocinonide Emulsified Base CREA.05% Fluocinonide GEL.05% Fluocinonide OINT.05% Fluocinonide SOLN.05% FLUOROMETHOLONE SUSP.1% Fluorouracil (Topical) CREA 5% Fluorouracil (Topical) SOLN 2%, 5% Fluorouracil SOLN 1 GM/20ML, 2.5 GM/50ML, 5 GM/100ML, 500 MG/10ML Fluoxetine HCl CAPS 10 MG Fluoxetine HCl CAPS 20 MG Fluoxetine HCl CAPS 40 MG Fluoxetine HCl SOLN 20 MG/5ML Fluoxetine HCl TABS 10 MG Fluoxetine HCl TABS 20 MG Fluphenazine Decanoate SOLN 25 MG/ML Fluphenazine HCl CONC 5 MG/ML Fluphenazine HCl ELIX 2.5 MG/5ML Fluphenazine HCl SOLN 2.5 MG/ML Fluphenazine HCl TABS 1 MG, 10 MG, 2.5 MG, 5 MG.. 41 Flurbiprofen Sodium SOLN.03% Flurbiprofen TABS 100 MG, 50 MG Flutamide CAPS 125 MG Fluticasone Furoate (Inhalation) AEPB 100 MCG/ACT, 200 MCG/ACT Fluticasone Furoate-Vilanterol Fluticasone Propionate (Nasal) SUSP 50 MCG/ACT Fluticasone Propionate CREA.05% Fluticasone Propionate OINT.005% Fluvoxamine Maleate TABS 100 MG Fluvoxamine Maleate TABS 25 MG, 50 MG FOLGARD FOLIC ACID CAPS 20 MG Folic Acid SOLN 5 MG/ML Folic Acid TABS 1 MG, 400 MCG, 800 MCG, 1 MG Folic Acid-Vitamin B6-Vitamin B FOLITAB Fondaparinux Sodium SOLN 10 MG/0.8ML, 5 MG/0.4ML, 7.5 MG/0.6ML Fondaparinux Sodium SOLN 2.5 MG/0.5ML FORTEO SOLN 600 MCG/2.4ML FORTICAL SOLN 200 UNIT/ACT Foscarnet Sodium SOLN 24 MG/ML Fosinopril Sodium & Hydrochlorothiazide Fosinopril Sodium TABS 10 MG, 20 MG, 40 MG FREAMINE HBC 6.9% FREAMINE III FRESHKOTE FUNGOID TINCTURE KIT 2% FUNGOID TINCTURE SOLN 2% Furosemide SOLN 10 MG/ML, 10 MG/ML, 8 MG/ML, 10 MG/ML Furosemide TABS 20 MG, 40 MG, 80 MG FUSILEV SOLR 50 MG FUZEON SOLR 90 MG FYCOMPA TABS 10 MG, 12 MG, 8 MG FYCOMPA TABS 2 MG FYCOMPA TABS 4 MG FYCOMPA TABS 6 MG G Gabapentin CAPS 100 MG Gabapentin CAPS 300 MG Gabapentin CAPS 400 MG Gabapentin SOLN 250 MG/5ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 99

101 Gabapentin TABS 600 MG Gabapentin TABS 800 MG GABITRIL TABS 12 MG, 16 MG Galantamine Hydrobromide CP24 16 MG, 8 MG Galantamine Hydrobromide CP24 24 MG Galantamine Hydrobromide SOLN 4 MG/ML Galantamine Hydrobromide TABS 12 MG Galantamine Hydrobromide TABS 4 MG Galantamine Hydrobromide TABS 8 MG GAMASTAN S/D GAMMAGARD LIQUID SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML GAMMAGARD S/D IGA LESS TH SOLR 10 GM, 5 GM GAMMAGARD S/D SOLR 2.5 GM GAMMAKED SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML GAMMAPLEX SOLN 10 GM/200ML, 2.5 GM/50ML, 5 GM/100ML GAMUNEX-C SOLN 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML Ganciclovir Sodium SOLR 500 MG GARDASIL GARDASIL Gatifloxacin (Ophth) SOLN.5% GATTEX KIT 5 MG GAVISCON GAVISCON EXTRA STRENGTH R Gemcitabine HCl SOLR 1 GM, 2 GM, 200 MG GEMCITABINE SOLN 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML Gemfibrozil TABS 600 MG Gentamicin in Saline Gentamicin Sulfate (Ophth) OINT.3% Gentamicin Sulfate (Ophth) SOLN.3% Gentamicin Sulfate (Topical) CREA.1% Gentamicin Sulfate (Topical) OINT.1% Gentamicin Sulfate SOLN 10 MG/ML, 40 MG/ML GENTIAN VIOLET SOLN 1%, 2% GEODON SOLR 20 MG GIANVI GILENYA CAPS.5 MG GILOTRIF TABS 20 MG, 30 MG, 40 MG Glatiramer Acetate SOSY 20 MG/ML GLEEVEC TABS 100 MG, 400 MG Glimepiride TABS 1 MG Glimepiride TABS 2 MG Glimepiride TABS 4 MG Glipizide TABS 10 MG Glipizide TABS 5 MG Glipizide TB24 10 MG Glipizide TB MG Glipizide TB24 5 MG Glipizide-Metformin HCl TABS GLUCAGEN HYPOKIT SOLR 1 MG GLUCAGON EMERGENCY KIT KIT 1 MG Glycerin-Hypromellose-Polyethylene Glycol Glycopyrrolate SOLN 4 MG/20ML Glycopyrrolate TABS 1 MG, 2 MG GOLYTELY GranisetronHCl SOLN.1 MG/ML, 1 MG/ML GranisetronHCl TABS 1 MG GRANIX SOSY 300 MCG/0.5ML, 480 MCG/0.8ML GriseofulvinMicrosize SUSP 125 MG/5ML GriseofulvinMicrosize TABS 500 MG GriseofulvinUltramicrosize TABS 125 MG, 250 MG Guaifenesin LIQD 100 MG/5ML, 200 MG/5ML Guaifenesin TABS 200 MG, 400 MG Guaifenesin TB MG Guaifenesin-Codeine Guanfacine HCl (ADHD) TB24 1 MG, 2 MG, 3 MG, 4 MG H Halobetasol Propionate CREA.05% Halobetasol Propionate OINT.05% Haloperidol Decanoate SOLN 100 MG/ML, 50 MG/ML Haloperidol Lactate CONC 2 MG/ML Haloperidol Lactate SOLN 5 MG/ML Haloperidol TABS.5 MG, 1 MG, 10 MG, 2 MG, 20 MG, 5 MG HARVONI HAVRIX SUSP 1440 ELU/ML, 720 ELU/0.5ML Heparin Sodium (Porcine) SOLN 1000 UNIT/ML, UNIT/ML, UNIT/ML, 5000 UNIT/ML HEPARIN SODIUM SOLN 2000 UNIT/ML, 2500 UNIT/ML.. 60 HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% HEPATAMINE HERCEPTIN SOLR 440 MG HETLIOZ CAPS 20 MG HEXALEN CAPS 50 MG HIBERIX SOLR 10 MCG HONEY BEARS HONEY BEARS W/IRON AND ZI HUMIRA PEN PNKT 40 MG/0.8ML HUMIRA PEN-CROHNS DISEASE PNKT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STAR PNKT 40 MG/0.8ML HUMIRA PSKT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML HUMULIN R U-500 CONCENTR SOLN 500 UNIT/ML Hydralazine HCl SOLN 20 MG/ML Hydralazine HCl TABS 10 MG, 100 MG, 25 MG, 50 MG Hydrochlorothiazide CAPS 12.5 MG Hydrochlorothiazide TABS 12.5 MG, 25 MG, 50 MG HYDROCIL INSTANT PACK 95% Hydrocodone-Acetaminophen SOLN Hydrocodone-Acetaminophen TABS Hydrocodone-Ibuprofen Hydrocortisone (Intrarectal) ENEM 100 MG/60ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 100

102 Hydrocortisone (Rectal) CREA 2.5%, 1%, 2.5% Hydrocortisone (Topical) CREA.5% Hydrocortisone (Topical) CREA 1% Hydrocortisone (Topical) CREA 1%, 2.5% Hydrocortisone (Topical) GEL 1% Hydrocortisone (Topical) LOTN 1% Hydrocortisone (Topical) LOTN 2.5% Hydrocortisone (Topical) OINT.5%, 1% Hydrocortisone (Topical) OINT 1%, 2.5% Hydrocortisone (Topical) SOLN 2.5% Hydrocortisone Acetate-Aloe Vera Hydrocortisone Butyrate CREA.1% Hydrocortisone Butyrate OINT.1% Hydrocortisone Butyrate SOLN.1% HYDROCORTISONE ENEM 100 MG/60ML Hydrocortisone Sod Succinate SOLR 100 MG Hydrocortisone Sod Succinate SOLR 250 MG Hydrocortisone TABS 10 MG, 20 MG, 5 MG Hydrocortisone Valerate CREA.2% Hydrocortisone Valerate OINT.2% Hydrocortisone-Aloe Vera Hydromorphone HCl LIQD 1 MG/ML Hydromorphone HCl SOLN 500 MG/50ML Hydromorphone HCl TABS 2 MG, 4 MG, 8 MG Hydroxocobalamin SOLN 1000 MCG/ML Hydroxychloroquine Sulfate TABS 200 MG Hydroxyurea CAPS 500 MG Hydroxyzine HCl SOLN 10 MG/5ML, 25 MG/ML, 50 MG/ML Hydroxyzine HCl TABS 10 MG, 25 MG, 50 MG Hydroxyzine Pamoate CAPS 100 MG, 25 MG, 50 MG HYPOTEARS Hypromellose (Gonioscopic) SOLN 2.5% Hypromellose (Ophth) SOLN.3%,.4% I Ibandronate Sodium TABS 150 MG IBRANCE CAPS 100 MG, 125 MG, 75 MG Ibuprofen CAPS 200 MG Ibuprofen CHEW 100 MG Ibuprofen SUSP 100 MG/5ML Ibuprofen SUSP 100 MG/5ML, 50 MG/1.25ML Ibuprofen TABS 200 MG Ibuprofen TABS 400 MG, 600 MG, 800 MG Ibuprofen-Diphenhydramine Citrate ICAPS LUTEIN/ZEAXANTHIN F ICLUSIG TABS 15 MG, 45 MG Icosapent Ethyl CAPS 1 GM Idarubicin HCl SOLN 10 MG/10ML, 20 MG/20ML, 5 MG/5ML Ifosfamide SOLN 1 GM/20ML, 3 GM/60ML Ifosfamide SOLR 1 GM Ifosfamide SOLR 3 GM, 3 GM ILEVRO SUSP.3% Iloperidone Iloperidone TABS 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG IMBRUVICA CAPS 140 MG Imiglucerase SOLR 200 UNIT Imipenem-Cilastatin Imipramine HCl TABS 10 MG, 25 MG, 50 MG Imiquimod CREA 5% Immune Globulin (Human) IV SOLN 10 GM/100ML IMOVAX RABIES (H.D.C.V.) INJ 2.5 UNIT/ML INCRELEX SOLN 40 MG/4ML Indapamide TABS 1.25 MG, 2.5 MG INFANRIX INLYTA TABS 1 MG, 5 MG INTEGRA INTELENCE TABS 100 MG, 200 MG, 25 MG INTRALIPID EMUL 20 GM/100ML, 30 GM/100ML INTRON A SOLN 10 MU/ML, UNIT/ML INTRON A SOLR 18 MU, 50 MU INTRON A W/DILUENT SOLR 10 MU INVANZ SOLR 1 GM INVIRASE CAPS 200 MG INVIRASE TABS 500 MG INVOKAMET TABS INVOKANA TABS 100 MG INVOKANA TABS 300 MG IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% IPOL INACTIVATED IPV Ipratropium Bromide (Nasal) SOLN.03%,.06% Ipratropium Bromide SOLN.02% Ipratropium-Albuterol Irbesartan TABS 150 MG, 300 MG, 75 MG Irbesartan-Hydrochlorothiazide Irinotecan HCl SOLN 100 MG/5ML, 40 MG/2ML, 500 MG/25ML IRON CHEWS PEDIATRIC CHEW 15 MG IRON TABS 256 MG IRON TABS 90 MG IRON UP LIQD 15 MG/0.5ML Iron w/ Vitamins Iron-Vitamin C Iron-Vitamin C-Vitamin B12-Folic Acid ISENTRESS CHEW 100 MG, 25 MG ISENTRESS PACK 100 MG ISENTRESS TABS 400 MG ISOLYTE-P/DEXTROSE 5% ISOLYTE-S Isoniazid SOLN 100 MG/ML Isoniazid SYRP 50 MG/5ML Isoniazid TABS 100 MG, 300 MG ISOPTO TEARS SOLN.5% Isosorbide Dinitrate TABS 10 MG, 20 MG, 30 MG, 5 MG Isosorbide Dinitrate TBCR 40 MG Isosorbide Mononitrate TABS 10 MG, 20 MG Isosorbide Mononitrate TB MG, 30 MG, 60 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 101

103 Isotretinoin CAPS 30 MG, 10 MG, 20 MG, 30 MG, 40 MG Isradipine CAPS 2.5 MG, 5 MG ISTALOL SOLN.5% ISTODAX SOLR 10 MG Itraconazole CAPS 100 MG Ivermectin TABS 3 MG IXIARO J J-MAX J-TAN D PD J-TAN PD LIQD 1 MG/ML JAKAFI TABS 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JALYN JANUMET JANUMET XR TB JANUVIA TABS 100 MG, 25 MG, 50 MG JENTADUETO JOLESSA JOLIVETTE TABS.35 MG JUXTAPID CAPS 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG K KADCYLA SOLR 100 MG, 160 MG KALETRA TABS KALYDECO PACK 50 MG, 75 MG KALYDECO TABS 150 MG KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% Ketoconazole (Topical) CREA 2% Ketoconazole (Topical) SHAM 2% Ketoconazole TABS 200 MG Ketoprofen CAPS 50 MG, 75 MG Ketorolac Tromethamine (Ophth) SOLN.4%,.5% Ketotifen Fumarate (Ophth) SOLN.025% KEYTRUDA SOLN 100 MG/4ML KEYTRUDA SOLR 50 MG KINRIX KLOR-CON 10 TBCR 10 MEQ KLOR-CON 8 TBCR 8 MEQ KONSYL PACK 100%, 28.3% KONSYL POWD 60.3%, 71.67% KONSYL-D POWD 52.3% KORLYM TABS 300 MG KPN PRENATAL KUVAN PACK 100 MG, 500 MG KUVAN TBSO 100 MG KYNAMRO SOSY 200 MG/ML L Labetalol HCl TABS 100 MG, 200 MG, 300 MG LACTATED RINGERS DEXTROSE LACTATED RINGERS VIAFLEX Lactic Acid (Ammonium Lactate) CREA 12% Lactic Acid (Ammonium Lactate) LOTN 12% Lactobacillus Lactobacillus Rhamnosus (GG) CAPS 10 B CELL Lactulose (Encephalopathy) SOLN 10 GM/15ML Lactulose SOLN 10 GM/15ML LAMISIL ADVANCED GEL 1% Lamivudine (HBV) TABS 100 MG Lamivudine SOLN 10 MG/ML Lamivudine TABS 150 MG, 300 MG Lamivudine-Zidovudine Lamotrigine CHEW 25 MG, 5 MG Lamotrigine TABS 100 MG, 150 MG, 200 MG, 25 MG Lamotrigine TB MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 MG Lansoprazole CPDR 15 MG LANTUS SOLN 100 UNIT/ML LANTUS SOLOSTAR SOPN 100 UNIT/ML LASTACAFT SOLN.25% Latanoprost SOLN.005% LATUDA TABS 120 MG, 40 MG LATUDA TABS 20 MG LATUDA TABS 60 MG, 80 MG LEENA Leflunomide TABS 10 MG, 20 MG LENVIMA 10MG DAILY DOSE CPPK 10 MG LENVIMA 14MG DAILY DOSE LENVIMA 20MG DAILY DOSE CPPK 10 MG LENVIMA 24MG DAILY DOSE LETAIRIS TABS 10 MG, 5 MG Letrozole TABS 2.5 MG Leucovorin Calcium SOLR 100 MG, 200 MG, 350 MG, 50 MG, 500 MG Leucovorin Calcium TABS 10 MG, 15 MG, 25 MG, 5 MG LEUKERAN TABS 2 MG LEUKINE SOLR 250 MCG Leuprolide Acetate (CPP) (3 Month) KIT MG Leuprolide Acetate KIT 1 MG/0.2ML Levalbuterol HCl NEBU 1.25 MG/0.5ML LEVEMIR FLEXTOUCH SOPN 100 UNIT/ML LEVEMIR SOLN 100 UNIT/ML LEVETIRACETAM Levetiracetam SOLN 100 MG/ML, 500 MG/5ML Levetiracetam TABS 1000 MG, 250 MG, 500 MG, 750 MG Levetiracetam TB MG, 750 MG Levobunolol HCl SOLN.5%,.25% Levocarnitine (Metabolic Modifiers) SOLN 1 GM/10ML, 200 MG/ML Levocarnitine (Metabolic Modifiers) TABS 330 MG Levocetirizine Dihydrochloride SOLN 2.5 MG/5ML Levocetirizine Dihydrochloride TABS 5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 102

104 Levofloxacin in D5W Levofloxacin SOLN 25 MG/ML Levofloxacin TABS 250 MG, 500 MG, 750 MG Levoleucovorin Calcium SOLN 175 MG/17.5ML Levomilnacipran HCl Levomilnacipran HCl CP MG, 80 MG Levomilnacipran HCl CP24 20 MG Levomilnacipran HCl CP24 40 MG Levonorgestrel & Eth Estradiol Levonorgestrel (Emergency OC) TABS.75 MG, 1.5 MG Levonorgestrel (Emergency OC) TABS 1.5 MG Levonorgestrel-Eth Estradiol (Triphasic) Levonorgestrel-Ethinyl Estradiol (91-Day) Levothyroxine Sodium TABS 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG LEVOXYL TABS 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG LEXIVA SUSP 50 MG/ML LEXIVA TABS 700 MG Lidocaine HCl (Local Anesth.) SOLN.5%, 1%, 1.5%, 2% Lidocaine HCl (Mouth-Throat) SOLN 2% Lidocaine HCl GEL 2% Lidocaine HCl SOLN 4% Lidocaine OINT 5% Lidocaine PTCH 5% Lidocaine-Prilocaine Linezolid SOLN 2 MG/ML LINEZOLID TABS 600 MG LINZESS CAPS 145 MCG LINZESS CAPS 290 MCG Liothyronine Sodium TABS 25 MCG, 5 MCG, 50 MCG LIQUID CALCIUM WITH D3 MA Lisinopril & Hydrochlorothiazide Lisinopril TABS 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG Lithium Carbonate CAPS 150 MG, 300 MG, 600 MG Lithium Carbonate TABS 300 MG Lithium Carbonate TBCR 300 MG, 450 MG LITHIUM SOLN 8 MEQ/5ML LOCALNESIUM LOCALNESIUM-C LODRANE D LOHIST-D LOMUSTINE CAPS 10 MG, 100 MG, 40 MG Loperamide HCl CAPS 2 MG Loperamide HCl LIQD 1 MG/5ML Loperamide HCl SUSP 1 MG/7.5ML Loperamide HCl TABS 2 MG Loratadine & Pseudoephedrine Loratadine SYRP 5 MG/5ML Loratadine TABS 10 MG Lorazepam CONC 2 MG/ML Lorazepam SOLN 2 MG/ML, 4 MG/ML Lorazepam TABS.5 MG, 1 MG, 2 MG Losartan Potassium & Hydrochlorothiazide Losartan Potassium TABS 100 MG, 25 MG, 50 MG LOTEMAX GEL.5% LOTEMAX OINT.5% LOTEMAX SUSP.5% LOTRIMIN ULTRA CREA 1% Lovastatin TABS 10 MG Lovastatin TABS 20 MG Lovastatin TABS 40 MG Loxapine Succinate CAPS 10 MG, 25 MG, 5 MG, 50 MG LUMIGAN SOLN.01% LUMITENE CAPS 30 MG LUMIZYME SOLR 50 MG LUPRON DEPOT KIT MG LUPRON DEPOT KIT 3.75 MG LUPRON DEPOT-PED KIT MG, 15 MG, 7.5 MG LUPRON DEPOT-PED KIT 30 MG LYNPARZA CAPS 50 MG LYRICA CAPS 100 MG, 150 MG, 25 MG, 50 MG, 75 MG LYRICA CAPS 200 MG LYRICA CAPS 225 MG, 300 MG LYRICA SOLN 20 MG/ML LYSODREN TABS 500 MG M M-END DMX M-M-R II Macitentan TABS 10 MG MAG-AL MAG-TAB SR TBCR 84 MG MAGINEX TBEC 615 MG MAGNEBIND MAGNESIUM CAPS 400 MG Magnesium Chloride TBCR 64 MG Magnesium Chloride-Calcium Magnesium Citrate SOLN GM/30ML MAGNESIUM CITRATE TABS 100 MG MAGNESIUM ELEMENTAL CAPS 300 MG MAGNESIUM ELEMENTAL TABS 30 MG Magnesium Hydroxide SUSP 1200 MG/15ML Magnesium Oxide (Laxative) TABS 500 MG Magnesium Oxide (Mg Supplement) CAPS 500 MG Magnesium Oxide (Mg Supplement) TABS 250 MG, 400 MG, 500 MG MAGNESIUM OXIDE CAPS 400 MG Magnesium Oxide TABS 250 MG, 400 MG, 420 MG Magnesium Sulfate (Laxative) MAGNESIUM SULFATE IN D5W MAGNESIUM SULFATE SOLN 40 MG/ML, 80 MG/ML Magnesium Sulfate SOLN 50%, 50% Magnesium TABS 200 MG Malathion LOTN.5% Maprotiline HCl TABS 25 MG, 50 MG, 75 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 103

105 MARPLAN TABS 10 MG MATULANE CAPS 50 MG MAXIDEX SUSP.1% Meclizine HCl CHEW 25 MG Meclizine HCl TABS 12.5 MG, 25 MG Meclizine HCl TABS 25 MG Medroxyprogesterone Acetate (Contraceptive) SUSP 150 MG/ML Medroxyprogesterone Acetate TABS 10 MG, 2.5 MG, 5 MG Mefloquine HCl TABS 250 MG MEGACE ES SUSP 625 MG/5ML Megestrol Acetate SUSP 40 MG/ML Megestrol Acetate TABS 20 MG, 40 MG MEKINIST TABS.5 MG, 2 MG MELOXICAM SUSP 7.5 MG/5ML Meloxicam TABS 15 MG, 7.5 MG Melphalan HCl SOLR 50 MG Memantine HCl TABS 10 MG, 5 MG MENACTRA MENOMUNE-A/C/Y/W MENVEO MEPHYTON TABS 5 MG Mercaptopurine TABS 50 MG Meropenem SOLR 1 GM, 500 MG Mesalamine CP GM Mesalamine ENEM 4 GM Mesalamine w/ Cleanser KIT 4 GM Mesna SOLN 100 MG/ML MESNEX TABS 400 MG METAMUCIL METAMUCIL MULTIHEALTH FIB POWD 63% METAMUCIL SMOOTH TEXTURE PACK 28% Metformin HCl TABS 1000 MG Metformin HCl TABS 500 MG Metformin HCl TABS 850 MG Metformin HCl TB MG Metformin HCl TB MG Methadone HCl CONC 10 MG/ML Methadone HCl SOLN 10 MG/5ML, 5 MG/5ML Methadone HCl TABS 10 MG, 5 MG Methazolamide TABS 25 MG, 50 MG Methenamine Hippurate TABS 1 GM Methimazole TABS 10 MG, 5 MG Methotrexate Sodium SOLN 1 GM/40ML, 25 MG/ML Methotrexate Sodium SOLR 1 GM Methotrexate Sodium TABS 2.5 MG Methyclothiazide TABS 5 MG Methylcellulose (Laxative) Methylcellulose (Laxative) TABS 500 MG Methylergonovine Maleate TABS.2 MG Methylphenidate HCl SOLN 10 MG/5ML Methylphenidate HCl SOLN 5 MG/5ML Methylphenidate HCl TABS 10 MG, 5 MG Methylphenidate HCl TABS 20 MG Methylphenidate HCl TBCR 10 MG, 20 MG Methylprednisolone Acetate SUSP 40 MG/ML, 80 MG/ML Methylprednisolone Sod Succ SOLR 125 MG, 1 GM, 40 MG Methylprednisolone TABS 16 MG, 32 MG, 4 MG, 8 MG Metipranolol SOLN.3% Metoclopramide HCl SOLN 5 MG/5ML, 5 MG/ML Metoclopramide HCl TABS 10 MG, 5 MG Metolazone TABS 10 MG, 2.5 MG, 5 MG Metoprolol & Hydrochlorothiazide Metoprolol Succinate TB MG Metoprolol Succinate TB MG Metoprolol Succinate TB24 25 MG, 50 MG Metoprolol Tartrate SOLN 1 MG/ML Metoprolol Tartrate TABS 100 MG, 25 MG, 50 MG Metronidazole (Topical) CREA.75% Metronidazole (Topical) GEL.75% Metronidazole (Topical) LOTN.75% Metronidazole in NaCl Metronidazole TABS 250 MG, 500 MG Metronidazole Vaginal GEL.75% Mexiletine HCl CAPS 150 MG, 200 MG, 250 MG MEXSANA POWD 10.8% MIACALCIN SOLN 200 UNIT/ML Miconazole Nitrate (Topical) AERO 2% Miconazole Nitrate (Topical) CREA 2% Miconazole Nitrate (Topical) OINT 2% Miconazole Nitrate (Topical) POWD 2% Miconazole Nitrate Vaginal Miconazole Nitrate Vaginal CREA 2%, 4% Miconazole Nitrate Vaginal SUPP 100 MG MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN FE MICROGESTIN FE 1.5/ Midodrine HCl TABS 10 MG, 2.5 MG, 5 MG MILK OF MAGNESIA CONCENTR SUSP 2400 MG/10ML Mineral Oil Minocycline HCl CAPS 100 MG, 50 MG, 75 MG Minoxidil TABS 10 MG, 2.5 MG Mirabegron TB24 25 MG Mirabegron TB24 50 MG Mirtazapine TABS 15 MG, 7.5 MG Mirtazapine TABS 30 MG, 45 MG Mirtazapine TBDP 15 MG Mirtazapine TBDP 30 MG, 45 MG Misoprostol TABS 100 MCG, 200 MCG MISSION PRENATAL MISSION PRENATAL HP Mitomycin SOLR 20 MG, 40 MG, 5 MG Mitoxantrone HCl CONC 2 MG/ML MODERIBA 1200 DOSE PACK TABS 600 MG Moexipril HCl TABS 15 MG, 7.5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 104

106 Moexipril-Hydrochlorothiazide Mometasone Furoate CREA.1% Mometasone Furoate OINT.1% Mometasone Furoate SOLN.1% MONONESSA Montelukast Sodium CHEW 4 MG, 5 MG Montelukast Sodium PACK 4 MG Montelukast Sodium TABS 10 MG Morphine Sulfate Beads CP MG, 30 MG, 45 MG, 60 MG, 75 MG, 90 MG Morphine Sulfate CP24 10 MG, 20 MG, 30 MG, 50 MG, 60 MG Morphine Sulfate CP MG, 80 MG MORPHINE SULFATE SOLN 10 MG/5ML, 20 MG/5ML, 20 MG/ML Morphine Sulfate SOLN 2 MG/ML,.5 MG/ML, 1 MG/ML, 1 MG/ML, 10 MG/ML, 15 MG/ML, 4 MG/ML, 8 MG/ML MORPHINE SULFATE TABS 15 MG, 30 MG Morphine Sulfate TBCR 100 MG, 15 MG, 30 MG, 60 MG Morphine Sulfate TBCR 200 MG MOVANTIK TABS 12.5 MG MOVANTIK TABS 25 MG MOXEZA SOLN.5% MOZOBIL SOLN 24 MG/1.2ML MUCINEX COUGH FOR KIDS MUCINEX D MUCINEX FOR KIDS PACK 100 MG MUCINEX MAXIMUM STRENGTH TB MG MULTAQ TABS 400 MG MULTI-DELYN/IRON Multiple Vitamins w/ Iron Multiple Vitamins w/ Minerals Mupirocin OINT 2% MURO 128 SOLN 2% MUSTARGEN SOLR 10 MG MYCAMINE SOLR 100 MG, 50 MG Mycophenolate Mofetil CAPS 250 MG Mycophenolate Mofetil SUSR 200 MG/ML Mycophenolate Mofetil TABS 500 MG Mycophenolate Sodium TBEC 180 MG Mycophenolate Sodium TBEC 360 MG MYKIDZ IRON MYKIDZ IRON 10 SUSP 15 MG/1.5ML MYOZYME SOLR 50 MG N Nabumetone TABS 500 MG, 750 MG Nadolol TABS 20 MG, 40 MG, 80 MG Nafcillin Sodium SOLR 1 GM Nafcillin Sodium SOLR 10 GM, 2 GM NAGLAZYME SOLN 1 MG/ML Nalbuphine HCl SOLN 10 MG/ML, 20 MG/ML Naloxone HCl SOLN.4 MG/ML, 1 MG/ML Naltrexone HCl TABS 50 MG NAMENDA SOLN 10 MG/5ML NAMENDA TABS 10 MG, 5 MG NAMENDA XR CP24 14 MG, 21 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK Naphazoline HCl SOLN.1% Naphazoline-Glycerin NAPROXEN SODIUM CAPS 220 MG Naproxen Sodium TABS 220 MG Naproxen Sodium TABS 275 MG, 550 MG Naproxen SUSP 125 MG/5ML Naproxen TABS 250 MG, 375 MG, 500 MG Naproxen TBEC 375 MG, 500 MG Naratriptan HCl TABS 1 MG, 2.5 MG NASAL DECONGESTANT LIQD 30 MG/5ML NASCOBAL SOLN 500 MCG/0.1ML NASOPEN PE NATACYN SUSP 5% Nateglinide TABS 120 MG, 60 MG NATPARA CART 100 MCG, 75 MCG NEBUPENT SOLR 300 MG NECON 1/ NECON 7/7/ Nefazodone HCl TABS 100 MG, 150 MG, 200 MG, 250 MG, 50 MG Neomycin Sulfate TABS 500 MG Neomycin-Bacitracin Zn-Polymyxin Neomycin-Bacitracin-Polymyxin Neomycin-Polymy-Dexameth OINT Neomycin-Polymyxin-Gramicidin Neomycin-Polymyxin-HC (Ophth) Neomycin-Polymyxin-HC (Otic) SOLN NEORAL CAPS 100 MG, 25 MG NEORAL SOLN 100 MG/ML NEPHRAMINE NEPHRONEX NEUMEGA SOLR 5 MG NEUPOGEN SOLN 300 MCG/0.5ML, 300 MCG/ML, 480MCG/0.8ML, 480 MCG/1.6ML NEUPRO PT24 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR NEVIRAPINE SUSP 50 MG/5ML Nevirapine TABS 200 MG Nevirapine TB MG NEXAFED SINUS PRESSURE NEXAVAR TABS 200 MG NEXIUM PACK 10 MG, 20 MG, 40 MG NEXIUM PACK 2.5 MG, 5 MG Niacin (Antihyperlipidemic) TABS 500 MG Niacin (Antihyperlipidemic) TBCR 1000 MG, 750 MG Niacin (Antihyperlipidemic) TBCR 500 MG Niacin CPCR 250 MG, 500 MG Niacin TABS 100 MG, 50 MG, 500 MG Niacin TBCR 250 MG, 500 MG, 750 MG NIACIN TR TBCR 1000 MG Niacinamide TABS 100 MG, 500 MG Nicardipine HCl CAPS 20 MG, 30 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 105

107 NICOTINE LOZG 2 MG Nicotine Polacrilex GUM 2 MG, 4 MG Nicotine Polacrilex LOZG 2 MG, 4 MG, 4 MG Nicotine PT24 14 MG/24HR, 21 MG/24HR, 7 MG/24HR NICOTINE TRANSDERMAL SYST NICOTROL INHALER INHA 10 MG NICOTROL NS SOLN 10 MG/ML Nifedipine TB24 30 MG Nifedipine TB24 60 MG, 90 MG NILANDRON TABS 150 MG Nimodipine CAPS 30 MG NIPENT SOLR 10 MG NITRO-DUR PT24.3 MG/HR,.8 MG/HR Nitrofurantoin Macrocrystal CAPS 100 MG, 50 MG Nitrofurantoin Monohyd Macro CAPS 100 MG Nitroglycerin OINT 2% Nitroglycerin PT24.1 MG/HR,.2 MG/HR,.4 MG/HR,.6 MG/HR NITROSTAT SUBL.3 MG,.4 MG,.6 MG NORA-BE TABS.35 MG NORDITROPIN FLEXPRO SOLN 10 MG/1.5ML, 15 MG/1.5ML, 5 MG/1.5ML NORDITROPIN NORDIFLEX PEN SOLN 30 MG/3ML NOREL AD Norelgestromin-Ethinyl Estradiol Norethin Acet & Estrad-Fe TABS Norethindrone & Eth Estradiol Norethindrone (Contraceptive) TABS.35 MG Norethindrone Acet & Eth Estra Norethindrone Acetate TABS 5 MG Norethindrone Acetate-Ethinyl Estradiol Norethindrone Acetate-Ethinyl Estradiol-Fe Norethindrone-Eth Estradiol (Biphasic) Norethindrone-Eth Estradiol (Triphasic) Norgestimate-Ethinyl Estradiol Norgestimate-Ethinyl Estradiol (Triphasic) Norgestrel & Ethinyl Estradiol NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W NORPACE CR CP MG, 150 MG Nortriptyline HCl CAPS 10 MG, 25 MG, 50 MG, 75 MG Nortriptyline HCl SOLN 10 MG/5ML NORVIR CAPS 100 MG NORVIR SOLN 80 MG/ML NORVIR TABS 100 MG NOVAFERRUM NOVAFERRUM PEDIATRIC DROP LIQD 15 MG/ML NOVOLIN 70/ NOVOLIN N SUSP 100 UNIT/ML NOVOLIN R SOLN 100 UNIT/ML NOVOLOG FLEXPEN SOPN 100 UNIT/ML NOVOLOG MIX 70/ NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL SOCT 100 UNIT/ML NOVOLOG SOLN 100 UNIT/ML NOXAFIL SUSP 40 MG/ML NOXAFIL TBEC 100 MG NUEDEXTA NULOJIX SOLR 250 MG NULYTELY/FLAVOR PACKS NUTRILIPID EMUL 20 GM/100ML NUTRISOURCE FIBER NUVARING NUVIGIL TABS 150 MG NUVIGIL TABS 250 MG NUVIGIL TABS 50 MG NYMALIZE SOLN 60 MG/20ML Nystatin (Mouth-Throat) SUSP UNIT/ML Nystatin (Topical) CREA UNIT/GM Nystatin (Topical) OINT UNIT/GM Nystatin (Topical) POWD UNIT/GM Nystatin TABS UNIT O OCELLA OCTAGAM SOLN 1 GM/20ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/100ML Octreotide Acetate SOLN 100 MCG/ML, 50 MCG/ML Octreotide Acetate SOLN 1000 MCG/ML, 200 MCG/ML, 500 MCG/ML OFEV CAPS 100 MG, 150 MG Ofloxacin (Ophth) SOLN.3% Ofloxacin (Otic) SOLN.3% Olanzapine SOLR 10 MG Olanzapine TABS 10 MG, 15 MG, 20 MG Olanzapine TABS 2.5 MG, 5 MG, 7.5 MG Olanzapine TBDP 10 MG, 15 MG, 20 MG Olanzapine TBDP 5 MG Olopatadine HCl (Nasal) SOLN.6% Omega-3-acid Ethyl Esters Omeprazole CPDR 10 MG, 40 MG Omeprazole CPDR 20 MG OMEPRAZOLE TBEC 20 MG Omeprazole-Sodium Bicarbonate Ondansetron HCl SOLN 4 MG/2ML, 40 MG/20ML Ondansetron HCl SOLN 4 MG/5ML Ondansetron HCl TABS 24 MG, 4 MG, 8 MG Ondansetron TBDP 4 MG, 8 MG ONFI SUSP 2.5 MG/ML ONFI TABS 10 MG, 20 MG Ophthalmic Irrigation Solution Oral Electrolytes ORAP TABS 1 MG, 2 MG ORFADIN CAPS 10 MG, 2 MG, 5 MG ORKAMBI OSTEO-PORETICAL Oxacillin Sodium SOLR 1 GM, 2 GM Oxacillin Sodium SOLR 10 GM Oxaliplatin SOLN 100 MG/20ML, 50 MG/10ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 106

108 Oxaliplatin SOLR 100 MG, 50 MG Oxandrolone TABS 10 MG Oxandrolone TABS 2.5 MG Oxcarbazepine SUSP 300 MG/5ML Oxcarbazepine TABS 150 MG, 300 MG, 600 MG Oxybutynin Chloride SYRP 5 MG/5ML Oxybutynin Chloride TABS 5 MG Oxybutynin Chloride TB24 10 MG, 15 MG Oxybutynin Chloride TB24 5 MG Oxycodone HCl CAPS 5 MG Oxycodone HCl CONC 100 MG/5ML OXYCODONE HCL SOLN 5 MG/5ML Oxycodone HCl TABS 10 MG, 15 MG, 20 MG, 30 MG, 5 MG Oxycodone w/ Acetaminophen Oxycodone w/ Acetaminophen TABS Oxymetazoline HCl SOLN.05% Oyster Shell TABS 500 MG P Paclitaxel CONC 100 MG/16.7ML, 150 MG/25ML, 30 MG/5ML, 300 MG/50ML Paliperidone Palmitate SUSP 117 MG/0.75ML, 156 MG/ ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML Paliperidone TB MG, 3 MG, 9 MG Paliperidone TB24 6 MG Pamidronate Disodium SOLN 30 MG/10ML, 6 MG/ML, 90 MG/10ML PANOXYL-4 CREAMY WASH LIQD 4% PANRETIN GEL.1% Pantoprazole Sodium TBEC 20 MG, 40 MG Parathyroid Hormone (Recombinant) CART 25 MCG, 50 MCG Paricalcitol CAPS 1 MCG, 2 MCG, 4 MCG Paromomycin Sulfate CAPS 250 MG Paroxetine HCl SUSP 10 MG/5ML Paroxetine HCl TABS 10 MG, 20 MG, 40 MG Paroxetine HCl TABS 30 MG PARVA-CAL PATADAY SOLN.2% PAZEO SOLN.7% PEDIA-LAX LIQD 50 MG/15ML Pediatric Multiple Vitamin w/ C Pediatric Multiple Vitamin w/ C & FA Pediatric Multiple Vitamin w/ Extra C & FA Pediatric Multiple Vitamin w/ Minerals & C Pediatric Multiple Vitamins Pediatric Multiple Vitamins w/ Iron Pediatric Vitamins ADC PEDVAX HIB SUSP 7.5 MCG/0.5ML PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate- Ascorbic Acid PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride PEG 3350/ELECTROLYTES PEG-3350/ELECTROLYTES PEG-INTRON KIT 50 MCG/0.5ML PEG-INTRON REDIPEN KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGANONE TABS 250 MG PEGINTRON KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 80 MCG/0.5ML PENICILLIN G POTASSIUM IN Penicillin G Potassium SOLR UNIT, UNIT Penicillin G Procaine SUSP UNIT/ML Penicillin G Sodium SOLR UNIT Penicillin V Potassium SOLR 125 MG/5ML, 250 MG/5ML Penicillin V Potassium TABS 250 MG, 500 MG PENTAM 300 SOLR 300 MG Pentoxifylline TBCR 400 MG PEPCID AC CHEW 10 MG PERFOROMIST NEBU 20 MCG/2ML Perindopril Erbumine TABS 2 MG, 4 MG, 8 MG Permethrin & Pyrethrins-Piperonyl Butoxide Permethrin CREA 5% Permethrin LIQD 1% Permethrin LOTN 1% Perphenazine TABS 16 MG, 2 MG, 4 MG, 8 MG PERRY PRENATAL PHENAGIL Phenelzine Sulfate TABS 15 MG Phenobarbital ELIX 20 MG/5ML Phenobarbital Sodium SOLN 130 MG/ML, 65 MG/ML Phenobarbital TABS 100 MG, 15 MG, 16.2 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG Phenylephrine HCl (Oral) TABS 10 MG Phenylephrine HCl SOLN.25% Phenylephrine w/ Acetaminophen Phenylephrine w/ DM-GG Phenylephrine-Acetaminophen-Guaifenesin Phenylephrine-Brompheniramine-DM Phenylephrine-Chlorphen-DM Phenylephrine-Chlorpheniramine-DM w/ APAP Phenylephrine-DM Phenylephrine-DM-GG w/ APAP Phenylephrine-Doxylamine-Dextromethorphan- Acetaminophen Phenylephrine-Guaifenesin Phenytoin CHEW 50 MG Phenytoin Sodium Extended CAPS 100 MG, 200 MG, 30 MG, 300 MG Phenytoin Sodium Extended CAPS 100 MG, 200 MG, 300 MG Phenytoin Sodium SOLN 50 MG/ML Phenytoin SUSP 125 MG/5ML PHOS-NAK POWDER CONCENTRA PHOSPHOLINE IODIDE SOLR.125% Phytonadione SOLN 1 MG/0.5ML, 10 MG/ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 107

109 Phytonadione TABS 100 MCG Pilocarpine HCl (Oral) TABS 7.5 MG PILOCARPINE HCL SOLN 1%, 2%, 4% PILOCARPINE HYDROCHLORIDE TABS 5 MG Pindolol TABS 10 MG, 5 MG Pioglitazone HCl TABS 15 MG, 30 MG, 45 MG Piperacillin Sodium-Tazobactam Sodium Piroxicam CAPS 10 MG, 20 MG PLASMA-LYTE A PLASMA-LYTE PLASMA-LYTE-56/D5W Podofilox SOLN.5% Polyethylene Glycol 3350, Polyethylene Glycol-Propylene Glycol (Ophth) Polymyxin B-Trimethoprim Polysaccharide Iron Complex CAPS 150 MG, 200 MG Polyvinyl Alcohol SOLN 1.4% Polyvinyl Alcohol-Povidone (Ophth) POMALYST CAPS 1 MG, 2 MG, 3 MG, 4 MG POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.22% POTASSIUM CHLORIDE 0.3% POTASSIUM CHLORIDE 0.3%/D Potassium Chloride CPCR 10 MEQ, 8 MEQ POTASSIUM CHLORIDE ER TBCR 10 MEQ, 20 MEQ Potassium Chloride in NaCl POTASSIUM CHLORIDE LIQD 10%, 20% Potassium Chloride Microencapsulated Crystals CR TBCR 10 MEQ, 15 MEQ, 20 MEQ Potassium Chloride PACK 20 MEQ Potassium Chloride SOLN 2 MEQ/ML,.4 MEQ/ML, 10 MEQ/100ML, 10 MEQ/50ML, 20 MEQ/100ML, 40 MEQ/100ML Potassium Chloride TBCR 8 MEQ POTASSIUM CITRATE ER TBCR 1080 MG, 540 MG POTIGA TABS 200 MG POTIGA TABS 300 MG, 400 MG POTIGA TABS 50 MG Povidone-Iodine Vaginal SOLN.3% PRADAXA CAPS 150 MG, 75 MG Pramipexole Dihydrochloride TABS.125 MG,.25 MG,.5 MG,.75 MG, 1 MG, 1.5 MG Pravastatin Sodium TABS 10 MG, 20 MG, 40 MG, 80 MG Prazosin HCl CAPS 1 MG, 2 MG, 5 MG PREDNISOLONE ACETATE SUSP 1% Prednisolone Sodium Phosphate (Ophth) SOLN 1% Prednisolone Sodium Phosphate SOLN 15 MG/5ML, 25 MG/5ML, 5 MG/5ML Prednisolone SOLN 15 MG/5ML Prednisone CONC 5 MG/ML Prednisone SOLN 5 MG/5ML Prednisone TABS 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG, 50 MG PRENATAL PRETZ PREZCOBIX PREZISTA SUSP 100 MG/ML PREZISTA TABS 150 MG, 600 MG, 75 MG, 800 MG PRIFTIN TABS 150 MG PRILOSEC OTC TBEC 20 MG PRIMAQUINE PHOSPHATE TABS 26.3 MG Primidone TABS 250 MG, 50 MG PRISTIQ TB24 25 MG PRIVIGEN SOLN 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML PRO-CHLO Probenecid TABS 500 MG PROCALAMINE Prochlorperazine Edisylate SOLN 5 MG/ML Prochlorperazine Maleate TABS 10 MG, 5 MG Prochlorperazine SUPP 25 MG PROCRIT SOLN UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ ML PROFE CAPS 180 MG PROGLYCEM SUSP 50 MG/ML PROGRAF CAPS.5 MG, 1 MG, 5 MG PROLASTIN-C SOLR 1000 MG PROLENSA SOLN.07% PROLEUKIN SOLR UNIT PROLIA SOLN 60 MG/ML PROMACTA TABS 12.5 MG PROMACTA TABS 25 MG PROMACTA TABS 50 MG PROMACTA TABS 75 MG Promethazine HCl SOLN 25 MG/ML, 50 MG/ML Promethazine HCl SUPP 12.5 MG, 25 MG, 50 MG Promethazine HCl SYRP 6.25 MG/5ML Promethazine HCl TABS 12.5 MG, 25 MG, 50 MG Propafenone HCl CP MG, 325 MG, 425 MG Propafenone HCl TABS 150 MG, 225 MG, 300 MG Proparacaine HCl SOLN.5% Propranolol & Hydrochlorothiazide Propranolol HCl CP MG, 160 MG, 60 MG, 80 MG Propranolol HCl SOLN 1 MG/ML, 20 MG/5ML, 40 MG/5ML Propranolol HCl TABS 10 MG, 20 MG, 40 MG, 60 MG, 80 MG Propylene Glycol-Glycerin Propylthiouracil TABS 50 MG PROQUAD PROSOL Protriptyline HCl TABS 10 MG, 5 MG PRUDOXIN CREA 5% Pseudoephed-Bromphen-DM, Pseudoephed-Doxyl-DM w/apap Pseudoephedrine HCl LIQD 15 MG/5ML Pseudoephedrine HCl SYRP 30 MG/5ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 108

110 Pseudoephedrine HCl TABA 30 MG Pseudoephedrine HCl TABS 60 MG Pseudoephedrine HCl TB MG Pseudoephedrine w/ DM-GG Pseudoephedrine-Chlorphen-DM Pseudoephedrine-Dexchlorpheniramine- Chlophedianol Pseudoephedrine-Guaifenesin Psyllium CAPS 520 MG Psyllium POWD 100%, 28.3%, 30%, 30.9%, 33%, 48.57%, 49%, 58.6%, 68%, 95% PULMICORT FLEXHALER AEPB 180 MCG/ACT, 90 MCG/ ACT PULMOZYME SOLN 1 MG/ML PURIXAN SUSP 2000 MG/100ML Pyrazinamide TABS 500 MG PYRETHINS/PIPERONYL BUTO Pyrethrins-Piperonyl Butoxide Pyridostigmine Bromide TABS 60 MG Pyridoxine HCl SOLN 100 MG/ML Pyridoxine HCl TABS 100 MG, 200 MG, 25 MG, 50 MG Pyridoxine HCl TBCR 200 MG Pyrilamine Maleate-Phenylephrine HCl Tannate Pyrilamine-Phenylephrine Q QUADRACEL Quetiapine Fumarate TABS 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG Quinapril HCl TABS 10 MG, 20 MG, 40 MG, 5 MG Quinapril-Hydrochlorothiazide Quinidine Gluconate TBCR 324 MG Quinidine Sulfate TABS 200 MG, 300 MG Quinine Sulfate CAPS 324 MG R RA CALAMINE RA CALCIUM/BORON RA OYSTER SHELL CALCIUM/V RA PROBIOTIC COMPLEX RABAVERT Raloxifene HCl TABS 60 MG Ramipril CAPS 1.25 MG, 10 MG, 2.5 MG, 5 MG RANEXA TB MG, 500 MG Ranitidine HCl SOLN 150 MG/6ML, 50 MG/2ML Ranitidine HCl SYRP 15 MG/ML Ranitidine HCl TABS 150 MG, 300 MG Ranitidine HCl TABS 150 MG, 75 MG RAVICTI LIQD 1.1 GM/ML REBETOL SOLN 40 MG/ML RECOMBIVAX HB SUSP 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML REFRESH CELLUVISC SOLN 1% REFRESH OPTIVE ADVANCED REGRANEX GEL.01% RELENZA DISKHALER AEPB 5 MG/BLISTER RELISTOR SOLN 12 MG/0.6ML, 8 MG/0.4ML RELPAX TABS 20 MG, 40 MG REMICADE SOLR 100 MG REMODULIN SOLN 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML RENVELA PACK.8 GM, 2.4 GM RENVELA TABS 800 MG Repaglinide TABS.5 MG, 1 MG Repaglinide TABS 2 MG RESCON RESCON DM RESCRIPTOR TABS 100 MG, 200 MG RESPAIRE RESTASIS EMUL.05% RETAINE MGD RETROVIR IV INFUSION SOLN 10 MG/ML REVATIO SUSR 10 MG/ML REVLIMID CAPS 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG REYATAZ CAPS 150 MG, 200 MG, 300 MG REYATAZ PACK 50 MG RHINARIS GEL.2% RHINARIS SOLN.2% Ribavirin (Hepatitis C) CAPS 200 MG Ribavirin (Hepatitis C) TABS 200 MG, 400 MG Ribavirin (Hepatitis C) TABS 400 MG, 600 MG Riboflavin TABS 25 MG, 50 MG RID ESSENTIAL LICE ELIMIN Rifabutin CAPS 150 MG Rifampin CAPS 150 MG, 300 MG Rifampin SOLR 600 MG RIFATER Riluzole TABS 50 MG Rimantadine Hydrochloride TABS 100 MG RINGERS INJECTION RISA-BID PROBIOTIC RISAMINE Risperidone Microspheres SUSR 12.5 MG, 25 MG, 37.5 MG, 50 MG Risperidone SOLN 1 MG/ML Risperidone TABS.25 MG,.5 MG Risperidone TABS 1 MG, 2 MG, 3 MG Risperidone TABS 4 MG Risperidone TBDP.25 MG,.5 MG Risperidone TBDP 1 MG, 2 MG, 3 MG Risperidone TBDP 4 MG RITUXAN CONC 10 MG/ML Rivastigmine Tartrate CAPS 1.5 MG, 3 MG, 4.5 MG, 6 MG Rizatriptan Benzoate TABS 10 MG, 5 MG Rizatriptan Benzoate TBDP 10 MG, 5 MG ROBITUSSIN CHILDRENS COUG... 80, 81 ROBITUSSIN PEAK COLD NIGH Ropinirole Hydrochloride TABS.25 MG,.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG ROTARIX NSLIJHealthPlans.com/FIDALiveWell 頁碼 109

111 ROTATEQ ROZEREM TABS 8 MG RYMED S SABRIL PACK 500 MG SABRIL TABS 500 MG Saline SANDIMMUNE SOLN 100 MG/ML SANDOSTATIN LAR DEPOT KIT 10 MG, 20 MG, 30 MG52 SANTYL OINT 250 UNIT/GM SAPHRIS SUBL 2.5 MG SCOOBY-DOO ONE A DAY SCOT-TUSSIN SENIOR SECURA EXTRA PROTECTIVE CREA 30.6% Selegiline HCl CAPS 5 MG Selegiline HCl TABS 5 MG Selegiline PT24 12 MG/24HR, 6 MG/24HR, 9 MG/24HR Selenium Sulfide LOTN 2.5% Selenium TABS 100 MCG SELENIUM TBCR 200 MCG SELZENTRY TABS 150 MG, 300 MG SENNA PROMPT SENNA SYRP 176 MG/5ML Sennosides CAPS 8.6 MG Sennosides SYRP 8.8 MG/5ML Sennosides TABS 15 MG, 17.2 MG, 25 MG, 8.6 MG Sennosides-Docusate Sodium SENSI-CARE PROTECTIVE BAR SENSIPAR TABS 30 MG, 90 MG SENSIPAR TABS 60 MG SEREVENT DISKUS AEPB 50 MCG/DOSE SEROQUEL XR TB MG, 200 MG SEROQUEL XR TB MG, 400 MG SEROQUEL XR TB24 50 MG Sertraline HCl CONC 20 MG/ML Sertraline HCl TABS 100 MG Sertraline HCl TABS 25 MG, 50 MG SIGNIFOR SOLN.3 MG/ML,.6 MG/ML,.9 MG/ML Sildenafil Citrate (Pulmonary Hypertension) TABS 20 MG34 SILENOR TABS 3 MG SILENOR TABS 6 MG SILVER SULFADIAZINE CREA 1% SIMBRINZA Simvastatin TABS 10 MG, 20 MG, 40 MG, 5 MG, 80 MG Sirolimus SOLN 1 MG/ML Sirolimus TABS.5 MG, 1 MG SIROLIMUS TABS 2 MG SIRTURO TABS 100 MG SIVEXTRO SOLR 200 MG SIVEXTRO TABS 200 MG SLOW RELEASE IRON TBCR 140 MG SLOW-MAG SM CORAL CALCIUM TABS 1000 MG SM SLOW RELEASE IRON TBCR 143 MG SM VITAMIN D3 MAXIMUM STR CAPS 4000 UNIT SODIUM BICARBONATE SODIUM CHLORIDE 0.45% VIA SOLN.45% SODIUM CHLORIDE 0.9% SOLN.9% Sodium Chloride Hypertonic OINT 5% Sodium Chloride Hypertonic SOLN 5% SODIUM CHLORIDE SOLN.9%, 3%, 5% SODIUM CHLORIDE SOLN 2.5 MEQ/ML Sodium Phenylbutyrate POWD 3 GM/TSP Sodium Phosphates Sodium Polystyrene Sulfonate Sodium Polystyrene Sulfonate SUSP 15 GM/60ML SOLIA SOLTAMOX SOLN 10 MG/5ML SOMATULINE DEPOT SOLN 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SOLR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SOOTHE Sotalol HCl (AFIB/AFL) TABS 120 MG, 160 MG, 80 MG Sotalol HCl TABS 120 MG, 160 MG, 240 MG, 80 MG SOVALDI TABS 400 MG Specialty Vitamins Products Spironolactone & Hydrochlorothiazide Spironolactone TABS 100 MG, 25 MG, 50 MG SPRYCEL TABS 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG SSD CREA 1% STAHIST AD, Stavudine CAPS 15 MG, 20 MG, 30 MG, 40 MG Stavudine SOLR 1 MG/ML STERILE LUBRICANT DROPS LIQD.7% STERILE WATER IRRIGATION STIVARGA TABS 40 MG STRATTERA CAPS 10 MG, 18 MG, 25 MG STRATTERA CAPS 100 MG, 60 MG, 80 MG STRATTERA CAPS 40 MG Streptomycin Sulfate SOLR 1 GM STRIBILD SUBOXONE SUCRAID SOLN 8500 UNIT/ML Sucralfate TABS 1 GM Sulfacetamide Sod-Prednisolone Sulfacetamide Sodium (Acne) SUSP 10% Sulfacetamide Sodium (Ophth) OINT 10% Sulfacetamide Sodium (Ophth) SOLN 10% Sulfadiazine TABS 500 MG Sulfamethoxazole-Trimethoprim,, SULFAMYLON CREA 85 MG/GM SULFAMYLON PACK 5% Sulfasalazine TABS 500 MG Sulfasalazine TBEC 500 MG Sulindac TABS 150 MG, 200 MG SUMATRIPTAN SOLN 20 MG/ACT SUMATRIPTAN SOLN 5 MG/ACT NSLIJHealthPlans.com/FIDALiveWell 頁碼 110

112 SUMATRIPTAN SUCCINATE REF SOCT 4 MG/0.5ML, 6 MG/0.5ML Sumatriptan Succinate SOAJ 6 MG/0.5ML, 4 MG/0.5ML Sumatriptan Succinate SOLN 6 MG/0.5ML Sumatriptan Succinate SOSY 6 MG/0.5ML Sumatriptan Succinate TABS 100 MG, 25 MG, 50 MG SUPRAX CAPS 400 MG SUPRAX SUSR 500 MG/5ML SUPREP BOWEL PREP SUSTIVA CAPS 200 MG, 50 MG SUSTIVA TABS 600 MG SUTENT CAPS 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON KIT 200 MCG, 300 MCG, 600 MCG SYMBICORT SYMLINPEN 120 SOPN 2700 MCG/2.7ML SYMLINPEN 60 SOPN 1500 MCG/1.5ML SYNAGIS SOLN 100 MG/ML, 50 MG/0.5ML SYNAREL SOLN 2 MG/ML SYNERCID SYNRIBO SOLR 3.5 MG SYNTHROID TABS 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG SYPRINE CAPS 250 MG SYSTANE BALANCE RESTORATI SOLN.6% SYSTANE OVERNIGHT THERAPY GEL.3% T TABLOID TABS 40 MG Tacrolimus (Topical) OINT.03%,.1% Tacrolimus CAPS.5 MG, 1 MG Tacrolimus CAPS 5 MG TAFINLAR CAPS 50 MG, 75 MG TAMIFLU CAPS 30 MG, 45 MG, 75 MG TAMIFLU SUSR 6 MG/ML Tamoxifen Citrate TABS 10 MG, 20 MG Tamsulosin HCl CAPS.4 MG TARCEVA TABS 100 MG, 150 MG, 25 MG TARGRETIN CAPS 75 MG TARGRETIN GEL 1% TASIGNA CAPS 150 MG, 200 MG TAZORAC CREA.05%,.1% TEARS AGAIN NIGHT & DAY TEFLARO SOLR 400 MG, 600 MG TEGRETOL SUSP 100 MG/5ML TEGRETOL TABS 200 MG TEGRETOL-XR TB MG, 200 MG, 400 MG TEKTURNA HCT TABS TEKTURNA TABS 150 MG TEKTURNA TABS 300 MG Temazepam CAPS 15 MG Temazepam CAPS 7.5 MG TENIVAC Terazosin HCl CAPS 1 MG, 10 MG, 2 MG, 5 MG Terbinafine HCl (Topical) CREA 1% Terbinafine HCl TABS 250 MG Terbutaline Sulfate SOLN 1 MG/ML Terbutaline Sulfate TABS 2.5 MG, 5 MG Terconazole Vaginal CREA.4%,.8% Terconazole Vaginal SUPP 80 MG Testosterone Cypionate SOLN 100 MG/ML, 200 MG/ML Testosterone Enanthate SOLN 200 MG/ML TETANUS/DIPHTHERIA TOXOID Tetrahydrozoline HCl (Ophth) SOLN.05% Tetrahydrozoline w/ Zinc Sulfate TGT EYE ALLERGY RELIEF THALOMID CAPS 100 MG, 150 MG, 200 MG, 50 MG Theophylline Theophylline CP MG, 300 MG, 400 MG Theophylline ELIX 80 MG/15ML Theophylline SOLN 80 MG/15ML Theophylline TB MG, 200 MG, 300 MG, 450 MG Theophylline TB MG, 600 MG THERA-D 4000 TABS 4000 UNIT THERA/BETA-CAROTENE THERANATAL CORE NUTRITION THERATEARS SOLN.25% Thiamine HCl SOLN 100 MG/ML Thiamine HCl TABS 100 MG, 50 MG Thiamine Mononitrate TABS 100 MG Thioridazine HCl TABS 10 MG, 100 MG, 25 MG, 50 MG Thiothixene CAPS 1 MG, 10 MG, 2 MG, 5 MG Tiagabine HCl TABS 2 MG, 4 MG Ticagrelor TABS 90 MG TIKOSYN CAPS 125 MCG, 250 MCG, 500 MCG Timolol Maleate (Ophth) SOLN.25%,.5% TIMOLOL MALEATE OPHTHALMI SOLG.25%,.5% Timolol Maleate TABS 10 MG, 20 MG, 5 MG Tioconazole Vaginal OINT 6.5% TIVICAY TABS 50 MG Tizanidine HCl TABS 2 MG, 4 MG TOBRADEX TOBRADEX ST Tobramycin (Ophth) SOLN.3% Tobramycin NEBU 300 MG/5ML Tobramycin Sulfate in Saline Tobramycin Sulfate SOLN 1.2 GM/30ML, 10 MG/ML, 40 MG/ML, 80 MG/2ML Tobramycin Sulfate SOLR 1.2 GM Tobramycin-Dexamethasone TOBREX OINT.3% Tolnaftate AERO 1% Tolnaftate AERP 1% Tolnaftate CREA 1% Tolnaftate POWD 1% Tolnaftate SOLN 1% Tolterodine Tartrate CP24 2 MG, 4 MG Tolterodine Tartrate TABS 1 MG, 2 MG Topiramate CPSP 15 MG, 25 MG Topiramate TABS 100 MG, 200 MG, 25 MG, 50 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 111

113 Topotecan HCl SOLR 4 MG Torsemide SOLN 50 MG/5ML Torsemide TABS 10 MG, 100 MG, 20 MG, 5 MG TOUJEO SOLOSTAR SOPN 300 UNIT/ML TOVIAZ TB24 4 MG, 8 MG TPN ELECTROLYTES TRACLEER TABS 125 MG TRACLEER TABS 62.5 MG TRADJENTA TABS 5 MG Tramadol HCl TABS 50 MG Tramadol-Acetaminophen Trandolapril TABS 1 MG, 2 MG, 4 MG Tranexamic Acid SOLN 100 MG/ML Tranexamic Acid TABS 650 MG TRANSDERM-SCOP PT72 1 MG/3DAYS Tranylcypromine Sulfate TABS 10 MG TRAVASOL TRAVATAN Z SOLN.004% Trazodone HCl TABS 100 MG, 150 MG, 50 MG TREANDA SOLN 180 MG/2ML, 45 MG/0.5ML TREANDA SOLR 100 MG, 25 MG TRECATOR TABS 250 MG TRELSTAR MIXJECT SUSR MG, 3.75 MG Tretinoin (Chemotherapy) CAPS 10 MG Tretinoin CREA.025%,.05%,.1% Tretinoin GEL.025%,.01% TRI-VI-SOL Triamcinolone Acetonide (Mouth) PSTE.1% Triamcinolone Acetonide (Topical) CREA.025%,.1%,.5% Triamcinolone Acetonide (Topical) LOTN.025%,.1% Triamcinolone Acetonide (Topical) OINT.025%,.1%,.5% TRIAMINIC COUGH & RUNNY N STRP 12.5 MG TRIAMINIC FEVER REDUCER P SYRP 160 MG/5ML.. 11 TRIAMINIC NIGHT TIME COLD Triamterene & Hydrochlorothiazide CAPS TRIBENZOR TABS Trifluoperazine HCl TABS 1 MG, 10 MG, 2 MG, 5 MG Trifluridine SOLN 1% Trihexyphenidyl HCl ELIX.4 MG/ML Trihexyphenidyl HCl TABS 2 MG, 5 MG Trimethoprim TABS 100 MG Trimipramine Maleate CAPS 100 MG Trimipramine Maleate CAPS 25 MG Trimipramine Maleate CAPS 50 MG TRINESSA TRIPLE PASTE OINT 12.8% Triprolidine & Pseudoephedrine TRISENOX SOLN 10 MG/10ML TRIUMEQ TROPHAMINE Trospium Chloride TABS 20 MG TRULICITY SOPN.75 MG/0.5ML, 1.5 MG/0.5ML TRUMENBA TRUVADA TUSNEL TUSNEL PEDIATRIC TUSNEL-DM PEDIATRIC TWINRIX TYBOST TABS 150 MG TYGACIL SOLR 50 MG TYKERB TABS 250 MG TYPHIM VI SOLN 25 MCG/0.5ML Typhoid VI Polysaccharide Vaccine SOLN 25 MCG/0.5ML TYSABRI CONC 300 MG/15ML TYZEKA TABS 600 MG U UCERIS TB24 9 MG Ulipristal Acetate TABS 30 MG ULORIC TABS 40 MG, 80 MG Umeclidinium Bromide AEPB 62.5 MCG/INH UNITHROID TABS 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UPCAL D Ursodiol CAPS 300 MG Ursodiol TABS 250 MG, 500 MG V VAGIFEM TABS 10 MCG Valacyclovir HCl TABS 1000 MG, 500 MG VALCHLOR GEL.016% VALCYTE SOLR 50 MG/ML Valganciclovir HCl TABS 450 MG Valproate Sodium SOLN 500 MG/5ML Valproate Sodium SYRP 250 MG/5ML Valproic Acid CAPS 250 MG Valsartan TABS 160 MG, 320 MG, 40 MG, 80 MG Valsartan-Hydrochlorothiazide Vancomycin HCl CAPS 125 MG, 250 MG Vancomycin HCl SOLR 10 GM, 1000 MG, 500 MG, 5000 MG, 750 MG VANDAZOLE GEL.75% VAQTA SUSP 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX INJ 1350 PFU/0.5ML VELCADE SOLR 3.5 MG Venlafaxine HCl CP MG Venlafaxine HCl CP MG, 75 MG Venlafaxine HCl TABS 100 MG, 25 MG, 37.5 MG, 50 MG, 75 MG Verapamil HCl CP MG, 120 MG, 180 MG, 200 MG, 240 MG, 300 MG Verapamil HCl SOLN 2.5 MG/ML VERAPAMIL HCL SR CP MG Verapamil HCl TABS 120 MG, 40 MG, 80 MG Verapamil HCl TBCR 120 MG, 180 MG, 240 MG VERSACLOZ SUSP 50 MG/ML VESICARE TABS 10 MG, 5 MG NSLIJHealthPlans.com/FIDALiveWell 頁碼 112

114 VICKS VAPORUB VICTOZA SOPN 18 MG/3ML VIDEX PEDIATRIC SOLR 2 GM, 4 GM VIGAMOX SOLN.5% Vilazodone HCl Vilazodone HCl TABS 10 MG, 20 MG, 40 MG VIMPAT SOLN 10 MG/ML VIMPAT SOLN 200 MG/20ML VIMPAT TABS 100 MG, 150 MG, 200 MG VIMPAT TABS 50 MG Vinblastine Sulfate SOLN 1 MG/ML Vincristine Sulfate SOLN 1 MG/ML Vinorelbine Tartrate SOLN 10 MG/ML, 50 MG/5ML VIRACEPT TABS 250 MG, 625 MG VIRAMUNE XR TB MG VIREAD POWD 40 MG/GM VIREAD TABS 150 MG, 200 MG, 250 MG, 300 MG VISINE-LR SOLN.025% VITALETS VITAMIN A PALMITATE TABS UNIT VITAMIN B12/FOLIC ACID VITAMIN C VITAMIN D2 TABS 2000 UNIT, 400 UNIT VITAMIN D3 LIQD 1200 UNIT/15ML VITAMIN D3 TABS 3000 UNIT Vitamin E CAPS 100 UNIT, 1000 UNIT, 200 UNIT Vitamin E OIL 100 UNT/0.25ML Vitamin E SOLN 15 UNIT/0.3ML VITAMIN E TABS 100 UNIT Vitamin Mixture Vitamins A & D VITEKTA TABS 150 MG, 85 MG VOLTAREN GEL 1% Voriconazole SOLR 200 MG Voriconazole SUSR 40 MG/ML Voriconazole TABS 200 MG, 50 MG Vortioxetine HBr TABS 10 MG Vortioxetine HBr TABS 20 MG Vortioxetine HBr TABS 5 MG VOTRIENT TABS 200 MG W Warfarin Sodium TABS 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG WELCHOL PACK 3.75 GM WELCHOL TABS 625 MG Wheat Dextrin-Calcium White Petrolatum-Mineral Oil XIFAXAN TABS 550 MG XOLAIR SOLR 150 MG XOPENEX HFA AERO 45 MCG/ACT XTANDI CAPS 40 MG XYREM SOLN 500 MG/ML Y YERVOY SOLN 200 MG/40ML, 50 MG/10ML YF-VAX Z Zafirlukast TABS 10 MG, 20 MG ZAVESCA CAPS 100 MG ZAZOLE CREA.8% ZELBORAF TABS 240 MG ZEMAIRA SOLR 1000 MG ZENPEP ZETIA TABS 10 MG ZIAGEN SOLN 20 MG/ML Zidovudine CAPS 100 MG Zidovudine SYRP 50 MG/5ML Zidovudine TABS 300 MG Zinc Oxide (Topical) CREA 10% Zinc Oxide (Topical) OINT 20% Zinc Oxide (Topical) OINT 40% ZINC OXIDE PSTE 25% Ziprasidone HCl CAPS 20 MG, 40 MG Ziprasidone HCl CAPS 60 MG, 80 MG ZIRGAN GEL.15% Zoledronic Acid CONC 4 MG/5ML Zoledronic Acid SOLN 5 MG/100ML ZOLINZA CAPS 100 MG Zolmitriptan TABS 2.5 MG, 5 MG Zolmitriptan TBDP 2.5 MG, 5 MG Zolpidem Tartrate TABS 10 MG, 5 MG Zonisamide CAPS 100 MG, 25 MG, 50 MG ZONTIVITY TABS 2.08 MG ZOO FRIENDS COMPLETE ZORTRESS TABS.25 MG,.5 MG,.75 MG ZOSTAVAX SOLR UNT/0.65ML ZYDELIG TABS 100 MG, 150 MG ZYKADIA CAPS 150 MG ZYLET ZYPREXA RELPREVV SUSR 210 MG, 300 MG ZYPREXA RELPREVV SUSR 405 MG ZYTIGA TABS 250 MG ZYVOX SUSR 100 MG/5ML ZYVOX TABS 600 MG X XALKORI CAPS 200 MG, 250 MG XARELTO STARTER PACK XARELTO TABS 10 MG, 15 MG, 20 MG XENAZINE TABS 12.5 MG XENAZINE TABS 25 MG XGEVA SOLN 120 MG/1.7ML NSLIJHealthPlans.com/FIDALiveWell 頁碼 113

115 如需詳細資訊 : 致電參與者服務部 : (855) 或造訪 : NSLIJHealthPlans.com/FIDALiveWell H3129_RX16_52_CH Alternate Format