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1 FOR HEALTHY LIVING CENTERS PLAN 中央計劃管理式長期護理護士服務 Centers Plan for Medicare Advantage Care (HMO) 2016 年度處方一覽表節選 此處方一覽表更新於 2016 年 4 月 1 日 如需取得更多最新資訊, 或者如果您有其他問題, 敬請致電以下電話, 連絡 Centers Plan for Healthy Living: ,TTY 使用者請致電 : , 工作時間為 : 週一至週日, 早上 8 點至晚上 8 點, 或者請瀏覽 : 如需取得更多資訊或欲加入我們請致電 : ( 免費 ) TTY 使用者 : 週一至週日, 早上 8 點至晚上 8 點 CustomerCareGroup@centersplan.com We CARE... about your CARE H6988_ENR1085_CH Accepted

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3 Medicare Advantage Care(HMO) 中心計劃 2016 年處方一覽表 承保藥物部分清單 請閱讀 : 本文件含有關於本計劃承保藥品的一些相關資訊 HPMS 已核准處方一覽表, 檔案提交 ID 16481, 版本號 12 本精簡版處方一覽表更新於 2016 年 4 月 1 日 這不是一份本計劃承保藥物的完整清單 要獲得完整清單或有其他問題, 請致電健康生活中心計劃 , 或者 TTY 使用者請致電 , 工作時間為每週 7 天, 每天早 8 點到晚 8 點, 或瀏覽我們的網站 本處方一覽表更新於 2016 年 4 月 1 日 要獲得最新資訊或有其他問題, 請致電健康生活中心計劃 , 或者 TTY 使用者請致電 , 工作時間為每週 7 天, 每天早 8 點到晚 8 點, 或瀏覽我們的網站 現有成員注意 : 此處方一覽表自去年以來發生了變更 請閱覽此文件, 確保處方一覽表仍然包含您服用的藥品 本藥品清單 ( 處方一覽表 ) 中的 我們 或 我們的 指代健康生活中心計劃 其中的 計劃 或 我們的計劃 指代 Medicare Advantage Care(HMO) 中心計劃 本檔案包含一份用於我們的計劃的藥品部分清單 ( 處方一覽表 ), 最後更新日期為 01/1/2016 如需獲得最新處方一覽表, 請連絡我們 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 一般情況下, 您必須使用網絡內藥店來使用您的處方藥福利 福利 處方一覽表 藥店網絡和 / 或自付費用 / 共同保險費可能會在 2016 年 1 月 1 日以及當年內多次發生變更 您可免費獲得以其他格式, 例如大字印刷 盲文或音訊, 編寫的此資訊 3 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 生效日期 :2016 年 4 月 1 日

4 什麼是健康生活中心計劃處方一覽表? 處方一覽表是健康生活中心計劃在諮詢醫療保健提供者團隊後選擇的承保藥品清單, 這個清單上列出了有效的治療計劃所必須的處方療法 健康生活中心計劃一般會承保處方一覽表內列出的藥品, 只要這些藥品屬於醫療必需藥品, 且處方由健康生活中心計劃網絡內的藥方開出, 也符合其他的計劃規則 如想獲得關於如何開處方藥的更多資訊, 請查閱您的承保福利說明 本文件只包含部分處方一覽表及健康生活中心計劃承保的部分藥物 要獲得健康生活中心計劃承保的全部處方藥清單, 請瀏覽我們的網站或致電我們 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 處方一覽表 ( 藥品清單 ) 會發生變更嗎? 一般情況下, 如果您正在服用我們的 2016 年處方一覽表上的藥品, 且此藥品年初屬於承保藥品, 我們不會在 2016 年保險年期間中斷或減少藥品承保, 除非出現更新更低價的普通藥品或發佈關於該藥品安全性或有效性的新的負面資訊 其他類型的處方一覽表變更, 例如將一種藥品從我們的處方一覽表上移除, 不會對目前正在服用該藥品的會員產生影響 正在服用該藥品的會員能夠在該保險年的剩餘時間以相同的分攤費用獲得該藥品 我們認為讓您在該保險年的剩餘時間繼續獲得您在選擇我們的計劃時能夠從處方一覽表中獲得的藥品是很重要的, 您能夠節省額外費用或我們能夠確保您的安全的情況除外 如果我們將藥品從處方一覽表中移除, 增加了一種藥品的事先核准 數量限制以和 / 或者逐步治療限制, 或將一種藥品移至更高的分攤費用等級, 我們必須在變更生效前至少 60 天內通知受影響的會員這一變更情況, 或在會員要求續開藥品時進行通知, 在這種情況下, 此會員將獲得 60 天的藥品供應量 如果食品與藥物管理局裁定我們處方一覽表上的一種藥品不安全或此藥品的製造商將藥品撤出市場, 我們會立即將此藥品從我們的處方一覽表上移除並通知服用此藥品的會員 隨信附上的處方一覽表最後更新日期為 2016 年 1 月 1 日 如想獲得由健康生活中心計劃承保的藥品的最新資訊, 請連絡我們 我們的連絡資料在封面和封底 如果在年中發生了無須徹底修訂的改動, 健康生活中心計劃將向您寄送一份勘誤表作為對您的紙本一覽表的更新 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 4 生效日期 :2016 年 4 月 1 日

5 如何使用處方一覽表? 有兩個方法可以在處方一覽表中尋找您的藥品 : 醫療狀況 處方一覽表的起始頁為此處方一覽表中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 用於治療心臟狀況的藥品被列於 心血管藥物 種類之下 如果您知道您的藥品的作用, 則可從清單的第 10 項中查詢種類名稱 然後在這一種類下方查詢您的藥品 字母排列 如果您不確定應該在哪個種類下方查詢, 您應該在從第 I-1 頁開始的索引中尋找您的藥品 索引提供了一份清單, 將本檔案包含的所有藥品按照字母順序進行排列 品牌藥品和普通藥品都列於此索引之中 查詢索引, 找到您的藥品 在您的藥品旁邊, 您將看到承保資訊所在頁面的頁碼 翻至索引中所列頁面, 並在清單第一欄找到您的藥品名稱 什麼是普通藥物? 健康生活中心計劃承保品牌藥品和普通藥品 普通藥品是透過 FDA 審核的與品牌藥品具有相同活性成分的藥品 一般情況下, 普通藥品的費用比品牌藥品低 我的受保範圍是否有約束或限制? 部分承保藥品可能有額外承保要求或限制 這些要求和限制可能包括 : 事前核准 : 健康生活中心計劃要求您 [ 或您的醫生 ] 為某些藥品獲得事前核准 這意味著您領取處方藥之前需要獲得健康生活中心計劃的核准 若您未獲得核准, 健康生活中心計劃可能不承保此藥品 數量限制 : 對於某些藥品, 健康生活中心計劃限制健康生活中心計劃將承保的藥量 例如, 健康生活中心計劃將 sumatriptan 的單次處方量限制為 12 片 這可能是對標準一個月或三個月供應量的補充 分步治療 : 在某些情況下, 健康生活中心計劃會要求您在其承保治療您所患病症的另一種藥物前先試用其他藥物 例如, 如果藥品 A 和藥品 B 都可治療您的疾病情況,Medicare Advantage Care 中心計劃可能會要求您先試用藥品 A, 否則就不承保藥品 B 如果藥品 A 對您無效, 健康生活中心計劃將承保藥品 B CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 5 生效日期 :2016 年 4 月 1 日

6 如想瞭解您的藥品是否有其他額外要求或限制, 您可從第 10 頁開始檢視處方一覽表 您也可以瀏覽我們的網站, 瞭解有關特定承保藥品所受約束的詳細資訊 我們已發佈文件解釋我們的事先核准和逐步治療限制 您也可以要求我們向您傳送一份副本 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 您可以要求健康生活中心計劃對這些約束和限制作出特例處理, 或對也許能夠治療您的健康狀況的其他類似藥品清單作出特例處理 參見第 7 頁的 如何向健康生活中心計劃請求特例處理 部分, 瞭解請求特例處理的方法 什麼是非處方 (OTC) 藥物? OTC 藥物是 Medicare 處方藥計劃通常不承保的非處方藥 健康生活中心計劃承保部分 OTC 藥物, 健康生活中心計劃將為您免費提供這些 OTC 藥物 這些健康生活中心計劃提供的 OTC 藥物的費用將不計入您的總 D 部分藥物費用中 ( 即您支付的費用不計入保障缺口中 ) 如果我的藥品未納入此處方一覽表該怎麼辦? 如果您的藥品未納入此處方一覽表 ( 承保藥品清單 ), 您首先應該連絡會員服務部, 詢問您的藥品是否在承保範圍內 本文件只包含承保藥物的部分清單, 所以健康生活中心計劃可能會承保您的藥物 更多詳細資訊, 請連絡我們 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 如果您瞭解到健康生活中心計劃不承保您的藥品, 您有兩個選項 : 您可以向會員服務部要求一份健康生活中心計劃承保的類似藥品清單 當您收到這份清單之後, 將這份清單給您的醫生檢視並要求醫生開一種與健康生活中心計劃承保藥品類似的藥品 您可以向健康生活中心計劃請求特例處理並要求承保您的藥品 參見下方資訊, 瞭解如何請求特例處理 如何向健康生活中心計劃請求處方一覽表特例處理? 您可以向健康生活中心計劃請求進行承保規則的特例處理 您可以向我們請求進行幾類特例處理 即使一種藥品不在我們的處方一覽表之上, 您也可以向我們請求承保此藥品 如果請求被核准, 此藥品將以事先決定的費用分攤水準被承保, 而您無法要求我們提供更低的費用分攤水準 您能夠請求我們以更低的費用分攤水準承保一種處方藥品 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 6 生效日期 :2016 年 4 月 1 日

7 您可以向我們請求撤銷對您的藥品承保約束或限制 例如, 對於某些藥品, 健康生活中心計劃限制我們承保的藥量 如果您的藥品有藥量限制, 您可以向我們請求撤銷此限制並承保更大藥量 一般情況下, 只有當計劃處方一覽表上包含的替代藥品 [ 分攤費用更低的藥品 ] 或額外使用約束限制對您的治療效果不佳以及 / 或者可能對您產生副作用, 健康生活中心計劃才會核准您的特例請求 您應該連絡我們, 要求獲得一份有關處方一覽表或使用限制特例的初始保險決定 當您請求一份處方一覽表或使用約束特例時, 您應該提交一份您的開藥醫生或醫師出具的支援您請求的聲明 一般情況下, 我們必須在收到您的開藥醫生出具的支援性聲明後的 72 小時內作出決定 如果您或您的醫生認為等待 72 小時才能裁定可能會對您的健康造成嚴重傷害, 您可以請求加急 ( 快速 ) 特例 如果您的加急請求得到許可, 我們必須在收到您的醫生或其他開藥醫生出具的支援性聲明的 24 小時之內告知您我們的決定 在我能夠和我的醫生討論變更我的藥品或請求特例之前我應該做什麼? 作為我們的計劃的新會員或持續會員, 您可能正在服用不在我們的處方一覽表上的藥品 或者, 您可能正在服用我們處方一覽表上的藥品, 但您獲得該藥品的能力受限 例如, 在開處方藥之前, 您可能需要得到我們的事前核准 您應該向您的醫生諮詢, 確認您是否應該更換為我們承保的合適藥品, 或請求處方一覽表特例處理, 要求我們承保您服用的藥品 在您向您的醫生諮詢並決定正確的處理措施之時, 我們可能會在特定情況下在您成為我們的計劃會員的最初 90 天內承保您的藥品 對於您所服用的不在我們處方一覽表上的每一種藥品或如果您獲得您的藥品的能力有限, 我們將暫時承保 30 天的供應藥量 ( 除非您的處方箋上註明的天數更少 ), 您可在網絡內藥房配藥 結束您最初 30- 天的供應藥量之後, 我們不會為這些藥品支付費用, 即使您成為本計劃會員的時間不超過 90 天亦如此 如果您在長期護理設施住院, 我們將允許您續配藥一直到您獲得 91 天的過渡供應藥量, 使其與配藥增量保持一致 ( 除非您的處方箋上註明的天數更少 ) 在您成為我們會員的最初 90 天, 我們將承保一次以上的這些藥物續配藥 如果您需要的藥物並不在我們的處方一覽表上或者如果您獲得藥物的能力有限, 而您加入我們計劃成為會員已經超過 90 天, 在您尋求處方一覽表例外處理期間, 我們將承保一次 31 天的急救用藥用量 ( 除非您的處方箋上註明的天數更少 ) 我們會向因護理等級改變而改變治療方式的會員提供過渡期藥物 ( 例如, 從醫院轉入長期護理機構或流動門診的個人 ) 更多資訊 為獲得關於您的健康生活中心計劃處方藥品承保的詳細資訊, 請閱覽您的 承保福利說明 和其他計劃材料 如果您對健康生活中心計劃有疑問, 請連絡我們 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 7 生效日期 :2016 年 4 月 1 日

8 如果您對 Medicare 處方藥品承保有一般性問題, 請致電 Medicare, 電話是 MEDICARE ( ), 每週 7 天 每天 24 小時開通 TTY 使用者應致電 或者瀏覽 健康生活中心計劃處方一覽表 從下頁開始的精簡版處方一覽表為您提供有關健康生活中心計劃承保的藥物資訊 如果您在藥物清單上找藥物有困難, 請翻至 I-1 頁, 開始閱讀索引部分 記住 : 本文件只包含健康生活中心計劃承保的部分藥物清單 如果您的處方藥不在本部分處方一覽表中, 請連絡我們 我們的連絡方式和處方一覽表最新更新日期會分別出現在封面和封底 圖表第一列是藥品名稱 品牌藥名稱大寫 ( 如 :TYLENOL), 普通藥為斜體小寫 ( 如 : acetaminophen) 要求 / 限制欄中的資訊告知您健康生活中心計劃對您的藥品承保是否有任何特殊要求 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 8 生效日期 :2016 年 4 月 1 日

9 縮寫描述說明 使用管理約束 PA PA BvD PA NSO QL ST LA 事前核准約束 B 部分及 D 部分判定的 事前核准約束 僅適用於新會員的事前核准約束 數量限制約束 逐步治療約束 獲得管道有限的藥物 在您獲得此藥配藥之前, 您 ( 或者您的醫生 ) 必須首先獲得健康生活中心計劃的事前核准 若您未獲得核准, 健康生活中心計劃可能不承保此藥品 在 Medicare B 部分或者 D 部分承保下, 該藥物可能符合支付資格 您 ( 或您的醫生 ) 必須在您獲得此藥配藥之前取得健康生活中心計劃關於此藥在 Medicare D 部分承保下的事先核准 若您未獲得核准, 健康生活中心計劃可能不承保此藥品 如果您是名新會員或者如果您之前未曾服用過此藥, 您 ( 或您的醫生 ) 必須在您為此藥配藥之前獲得健康生活中心計劃的事先核准 若您未獲得核准, 健康生活中心計劃可能不承保此藥品 健康生活中心計劃限制每份處方或某指定期間所承保的藥量 在健康生活中心計劃將為此藥提供承保之前, 您必須首先使用其他藥物以應對您的醫療病症 只有當其他藥物對您並不起作用的情況下, 此藥才可能獲得承保 其他特殊承保要求 該處方可能只能在一些藥房配藥 更多資訊, 請諮詢您的提供者和查閱藥房名錄或致電會員服務部, 免費電話是 , 該熱線週一至週日東部時間早八點至晚八點均開放接聽 TTY/TDD 使用者應致電 CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 9 生效日期 :2016 年 4 月 1 日

10 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 120 mg-12 mg/5 ml solution acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Acetaminophen with Codeine) 1 QL (2700 per 30 (Acetaminophen with 1 QL (2700 per 30 Codeine) (Tylenol-Codeine No.3) 1 QL (360 per 30 (Tylenol-Codeine No.3) 1 QL (180 per 30 (Hycet) 1 QL (2700 per 30 (Norco) 1 (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 (Norco) 1 QL (360 per 30 morphine 10 mg/ml carpuject (Morphine Sulfate) 1 morphine 2 mg/ml carpuject (Morphine Sulfate) 1 morphine 4 mg/ml carpuject (Morphine Sulfate) 1 morphine 8 mg/ml syringe (Morphine Sulfate) 1 morphine concentrate oral solution (Morphine Sulfate) 1 QL (200 per 30 morphine intravenous syringe (Morphine Sulfate) 1 morphine oral solution 10 mg/5 ml (Morphine Sulfate) 1 QL (700 per 30 morphine oral solution 20 mg/5 ml (Morphine Sulfate) 1 QL (300 per 30 MORPHINE ORAL TABLET 3 QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) 1 QL (120 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 (MS Contin) 1 QL (180 per 30 mg, 200 mg oxycodone hcl-acetaminophen oral tablet (Xolox) 1 QL (360 per mg, mg, mg oxycodone oral concentrate (Oxycodone HCl) 1 QL (180 per 30 oxycodone oral solution (Oxycodone HCl) 1 QL (1300 per 30 oxycodone oral tablet (Roxicodone) 1 QL (180 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg (Xolox) 1 QL (360 per 30 10

11 OXYCONTIN ORAL TABLET,ORAL 2 QL (60 per 30 ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 2 QL (120 per 30 ONLY,EXT.REL.12 HR 80 MG tramadol oral tablet (Ultram) 1 QL (240 per 30 Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) 1 release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) 1 release (dr/ec) diclofenac sodium topical gel (Solaraze) 4 ibuprofen oral suspension (Ibuprofen) 1 ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) 1 mg indomethacin oral capsule 25 mg (Indomethacin) 1 PA-HRM; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) 1 PA-HRM; QL (120 per 30 indomethacin oral capsule, extended release (Indomethacin) 1 PA-HRM; QL (60 per 30 meloxicam (Mobic) 1 nabumetone (Nabumetone) 1 naproxen oral suspension (Naprosyn) 1 naproxen oral tablet (Naprosyn) 1 naproxen oral tablet,delayed release (Ec-Naprosyn) 1 (dr/ec) VOLTAREN TOPICAL 2 Anesthetics Local Anesthetics lidocaine 2% viscous soln 2 % (Xylocaine) 1 lidocaine hcl injection solution 20 mg/ml (Xylocaine) 1 (PA for ESRD Only) (2 %) lidocaine hcl mucous membrane gel (Lidocaine HCl) 1 lidocaine hcl mucous membrane jelly in (Lidocaine HCl) 1 applicator lidocaine hcl mucous membrane solution (Xylocaine) 1 lidocaine hcl urethral (Lidocaine HCl) 1 11

12 lidocaine topical adhesive patch,medicated Drug Name Drug Tier Requirements/Limits (Lidoderm) 1 PA lidocaine topical ointment (Lidocaine) 1 (PA for ESRD Only) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) 1 PA; QL (90 per 30 CHANTIX 2 QL (168 per 84 CHANTIX STARTING MONTH BOX 2 QL (53 per 28 ZUBSOLV 2 PA; QL (90 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet (Xanax) 1 QL (120 per 30 lorazepam oral tablet (Ativan) 1 QL (90 per 30 Antibacterials Aminoglycosides BETHKIS 4 PA BvD gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) 1 neomycin (Neomycin Sulfate) 1 TOBI PODHALER INHALATION 4 QL (224 per 28 CAPSULE, W/INHALATION DEVICE Antibacterials, Miscellaneous clindamycin hcl (Cleocin HCl) 1 metronidazole oral (Flagyl) 1 nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg nitrofurantoin macrocrystal oral capsule 50 mg (Macrodantin/Macrobid) 1 PA-HRM; QL (120 per 30 (Macrodantin/Macrobid) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 12

13 nitrofurantoin monohyd/m-cryst (Macrobid) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 trimethoprim (Trimethoprim) 1 XIFAXAN ORAL TABLET 200 MG 4 PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 4 PA Cephalosporins cefadroxil oral capsule (Cefadroxil) 1 cefadroxil oral suspension for (Cefadroxil) 1 reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) 1 cefdinir (Cefdinir) 1 cefpodoxime (Cefpodoxime Proxetil) 1 cefprozil (Cefprozil) 1 cefuroxime axetil oral tablet (Ceftin) 1 cephalexin oral capsule (Keflex) 1 cephalexin oral suspension for (Cephalexin) 1 reconstitution cephalexin oral tablet (Cephalexin) 1 Macrolides azithromycin (Zithromax) 1 clarithromycin oral suspension for (Biaxin) 1 reconstitution clarithromycin oral tablet (Biaxin) 1 clarithromycin oral tablet extended (Clarithromycin) 1 release 24 hr Miscellaneous B-Lactam Antibiotics CAYSTON 4 LA INVANZ INJECTION 3 Penicillins amoxicillin oral capsule (Amoxicillin) 1 amoxicillin oral suspension for (Amoxicillin) 1 reconstitution amoxicillin oral tablet (Amoxicillin) 1 13

14 amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) mg amoxicillin-pot clavulanate oral (Augmentin) 1 suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) 1 amoxicillin-pot clavulanate oral tablet (Augmentin XR) 1 extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium 1 tablet,chewable Clav) dicloxacillin (Dicloxacillin Sodium) 1 penicillin v potassium (Penicillin V Potassium) 1 Quinolones ciprofloxacin hcl oral (Cipro) 1 levofloxacin intravenous (Levofloxacin) 1 levofloxacin oral (Levaquin) 1 Sulfonamides sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim 1 intravenous ethoprim) sulfamethoxazole-trimethoprim oral suspension (Sulfamethoxazole/Trim ethoprim) 1 sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 sulfasalazine dr 500 mg tab (Azulfidine) 1 sulfasalazine oral tablet (Azulfidine) 1 sulfazine ec (Azulfidine) 1 Tetracyclines doxycycline hyclate oral capsule 100 mg (Adoxa) 1 doxycycline hyclate oral tablet 100 mg, 50 (Avidoxy) 1 mg doxycycline mono 100 mg cap (Adoxa) 1 doxycycline mono 100 mg tablet f/c (Avidoxy) 1 doxycycline mono 50 mg tablet (Avidoxy) 1 doxycycline monohydrate oral capsule 150 (Adoxa) 1 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension (Vibramycin) 1 for reconstitution doxycycline monohydrate oral tablet 150 mg, 75 mg (Avidoxy) 1 minocycline oral capsule (Minocin) 1 minocycline oral tablet (Minocycline HCl) 1 Anticancer Agents 14

15 Anticancer Agents AFINITOR DISPERZ 4 PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 4 PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 4 PA NSO; QL (28 per 28 anastrozole (Arimidex) 1 bicalutamide (Casodex) 1 DROXIA 2 ELIGARD SUBCUTANEOUS SYRINGE 3 QL (1 per MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 3 QL (1 per MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 3 QL (1 per MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) 3 exemestane (Aromasin) 1 GLEEVEC ORAL TABLET 100 MG 4 PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 4 PA NSO; QL (60 per 30 hydroxyurea (Hydrea) 1 JAKAFI 4 PA NSO; QL (60 per 30 letrozole (Femara) 1 LEUKERAN 3 leuprolide subcutaneous kit (Leuprolide Acetate) 1 LUPRON DEPOT 4 LUPRON DEPOT (3 MONTH) 4 QL (1 per 84 LUPRON DEPOT (4 MONTH) 4 QL (1 per 84 LUPRON DEPOT (6 MONTH) 4 QL (1 per 168 megestrol oral tablet (Megestrol Acetate) 1 mercaptopurine (Mercaptopurine) 1 methotrexate 50 mg/2 ml vial latex-free, (Methotrexate Sodium) 1 PA BvD 5's, mdv methotrexate sodium (pf) injection (Methotrexate Sodium) 1 PA BvD solution methotrexate sodium oral (Methotrexate Sodium) 1 PA BvD; ST 15

16 NEXAVAR 4 PA NSO; QL (120 per 30 POMALYST 4 PA NSO; QL (21 per 28 PURIXAN 4 REVLIMID 4 PA NSO; LA SOLTAMOX 3 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 4 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 4 PA NSO; QL (60 per 30 SUTENT 4 PA NSO; QL (30 per 30 tamoxifen (Tamoxifen Citrate) 1 TARCEVA ORAL TABLET 100 MG, 25 MG 4 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 4 PA NSO; QL (90 per 30 TASIGNA 4 PA NSO; QL (112 per 28 TREXALL 3 PA BvD; ST VOTRIENT 4 PA NSO; QL (120 per 30 XTANDI 4 PA NSO; QL (120 per 30 ZYTIGA 4 PA NSO; QL (120 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) 1 mg/ml propantheline (Propantheline Bromide) 1 STIOLTO RESPIMAT 2 QL (4 per 28 Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) 1 multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml (Tegretol) 1 16

17 carbamazepine oral tablet extended (Tegretol XR) 1 release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) 1 divalproex oral capsule, sprinkle (Depakote Sprinkle) 1 divalproex oral tablet extended release 24 (Depakote ER) 1 hr divalproex oral tablet,delayed release (Depakote) 1 (dr/ec) gabapentin oral capsule (Neurontin) 1 gabapentin oral solution 250 mg/5 ml (Neurontin) 1 gabapentin oral tablet 600 mg, 800 mg (Neurontin) 1 lamotrigine oral tablet (Lamictal) 1 lamotrigine oral tablet extended release (Lamictal XR) 1 24hr lamotrigine oral tablet, chewable (Lamictal) 1 dispersible levetiracetam intravenous (Keppra) 1 levetiracetam oral solution 100 mg/ml (Keppra) 1 levetiracetam oral tablet (Keppra) 1 levetiracetam oral tablet extended release 24 hr (Keppra XR) 1 LYRICA ORAL CAPSULE 2 QL (90 per 30 LYRICA ORAL SOLUTION 2 QL (900 per 30 topiramate oral capsule, sprinkle (Topamax) 1 topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 1 topiramate oral tablet (Topamax) 1 TROKENDI XR 3 ST Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) 1 QL (30 per 30 donepezil oral tablet,disintegrating (Donepezil HCl) 1 QL (30 per 30 EXELON TRANSDERMAL 1 QL (30 per 30 NAMENDA XR ORAL 2 QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL 2 QL (30 per 30 CAPSULE,SPRINKLE,ER 24HR rivastigmine (Exelon) 1 QL (30 per 30 Antidepressants Antidepressants 17

18 amitriptyline (Amitriptyline HCl) 1 PA NSO-HRM bupropion hcl oral tablet (Wellbutrin) 1 bupropion hcl oral tablet extended release (Wellbutrin SR) 1, 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 1 24 hr citalopram oral solution (Citalopram 1 Hydrobromide) citalopram oral tablet (Celexa) 1 QL (30 per 30 escitalopram oxalate (Lexapro) 1 fluoxetine oral capsule (Prozac) 1 fluoxetine oral capsule,delayed (Prozac Weekly) 1 release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) 1 fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 1 paroxetine hcl oral tablet (Paxil) 1 paroxetine hcl oral tablet extended release (Paxil CR) 1 24 hr PAXIL ORAL SUSPENSION 3 sertraline (Zoloft) 1 trazodone (Trazodone HCl) 1 venlafaxine oral capsule,extended release (Effexor XR) 1 24hr venlafaxine oral tablet (Venlafaxine HCl) 1 venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg (Venlafaxine HCl) 1 Antidiabetic Agents Antidiabetic Agents, Miscellaneous JANUMET 2 JANUMET XR 2 JANUVIA 2 metformin oral tablet 1,000 mg (Glucophage) 1 QL (60 per 30 metformin oral tablet 500 mg (Glucophage) 1 QL (150 per 30 metformin oral tablet 850 mg (Glucophage) 1 QL (90 per 30 metformin oral tablet extended release 24 (Glucophage XR) 1 QL (120 per 30 hr 500 mg metformin oral tablet extended release 24 hr 750 mg (Glucophage XR) 1 QL (90 per 30 18

19 metformin oral tablet extended release (Fortamet) 1 QL (60 per 30 24hr 1,000 mg pioglitazone (Actos) 1 QL (30 per 30 TRADJENTA 2 VICTOZA 3-PAK 2 Insulins LANTUS 2 LANTUS SOLOSTAR 2 NOVOLOG 2 QL (40 per 28 NOVOLOG FLEXPEN 2 QL (30 per 28 NOVOLOG PENFILL 2 QL (30 per 28 TOUJEO SOLOSTAR 2 Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) 1 QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) 1 QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) 1 QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) 1 QL (60 per mg glipizide oral tablet extended release 24hr (Glucotrol XL) 1 QL (30 per mg, 5 mg Antifungals Antifungals clotrimazole mucous membrane (Clotrimazole) 1 clotrimazole topical (Clotrimazole) 1 clotrimazole-betamethasone topical cream (Lotrisone) 1 clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth 1 asone Dip) fluconazole (Diflucan) 1 ketoconazole oral (Ketoconazole) 1 ketoconazole topical cream (Ketoconazole) 1 ketoconazole topical shampoo (Nizoral) 1 nystatin oral suspension (Nystatin) 1 nystatin oral tablet (Nystatin) 1 nystatin topical (Nystatin) 1 nystatin topical powder 100,000 unit/gram (Nystatin) 1 terbinafine hcl oral (Lamisil) 1 Antihistamines Antihistamines 19

20 cyproheptadine (Cyproheptadine HCl) 1 levocetirizine (Xyzal) 1 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal (Metrogel-Vaginal) 1 terconazole vaginal cream (Terazol 7) 1 terconazole vaginal suppository (Terconazole) 1 Antimigraine Agents Antimigraine Agents rizatriptan oral tablet (Maxalt) 1 QL (18 per 28 rizatriptan oral tablet,disintegrating (Maxalt Mlt) 1 QL (18 per 28 sumatriptan 4 mg/0.5 ml inject latex-free (Sumatriptan Succinate) 1 QL (4 per 28 sumatriptan 6 mg/0.5 ml refill latex-free (Imitrex) 1 QL (4 per 28 sumatriptan succinate oral (Imitrex) 1 QL (18 per 28 sumatriptan succinate subcutaneous (Sumatriptan Succinate) 1 QL (4 per 28 cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) 1 QL (4 per 28 injector 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Sumatriptan Succinate) 1 QL (4 per 28 injector 6 mg/0.5 ml (auto-injector) sumatriptan succinate subcutaneous solution (Imitrex) 1 QL (4 per 28 Antimycobacterials Antimycobacterials dapsone (Dapsone) 1 isoniazid oral (Isoniazid) 1 rifampin intravenous (Rifadin) 1 rifampin oral (Rifadin) 1 Antinausea Agents Antinausea Agents meclizine oral tablet 12.5 mg, 25 mg (Antivert) 1 ondansetron (Zofran Odt) 1 PA BvD prochlorperazine maleate oral (Compazine) 1 promethazine hcl rectal suppository 12.5 (Phenergan) 1 PA-HRM mg, 25 mg, 50 mg promethazine oral tablet (Promethazine HCl) 1 PA-HRM promethazine rectal (Phenergan) 1 PA-HRM 20

21 Antiparasite Agents Antiparasite Agents ALBENZA 3 atovaquone-proguanil (Malarone) 1 hydroxychloroquine oral (Plaquenil) 1 mefloquine (Mefloquine HCl) 1 Antiparkinsonian Agents Antiparkinsonian Agents benztropine oral (Benztropine Mesylate) 1 PA-HRM carbidopa-levodopa oral tablet (Sinemet CR) 1 carbidopa-levodopa oral tablet extended (Sinemet CR) 1 release pramipexole oral tablet (Mirapex) 1 ropinirole oral tablet (Requip) 1 ropinirole oral tablet extended release 24 hr (Requip XL) 1 Antipsychotic Agents Antipsychotic Agents clozapine oral tablet 100 mg (Clozaril) 1 QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) 1 QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) 1 QL (90 per 30 clozapine oral tablet,disintegrating (Fazaclo) 1 ST haloperidol (Haloperidol) 1 LATUDA 3 olanzapine intramuscular (Zyprexa) 1 QL (30 per 30 olanzapine oral tablet (Zyprexa) 1 QL (30 per 30 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) 1 QL (30 per 30 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 (Zyprexa Zydis) 1 QL (31 per 30 mg quetiapine (Seroquel) 1 QL (90 per 30 risperidone oral solution (Risperdal) 1 QL (480 per 30 risperidone oral tablet (Risperdal) 1 QL (60 per 30 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) 1 QL (60 per 30 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) 1 QL (120 per 30 mg, 4 mg VERSACLOZ 4 ST; QL (540 per 30 21

22 ziprasidone hcl (Geodon) 1 QL (60 per 30 Antivirals (Systemic) Antiretrovirals ATRIPLA 4 COMPLERA 4 EPZICOM 4 ISENTRESS ORAL POWDER IN 2 PACKET ISENTRESS ORAL TABLET 4 ISENTRESS ORAL 2 TABLET,CHEWABLE NORVIR 2 PREZISTA ORAL SUSPENSION 3 PREZISTA ORAL TABLET 150 MG, 75 2 MG PREZISTA ORAL TABLET 600 MG, MG REYATAZ ORAL CAPSULE 150 MG, MG, 300 MG REYATAZ ORAL POWDER IN 4 PACKET STRIBILD 4 TRUVADA 4 VIREAD 4 Antivirals, Miscellaneous SYNAGIS 100 MG/1 ML VIAL 4 SYNAGIS INTRAMUSCULAR 4 SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 30 MG 2 QL (84 per 180 TAMIFLU ORAL CAPSULE 45 MG 2 QL (48 per 180 TAMIFLU ORAL CAPSULE 75 MG 2 QL (42 per 180 TAMIFLU ORAL SUSPENSION FOR 2 QL (540 per 180 RECONSTITUTION Hcv Antivirals OLYSIO 4 PA; QL (28 per 28 SOVALDI 4 PA; QL (28 per 28 Interferons INTRON A 10 MILLION UNIT/ML 3 PA NSO INTRON A INJECTION RECON SOLN 3 PA NSO 22

23 INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 3 PA NSO PEGASYS 4 PA PEGASYS PROCLICK 4 PA Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) 1 acyclovir oral suspension 200 mg/5 ml (Zovirax) 1 acyclovir oral tablet (Zovirax) 1 famciclovir (Famvir) 1 valacyclovir (Valtrex) 1 Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin subcutaneous solution (Lovenox) 1 QL (36 per 30 enoxaparin subcutaneous syringe 100 (Lovenox) 4 QL (36 per 30 mg/ml enoxaparin subcutaneous syringe 120 (Lovenox) 4 QL (27.2 per 30 mg/0.8 ml enoxaparin subcutaneous syringe 150 (Lovenox) 4 QL (34 per 30 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) 1 QL (18 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) 1 QL (13.6 per 30 mg/0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) 1 QL (20.4 per 30 mg/0.6 ml enoxaparin subcutaneous syringe 80 (Lovenox) 1 QL (27.2 per 30 mg/0.8 ml jantoven (Coumadin) 1 warfarin (Coumadin) 1 XARELTO 2 Blood Formation Modifiers EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML NEULASTA SUBCUTANEOUS SYRINGE 2 PA; QL (12 per 28 2 PA; QL (12 per

24 NEUPOGEN 4 PROCRIT 10,000 UNITS/ML VIAL 4'S, 2 PA; QL (12 per 28 MDV, OUTER PROCRIT INJECTION SOLUTION 2 PA; QL (12 per 28 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 4 PA; QL (12 per 28 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 4 PA; QL (6 per 28 Hematologic Agents, Miscellaneous anagrelide (Agrylin) 1 tranexamic acid intravenous (Tranexamic Acid) 1 tranexamic acid oral (Lysteda) 1 QL (30 per 30 Platelet-Aggregation Inhibitors clopidogrel (Plavix) 1 EFFIENT 2 QL (30 per 30 Caloric Agents Caloric Agents AMINO ACIDS 15 % 3 PA BvD CLINIMIX 5%-D20W(SULFITE-FREE) 3 PA BvD CLINIMIX E 4.25%/D25W SUL FREE 3 PA BvD CLINIMIX E 5%/D15W SULFIT FREE 3 PA BvD CLINIMIX E 5%/D20W SULFIT FREE 3 PA BvD CLINISOL SF 15 % 3 PA BvD dextrose 10 % in water (d10w) (Dextrose 10 % in 1 PA BvD Water) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) 1 parenteral solution INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % 3 PA BvD NUTRILIPID 3 PA BvD PROSOL 20 % 3 PA BvD TRAVASOL 10 % 3 PA BvD TROPHAMINE 10 % 3 PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet (Catapres) 1 doxazosin (Cardura) 1 24

25 Angiotensin Ii Receptor Antagonists irbesartan (Avapro) 1 losartan (Cozaar) 1 losartan-hydrochlorothiazide (Hyzaar) 1 valsartan-hydrochlorothiazide (Diovan HCT) 1 Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) 1 enalapril maleate (Vasotec) 1 lisinopril (Zestril) 1 lisinopril-hydrochlorothiazide (Zestoretic) 1 ramipril (Altace) 1 Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 (Cordarone) 1 mg, 400 mg amiodarone oral tablet 200 mg, 400 mg (Cordarone) 1 flecainide (Tambocor) 1 propafenone oral capsule,extended release (Rythmol SR) 1 12 hr propafenone oral tablet (Rythmol) 1 Beta-Adrenergic Blocking Agents atenolol (Tenormin) 1 carvedilol (Coreg) 1 metoprolol succinate (Toprol XL) 1 metoprolol tartrate intravenous solution (Lopressor) 1 metoprolol tartrate oral tablet 100 mg, 25 (Lopressor) 1 mg, 50 mg propranolol intravenous (Propranolol HCl) 1 propranolol oral capsule,extended release (Inderal LA) 1 24 hr propranolol oral solution (Propranolol HCl) 1 propranolol oral tablet (Propranolol HCl) 1 Calcium-Channel Blocking Agents cartia xt (Cardizem CD) 1 diltiazem 24hr er 180 mg cap (Cardizem CD) 1 diltiazem 24hr er 360 mg cap once a day (Cardizem CD) 1 dosage diltiazem hcl intravenous (Cardizem CD) 1 25

26 diltiazem hcl oral capsule, extended (Cardizem CD) 1 release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) 1 release 12 hr diltiazem hcl oral capsule,extended (Cardizem CD) 1 release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet (Cardizem CD) 1 dilt-xr (Cardizem CD) 1 matzim la (Cardizem CD) 1 taztia xt (Cardizem CD) 1 verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 1 verapamil oral capsule,ext rel. pellets 24 (Verelan) 1 hr verapamil oral tablet (Calan) 1 verapamil oral tablet extended release (Calan SR) 1 Cardiovascular Agents, Miscellaneous digitek oral tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) 1 PA-HRM; QL (30 per 30 digox 125 mcg tablet 125 mcg (Lanoxin) 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digox 250 mcg tablet 250 mcg (Lanoxin) 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 digoxin 0.25 mg/ml syringe (Digoxin) 1 PA-HRM digoxin injection solution (Digoxin) 1 PA-HRM DIGOXIN ORAL SOLUTION 50 MCG/ML 2 PA-HRM; QL (300 per 30 26

27 digoxin oral tablet (Lanoxin) 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 hydralazine (Hydralazine HCl) 1 LANOXIN ORAL TABLET MCG, 62.5 MCG Dihydropyridines amlodipine (Norvasc) 1 amlodipine-benazepril (Lotrel) 1 nifedipine er 30 mg tablet f/c (Adalat CC) 1 nifedipine oral tablet extended release (Adalat CC) 1 24hr 30 mg nifedipine oral tablet extended release (Procardia XL) 1 24hr 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) 1 mg, 60 mg Diuretics chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 1 furosemide injection (Furosemide) 1 furosemide oral solution 10 mg/ml, 40 (Furosemide) 1 mg/5 ml furosemide oral tablet (Lasix) 1 hydrochlorothiazide oral capsule (Microzide) 1 hydrochlorothiazide oral tablet (Hydrochlorothiazide) 1 triamterene-hydrochlorothiazid oral capsule (Dyazide) 1 triamterene-hydrochlorothiazid oral tablet (Maxzide) 1 Dyslipidemics atorvastatin (Lipitor) 1 CRESTOR 2 gemfibrozil oral (Lopid) 1 lovastatin (Mevacor) 1 pravastatin (Pravachol) 1 3 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 27

28 simvastatin oral tablet 10 mg, 20 mg, 40 (Zocor) 1 mg, 5 mg simvastatin oral tablet 80 mg (Zocor) 1 QL (30 per 30 Renin-Angiotensin-Aldosterone System Inhibitors spironolactone (Aldactone) 1 spironolacton-hydrochlorothiaz (Aldactazide) 1 Vasodilators isosorbide mononitrate oral tablet (Isosorbide Mononitrate) 1 isosorbide mononitrate oral tablet (Imdur) 1 extended release 24 hr minitran transdermal patch 24 hour 0.1 (Nitro-Dur) 1 QL (30 per 30 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) 1 QL (60 per 30 mg/hr NITRO-BID 2 nitroglycerin intravenous (Nitroglycerin) 1 nitroglycerin transdermal patch 24 hour (Nitro-Dur) 1 QL (30 per mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr (Nitro-Dur) 1 QL (60 per 30 NITROSTAT 2 Central Nervous System Agents Central Nervous System Agents amphetamine salt combo (Adderall) 1 QL (60 per 30 dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) 1 QL (30 per 30 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg (Adderall XR) 1 QL (60 per 30 lithium carbonate oral capsule (Lithium Carbonate) 1 lithium carbonate oral tablet (Lithobid) 1 lithium carbonate oral tablet extended (Lithobid) 1 release methylphenidate cd 20 mg cap (Metadate Cd) 1 QL (30 per 30 methylphenidate cd 40 mg cap (Metadate Cd) 1 QL (30 per 30 methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg (Metadate Cd) 1 QL (30 per 30 28

29 methylphenidate oral capsule, er biphasic (Metadate Cd) 1 QL (60 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) 1 QL (30 per mg, 40 mg methylphenidate oral solution (Methylin) 1 QL (900 per 30 methylphenidate oral tablet (Ritalin) 1 QL (90 per 30 methylphenidate oral tablet extended (Methylphenidate HCl) 1 QL (90 per 30 release methylphenidate oral tablet extended (Concerta) 1 QL (30 per 30 release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended (Concerta) 1 QL (60 per 30 release 24hr 36 mg QUILLIVANT XR 2 STRATTERA 2 Contraceptives Contraceptives blisovi 24 fe (Loestrin Fe) 1 blisovi fe 1.5/30 (28) (Loestrin Fe) 1 blisovi fe 1/20 (28) (Loestrin Fe) 1 drospirenone-ethinyl estradiol (Yaz) 1 ethinyl estradiol/drospirenone oral tablet (Yaz) mg, mg gildess 24 fe (Loestrin Fe) 1 junel fe 24 (Loestrin Fe) 1 larin fe 1/20 (28) (Loestrin Fe) 1 levonor-eth estrad outer (Amethyst) 1 QL (91 per 84 levonorgestrel-ethin estradiol oral tablet (Amethyst) mg-mcg, mg, (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethin 1 QL (91 per 84 tablets,dose pack,3 month mg-mcg Estradiol) levonorgestrel-ethinyl estrad oral tablet (Amethyst) mg-mcg levonorgestrel-ethinyl estrad oral (Amethyst) 1 QL (91 per 84 tablets,dose pack,3 month norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) 1 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), 1-20(5)/1-30(7) /1mg- 35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norg-ee /0.035 (Ortho-Cyclen) 1 29

30 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg setlakin (Ortho-Cyclen) 1 (Levonorgestrel-Ethin Estradiol) tarina fe 1/20 (28) (Loestrin Fe) 1 tri-lo-estarylla (Ortho-Cyclen) 1 tri-lo-sprintec (Ortho-Cyclen) 1 vienva (Amethyst) 1 Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous membrane triamcinolone acetonide dental (Peridex) 1 (Triamcinolone Acetonide) 1 QL (91 per 84 Dermatological Agents Dermatological Agents, Other acyclovir topical (Zovirax) 1 QL (30 per 30 ammonium lactate topical (Lac-Hydrin) 1 calcipotriene scalp (Calcipotriene) 1 calcipotriene topical cream (Dovonex) 1 calcipotriene topical ointment (Calcipotriene) 1 fluorouracil topical cream (Carac) 1 fluorouracil topical solution (Fluorouracil) 1 imiquimod (Aldara) 1 PA NSO; QL (24 per 30 TOLAK 3 ZOVIRAX TOPICAL CREAM 2 QL (15 per 30 Dermatological Antibacterials clindamycin phosphate topical gel (Cleocin T) 1 clindamycin phosphate topical lotion (Cleocin T) 1 clindamycin phosphate topical solution (Cleocin T) 1 clindamycin phosphate topical swab (Cleocin T) 1 metronidazole topical cream (Metrocream) 1 metronidazole topical gel (Rosadan) 1 metronidazole topical lotion (Metrolotion) 1 mupirocin (Centany)

31 Dermatological Anti- Inflammatory Agents clobetasol 0.05% cream (Temovate) 1 clobetasol propionate scalp solution 0.05 (Clobetasol Propionate) 1 % clobetasol scalp (Clobetasol Propionate) 1 clobetasol topical foam (Olux) 1 clobetasol topical gel (Clobetasol Propionate) 1 clobetasol topical lotion (Clobex) 1 clobetasol topical ointment (Temovate) 1 clobetasol topical shampoo (Clobex) 1 clobetasol-emollient topical cream (Temovate) 1 desonide topical cream (Desowen) 1 desonide topical ointment (Desonide) 1 fluocinonide 0.05% cream (Vanos) 1 fluocinonide topical gel (Fluocinonide) 1 fluocinonide topical ointment (Fluocinonide) 1 fluocinonide topical solution (Fluocinonide) 1 fluocinonide-emollient base (Vanos) 1 hydrocortisone rectal cream 1 % (Anusol-HC) 1 hydrocortisone rectal cream 2.5 % (Hydrocortisone) 1 hydrocortisone rectal enema (Cortenema) 1 hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 1 hydrocortisone topical lotion 2 %, 2.5 % (Scalacort) 1 hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) 1 % triamcinolone acetonide topical cream (Triamcinolone 1 Acetonide) triamcinolone acetonide topical lotion (Triamcinolone 1 Acetonide) triamcinolone acetonide topical ointment (Triamcinolone %, 0.05 %, 0.1 %, 0.5 % Acetonide) Dermatological Retinoids adapalene topical cream (Differin) 1 adapalene topical gel 0.1 % (Differin) 1 tretinoin topical (Retin-A) 1 PA Scabicides And Pediculicides malathion (Ovide) 1 permethrin topical cream (Elimite) 1 31

32 Devices Devices BD INSULIN SYR 0.5 ML 31GX5/16" 1 BD INSULIN SYR 1 ML 31GX5/16" 1 INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 X 1/2", 1/2 ML 28 GAUGE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CREON 2 KUVAN ORAL TABLET,SOLUBLE 4 ORFADIN 4 PULMOZYME 4 PA BvD ZENPEP 2 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous azelastine nasal aerosol,spray (Astepro) 1 QL (30 per 25 azelastine ophthalmic (Azelastine HCl) 1 cromolyn ophthalmic (Cromolyn Sodium) 1 ipratropium bromide nasal spray,nonaerosol (Atrovent) 1 QL (30 per % ipratropium bromide nasal spray,nonaerosol (Atrovent) 1 QL (15 per % olopatadine ophthalmic (Patanol) 1 PATADAY 3 ST Eye, Ear, Nose, Throat Anti- Infectives Agents CIPRODEX 2 erythromycin ophthalmic (Ilotycin) 1 gentamicin ophthalmic (Garamycin) 1 gentamicin sulfate ophthalmic ointment (Garamycin) % (3 mg/gram) MOXEZA 2 neomycin-polymyxin b-dexameth (Maxitrol) 1 neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B 1 Sulf/HC) neomycin-polymyxin-hc otic drops,suspension (Neomycin/Polymyxin B Sulf/HC)

33 neomycin-polymyxin-hc otic solution (Cortisporin) 1 ofloxacin ophthalmic (Ocuflox) 1 ofloxacin otic (Ocuflox) 1 TOBRADEX OPHTHALMIC OINTMENT 3 TOBRADEX ST 2 tobramycin-dexamethasone (Tobradex) 1 VIGAMOX 2 Eye, Ear, Nose, Throat Anti- Inflammatory Agents fluticasone nasal (Fluticasone Propionate) 1 ketorolac ophthalmic (Acular) 1 prednisolone acetate (Omnipred) 1 RESTASIS 2 QL (60 per 30 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants omeprazole oral capsule,delayed release(dr/ec) (Prilosec) 1 pantoprazole oral (Protonix) 1 ranitidine hcl 50 mg/2 ml vial sdv (Zantac) 1 (Rx Product Only) ranitidine hcl injection solution 25 mg/ml (Zantac) 1 (Rx Product Only) ranitidine hcl oral capsule (Ranitidine HCl) 1 (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) 1 (Rx Product Only) ranitidine hcl oral tablet 150 mg, 300 mg (Zantac) 1 (Rx Product Only) Gastrointestinal Agents, Other dicyclomine oral capsule (Bentyl) 1 dicyclomine oral solution (Dicyclomine HCl) 1 dicyclomine oral tablet (Bentyl) 1 diphenoxylate-atropine oral liquid (Diphenoxylate 1 HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) 1 lactulose oral solution 10 gram/15 ml (Lactulose) 1 metoclopramide hcl injection solution (Metoclopramide HCl) 1 metoclopramide hcl oral solution (Metoclopramide HCl) 1 metoclopramide hcl oral tablet (Reglan) 1 ursodiol oral capsule (Actigall) 1 ursodiol oral tablet (Urso) 1 Laxatives 33

34 peg 3350-electrolytes oral recon soln 236- (Golytely) gram peg 3350-na sulf,bicarb,cl-kcl (Golytely) 1 peg-electrolyte soln (Nulytely with Flavor 1 Packs) sodium chloride-nahco3-kcl-peg oral recon soln 420 gram (Nulytely with Flavor Packs) 1 Phosphate Binders calcium acetate oral capsule (Phoslo) 1 PHOSLYRA 3 RENVELA 2 Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet (Oxybutynin Chloride) 1 oxybutynin chloride oral tablet extended (Ditropan XL) 1 release 24hr trospium (Trospium Chloride) 1 Genitourinary Agents, Miscellaneous tamsulosin (Flomax) 1 terazosin (Terazosin HCl) 1 Heavy Metal Antagonists Heavy Metal Antagonists EXJADE ORAL TABLET, DISPERSIBLE 125 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG SYPRINE 4 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM 2 PA; QL (30 per 30 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) 2 PA; QL (150 per 30 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) testosterone cypionate (Depo-Testosterone) 1 PA PA; QL (150 per 30 34

35 testosterone transdermal gel in metereddose pump 1.25 gram/ actuation (1 %) (Vogelxo) 1 PA; QL (300 per 30 testosterone transdermal gel in packet 1 % (25 mg/2.5gram) (Androgel) 1 PA; QL (300 per 30 testosterone transdermal gel in packet 1 % (50 mg/5 gram) (Testim) 1 PA; QL (300 per 30 Estrogens And Antiestrogens ESTRACE VAGINAL 2 estradiol oral (Estrace) 1 PA-HRM estradiol transdermal patch semiweekly (Vivelle-Dot) 1 PA-HRM; QL (8 per 28 estradiol transdermal patch weekly (Climara) 1 PA-HRM; QL (4 per 28 PREMARIN INJECTION 2 PREMARIN ORAL 2 PA-HRM PREMARIN VAGINAL 2 PREMPHASE 2 PA-HRM PREMPRO 2 PA-HRM VAGIFEM 2 QL (18 per 28 Glucocorticoids/Mineralocorticoid methylprednisolone (Medrol) 1 PA BvD prednisolone sodium phosphate oral (Pediapred) 1 PA BvD solution 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution (Prednisone) 1 PA BvD prednisone oral tablet (Prednisone) 1 PA BvD Pituitary desmopressin injection (Desmopressin Acetate) 1 desmopressin nasal solution (DDAVP) 1 QL (15 per 30 desmopressin nasal spray,non-aerosol (Desmopressin Acetate) 1 QL (15 per 30 desmopressin oral (DDAVP) 1 GENOTROPIN 4 PA GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML 3 PA 35

36 GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML NORDITROPIN FLEXPRO 4 PA SAIZEN 4 PA SAIZEN CLICK.EASY 4 PA SEROSTIM SUBCUTANEOUS RECON 4 PA SOLN 4 MG, 5 MG, 6 MG Progestins DEPO-PROVERA INTRAMUSCULAR 3 QL (10 per 28 SOLUTION medroxyprogesterone intramuscular (Depo-Provera) 1 QL (1 per 84 suspension medroxyprogesterone oral (Provera) 1 progesterone micronized (Prometrium) 1 Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg (Levothyroxine Sodium) 1 levothyroxine oral (Levoxyl) 1 liothyronine oral (Cytomel) 1 Immunological Agents Immunological Agents ASTAGRAF XL 3 PA BvD azathioprine (Imuran) 1 PA BvD CIMZIA 4 PA CIMZIA POWDER FOR RECONST 4 PA cyclosporine modified (Neoral) 1 PA BvD cyclosporine, modified (Neoral) 1 PA BvD ENBREL 4 PA ENBREL SURECLICK 4 PA ENVARSUS XR 3 PA BvD HUMIRA 4 PA HUMIRA PEN 4 PA HUMIRA PEN CROHN'S-UC-HS START 4 PA leflunomide (Arava) 1 36

37 mycophenolate mofetil oral capsule (Cellcept) 1 PA BvD mycophenolate mofetil oral suspension for (Cellcept) 4 PA BvD reconstitution mycophenolate mofetil oral tablet (Cellcept) 1 PA BvD PROGRAF INTRAVENOUS 3 PA BvD tacrolimus oral (Hecoria) 1 PA BvD Vaccines ADACEL(TDAP 2 ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION BOOSTRIX TDAP 2 ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 2 PA BvD; QL (3 per 365 ENGERIX-B 20 MCG/ML VIAL 10'S,ADULT,P/F,OUTER 2 PA BvD; QL (3 per 365 ENGERIX-B PEDIATRIC (PF) 2 PA BvD; QL (3 per 365 GARDASIL (PF) 2 QL (1.5 per 365 HAVRIX (PF) INTRAMUSCULAR 2 SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR 2 SYRINGE 720 ELISA UNIT/0.5 ML MENACTRA (PF) INTRAMUSCULAR 2 SOLUTION MENVEO A-C-Y-W-135-DIP (PF) 2 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 2 PA BvD; QL (3 per 365 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 2 PA BvD; QL (3 per 365 TWINRIX (PF) INTRAMUSCULAR 2 SUSPENSION TYPHIM VI 2 VAQTA (PF) INTRAMUSCULAR 2 SYRINGE VAQTA 25 UNITS/0.5 ML VIAL SDV, 2 OUTER ZOSTAVAX (PF) 2 QL (1 per 365 Inflammatory Bowel Disease Agents 37

38 Inflammatory Bowel Disease Agents APRISO 2 ASACOL HD 2 budesonide oral (Entocort EC) 4 DELZICOL 2 Irrigating Solutions Irrigating Solutions sodium chloride irrigation water for irrigation, sterile Metabolic Bone Disease Agents Metabolic Bone Disease Agents (Sodium Chloride Irrig Solution) (Water For Irrigation,Sterile) alendronate oral solution (Alendronate Sodium) 1 QL (300 per 28 alendronate oral tablet 10 mg, 40 mg, 5 (Fosamax) 1 mg alendronate oral tablet 35 mg, 70 mg (Fosamax) 1 QL (4 per 28 calcitriol intravenous solution 1 mcg/ml (Calcitriol) 1 (PA for ESRD Only) calcitriol oral (Rocaltrol) 1 (PA for ESRD Only) ibandronate intravenous solution (Ibandronate Sodium) 1 (PA for ESRD Only); QL (3 per 84 ibandronate oral (Boniva) 1 QL (1 per 28 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents allopurinol (Zyloprim) 1 AVONEX (WITH ALBUMIN) 4 ST AVONEX INTRAMUSCULAR PEN 4 ST INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE KIT 4 ST buspirone (Buspirone HCl) 1 COPAXONE SUBCUTANEOUS 4 SYRINGE ELMIRON 3 finasteride oral tablet 5 mg (Proscar) 1 GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT (HUMAN)

39 hydroxyzine hcl intramuscular (Hydroxyzine HCl) 1 PA-HRM hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) 1 PA-HRM hydroxyzine hcl oral tablet (Hydroxyzine HCl) 1 PA-HRM hydroxyzine pamoate (Vistaril) 1 PA-HRM MESTINON ORAL SYRUP 3 MESTINON TIMESPAN 3 pyridostigmine bromide (Mestinon) 1 REBIF (WITH ALBUMIN) 4 REBIF REBIDOSE 4 REBIF TITRATION PACK 4 SENSIPAR ORAL TABLET 30 MG 2 SENSIPAR ORAL TABLET 60 MG, 90 MG 4 ULORIC 2 ST; QL (30 per 30 Ophthalmic Agents Antiglaucoma Agents ALPHAGAN P OPHTHALMIC DROPS % bimatoprost (Bimatoprost) 1 brimonidine (Alphagan P) 1 (drops: 0.15%, 0.20%) dorzolamide-timolol (Cosopt) 1 latanoprost (Xalatan) 1 LUMIGAN OPHTHALMIC DROPS 0.01 % 2 QL (2.5 per 25 timolol maleate ophthalmic drops (Timoptic) 1 timolol maleate ophthalmic gel forming (Timoptic-Xe) 1 solution Replacement Preparations Replacement Preparations d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % NaCl) dextrose 5 %-lactated ringers (Dextrose 5%-Lactated 1 Ringers) klor-con 10 (Potassium Chloride) 1 klor-con m10 tablet (Potassium Chloride) 1 klor-con m15 (Potassium Chloride) 1 klor-con m20 (Potassium Chloride) 1 klor-con sprinkle (Potassium Chloride) 1 magnesium sulfate injection (Magnesium Sulfate)

40 potassium chlorid-d5-0.45%nacl potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml (Potassium Chloride/D nacl) (Potassium Chloride) 1 potassium chloride intravenous solution (Potassium Chloride) 1 potassium chloride oral capsule, extended (Potassium Chloride) 1 release potassium chloride oral liquid (Potassium Chloride) 1 potassium chloride oral tablet extended (K-Tab ER) 1 release 8 meq potassium chloride oral tablet,er (K-Tab ER) 1 particles/crystals 10 meq potassium chloride oral tablet,er (Potassium Chloride) 1 particles/crystals 20 meq potassium citrate (Urocit-K) 1 potassium cl 10 meq/50 ml sol (Potassium Chloride) 1 potassium cl 20 meq/50 ml sol (Potassium Chloride) 1 potassium cl er 10 meq tablet f/c (K-Tab ER) 1 sodium chloride 0.45 % intravenous (Sodium Chloride parenteral solution %) sodium chloride 0.9 % intravenous (0.9 % Sodium 1 parenteral solution Chloride) sodium chloride intravenous parenteral solution 2.5 meq/ml (Sodium Chloride) 1 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 2 QL (60 per 30 ADVAIR HFA 2 QL (12 per 28 QVAR 2 QL (17.4 per 25 Antileukotrienes montelukast (Singulair) 1 zafirlukast (Accolate) 1 Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml (Albuterol Sulfate) 1 PA BvD albuterol sulfate oral syrup (Albuterol Sulfate) 1 albuterol sulfate oral tablet (Albuterol Sulfate) 1 40

41 albuterol sulfate oral tablet extended release 12 hr (Vospire ER) 1 COMBIVENT RESPIMAT 2 QL (8 per 30 PROAIR HFA 2 PROAIR RESPICLICK 2 SPIRIVA RESPIMAT 2 SPIRIVA WITH HANDIHALER 2 VENTOLIN HFA 2 Respiratory Tract Agents, Other acetylcysteine (Acetadote) 1 PA BvD DALIRESP 2 QL (30 per 30 XOLAIR 4 PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) 1 cyclobenzaprine oral tablet 10 mg, 5 mg (Fexmid) 1 PA-HRM methocarbamol oral (Robaxin) 1 PA-HRM Sleep Disorder Agents Sleep Disorder Agents NUVIGIL 2 PA zolpidem oral tablet (Ambien) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 zolpidem oral tablet,ext release multiphase (Ambien CR) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 Vasodilating Agents Vasodilating Agents 41

42 ADCIRCA 4 PA; QL (60 per 30 sildenafil intravenous (Revatio) 4 PA; QL (37.5 per 1 day) sildenafil oral (Revatio) 1 PA; QL (90 per 30 TRACLEER 4 PA; LA; QL (60 per 30 Vitamins And Minerals Vitamins And Minerals multivit-fluor 0.5 mg tab chew chewable, d/f, s/f 0.5 mg pnv prenatal plus multivit tab s/f, glutenfree 27 mg iron- 1 mg prenatal vitamins oral tablet 27 mg iron- 1 mg sodium fluoride oral tablet (Pedi M.Vit No.17 with Fluoride) (Pnv with Ca,No.72/Iron/Fa) (Pnv with Ca,No.72/Iron/Fa) (Pedi M.Vit No.17 with Fluoride) 1 2 (All Rx Prenatal Vitamins Covered) 2 (All Rx Prenatal Vitamins Covered) 1 42

43 索引 A acetaminophen-codeine acetylcysteine acyclovir... 23, 30 ADACEL(TDAP ADOLESN/ADULT)(PF).. 37 adapalene ADCIRCA... 41, 42 ADVAIR DISKUS ADVAIR HFA AFINITOR AFINITOR DISPERZ... 14, 15 ALBENZA albuterol sulfate... 40, 41 alendronate allopurinol ALPHAGAN P alprazolam AMINO ACIDS 15 % amiodarone amiodarone hcl amitriptyline... 17, 18 amlodipine amlodipine-benazepril ammonium lactate amoxicillin... 13, 14 amoxicillin-pot clavulanate amphetamine salt combo anagrelide anastrozole ANDRODERM ANDROGEL APRISO... 37, 38 ASACOL HD ASTAGRAF XL atenolol atorvastatin atovaquone-proguanil ATRIPLA atropine AVONEX AVONEX (WITH ALBUMIN) azathioprine azelastine azithromycin B baclofen BD INSULIN SYRINGE ULTRA-FINE benazepril benztropine BETHKIS bicalutamide bimatoprost blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) BOOSTRIX TDAP brimonidine budesonide buprenorphine-naloxone bupropion hcl buspirone C calcipotriene calcitriol calcium acetate carbamazepine... 16, 17 carbidopa-levodopa cartia xt carvedilol CAYSTON cefadroxil cefdinir cefpodoxime cefprozil cefuroxime axetil cephalexin CHANTIX CHANTIX STARTING MONTH BOX chlorhexidine gluconate chlorthalidone CIMZIA CIMZIA POWDER FOR RECONST CIPRODEX ciprofloxacin hcl citalopram clarithromycin clindamycin hcl clindamycin phosphate CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol propionate clobetasol-emollient clonidine hcl clopidogrel clotrimazole clotrimazole-betamethasone.. 19 clozapine COMBIVENT RESPIMAT CPHL Advantage Care 2016 年 D 部分處方一覽表處方一覽表 ID: , 版本 :12 I-1 生效日期 :2016 年 4 月 1 日