2017 處方藥物清單 （藥物清單）

Transcription

1 處方藥物清單 ( 藥物清單 ) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2017 Provider and Pharmacy Directory CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 請仔細閱讀 : 此清單包含本計畫所給付藥物的相關資訊 Los Angeles County, CA 2016 本處方藥物清單更新日期為 08/08/2016 如果您有疑問, 請致電 CareMore Cal MediConnect Plan 會員服務部 (TTY 711), 太平洋時間週一至週五上午 8 點至下午 8 點 This directory was updated on 09/30/2015. If you have questions, please H6229_17_19648_T_CT call CareMore CalCMS MediConnect Approved 08/12/2016 如需更多資訊, 請瀏覽網站 Plan duals.caremore.com Member Services at Formulary ID: (TTY Version: 711 ), 7 Monday through Friday from 8 a.m. to 8 p.m. Pacific Issued 01/01/2017 time. For more information, visit

2 H6229_17_19648_T_CT CMS Approved 08/12/2016 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 2017 年給付藥物清單 ( 處方藥物清單 ) 這是會員可在 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 中取得的藥物清單 CareMore Cal MediConnect Plan 是一個同時與 Medicare 和 Medi-Cal 訂立合約的醫療保健計畫, 從而為參保人提供這兩個計畫的福利 CareMore 代表 CareMore 的附屬公司負責執行合約 CareMore 為 CareMore Health System 的註冊商標 給付藥物清單 和 / 或網路內藥房和醫療服務提供者可能於全年內隨時變動 在我們做的改變對您造成影響之前, 我們會向您寄送通知 福利和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時查詢 CareMore Cal MediConnect Plan 最新的給付藥物清單, 請上網至網站 duals.caremore.com 或致電 (TTY 711) 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或查閱 CareMore Cal MediConnect Plan 會員手冊 You can get this information for free in other languages. Call (TTY 711), Monday through Friday from 8 am to 8 pm. The call is free. Դուք կարող եք անվճար ստանալ այս ձեռնարկը այլ լեզուներով: Զանգահարեք երկուշաբթիից - ուրբաթ ` 8:00 - ից 20:00 -ն: TTY օգտվողները պետք է զանգահարեն 711: Հեռախոսազանգն անվճար է: 您可以免費取得本手冊其他語言版本 請致電 , 週一至週五, 上午 8:00 至晚上 8:00 TTY 使用者可撥打 711 此為免費電話 ( الخط الخاص بالاعضاء ممن با مكانك الحصول على هذه المعلومات مجانا بلغات ا خرى. اتصل على الرقم ) 711 (من يوم الاثنين لغاية يوم الجمعة ومن الساعة 8 صباحا لغاية 8 مساءا ). هذه TTYلديهم ضعف في السمع ا و النظر المكالمة مجانية. شب 8:00 صبح تا 8:00 "می توانيد اين دفترچه را به طور رايگان به ساير زبان ها دريافت کنيد. از دوشنبه تا جمعه و از ساعت تماس بگيرند. اين تماس رايگان است" 711 بايد با شماره TTY تماس بگيريد. ک را بران با شماره ល កអនកអ ចទទលប ន ស វ ភ ណន ន ដ យឥតគត ថល ជ ភ ស ផសង ទ ត ស មទរសពមក លខ ទ ព ថ ចន ង ទ ដល ថសង រក ព ម ង 8:00រព ក ដល ម ង 8:00ល ង ច អន ក របរប ស TTY ស ម ហ មក លខ 711 ក រ ហ ទរស ព គទ ឥតគត ថ ល CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 1

3 귀하께서는이안내서를다른언어로무료로받아보실수있습니다. 주중 ( 월 - 금 ) 오전 8:00 시에서오후 8:00 시사이에 번으로전화해주십시오. TTY 사용자는 711 로전화해주십시오. 통화는무료입니다. Этот справочник можно бесплатно получить в переводе на другие языки. Звоните по телефону , линия работает с понедельника по пятницу с 8:00 до 20:00. Если вы пользуетесь устройством TTY, звоните по телефону 711. Звонки бесплатные. Puedes recibir este manual en otros idiomas sin cargo. Llama al de lunes a viernes, de 8.00 a.m. a 8.00 p.m. Los usuarios de TTY deben llamar al 711. La llamada es gratuita. Makukuha ninyo nang libre ang handbook na ito sa ibang wika. Tawagan ang , Lunes hanggang Biyernes 8:00 a.m. hanggang 8:00 p.m. Ang mga gumagamit ng TTY ay dapat tawagan ang 711. Libre ang pagtawag. Quy vi co thê nhâ n sô tay nay miê n phı bă ng cac ngôn ngư khac. Hay goi sô , tư Thư Hai đê n Thư Sa u, từ 8 giơ sa ng đên 8 giơ tôi. Ngươ i du ng TTY cân goi đên sô 711. Cuô c goi được miê n phı. 您可以免費索取本資訊的其他格式版本, 如大型字體版本 點字或音訊版本 請於週一至週五上午 8 點至下午 8 點, 致電 (TTY 711), 此為免費電話 現在與將來您都可以要求以您的語言或其他格式 ( 點字 音訊或大型字體印刷 ) 將醫療保健計畫資訊寄給您 要求這個服務時, 請於週一至週五上午 8 點至下午 8 點, 致電會員服務部 (TTY 711), 此為免費電話 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 2

4 常見問題 (FAQ) 如果您對本給付藥物清單有疑問, 您可以在此尋找解答 您可以閱讀所有常見問題了解更多資訊, 或尋找問題和答案 1. 給付藥物清單中有哪些處方藥物 ( 處方藥物清單簡稱為 藥物清單 ) 藥物清單上的藥物是 CareMore Cal MediConnect Plan 給付的藥物 藥物可於我們的網路內藥房取得 若藥房與我們簽署合作的合約並提供服務, 該藥房即為我們的網路內藥房 這些藥房稱為 網路內藥房 若符合以下條件, CareMore Cal MediConnect Plan 會給付藥物清單上有醫療必要性的所有藥物 : 您的醫師或其他處方醫師表示您需要這些藥物以使病情好轉或保持健康, 且 您至 CareMore Cal MediConnect Plan 的網路內藥房領取處方藥物 在某些情況下, 您必須先完成某些行動措施才能取得藥物 ( 參閱下方問題 5) 您也可以在我們的網站 duals.caremore.com 查看我們給付的藥物最新清單, 或是週一至週五上午 8 點至下午 8 點, 撥打電話 (TTY 711) 致電會員服務部 2. 藥物清單會更動嗎 是 CareMore Cal MediConnect Plan 可能會在年度內新增或刪除藥物清單上的藥物 一般而言, 藥物清單只會在以下情況時更動 : 有較便宜, 且療效與藥物清單上的藥物一樣好的藥物問世時, 或者 我們得知某藥物不安全時 我們亦可能變更我們的藥物相關規定 例如, 我們可能會 : 決定某藥物需要或不需要事先核准 ( 事先核准是指獲得 CareMore Cal MediConnect Plan 的許可後才能取得藥物 ) 增加或變更您可取得的藥物數量 ( 稱為 藥量限制 ) 新增或變更藥物的 漸進式治療 限制 ( 漸進式治療 是指您必須先試用某種藥物, 然後我們才會給付另一種藥物 ) ( 如需這些藥物規定的進一步資訊, 請參閱第 4 頁 ) 當我們從藥物清單中刪除您正在使用的藥物時, 我們將會告知您 當我們變更藥物給付的規定時, 我們也會告知您 下列的問題 3 4 和 7 提供更多藥物清單更動的相關資訊 您可以隨時至網站 duals.caremore.com 查詢 CareMore Cal MediConnect Plan 最新的給付藥物清單 您也可以在週一至週五上午 8 點至下午 8 點, 撥打電話 (TTY 711) 致電會員服務部查詢目前的藥物清單 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 3

5 3. 有較便宜, 且療效與藥物清單上的藥物一樣好的藥物問世時, 會如何 若您正在使用的藥物因為有效果一樣好但較便宜的藥物而遭到刪除, 我們會告知您 我們至少會在該藥物遭到刪除前 60 天, 或您要求再領取藥物時告知您 那麼您可在該藥物從藥物清單中刪除前, 領取 60 天份的供藥量 我們將會向您寄送關於藥物清單的任何非維護性變更之信件 我們也會將信件的副本發布至網站上 4. 當我們發現藥物不安全時, 會怎麼做 若 Food and Drug Administration (FDA) 表示您正在使用的藥物並不安全, 我們會立即從藥物清單中將其刪除 我們還將向您發送一封信件告知此資訊 如果您收到不安全藥物訊息的通知, 請立即電話聯絡您的醫師 您的醫師可以幫助您找到另一種適合您的藥物 5. 有藥物給付限制或上限嗎 或有任何必須完成的必要行動措施, 才能取得某些特定藥物嗎 有, 部分藥物有給付規定或有藥量限制 在某些情況下, 您或您的醫師或其他處方醫師必須先完成某些行動措施, 您才能取得藥物 例如 : 事先核准 ( 或事先授權 ): 針對某些藥物, 在領取處方藥物之前, 您或您的醫師或其他處方醫師必須取得 CareMore Cal MediConnect Plan 的核准 如果您未得到核准, CareMore Cal MediConnect Plan 可能不會給付該藥物 藥量限制..有時候 CareMore Cal MediConnect Plan 會限制您可以取得的藥量 您可以查詢第 8 頁的表格, 了解您的藥物是否有任何額外要求或限制 亦可瀏覽我們的網站 duals.caremore.com 取得更多資訊 我們已在網路上發布了解釋我們事先授權的限制的文件檔案 您也可以要求我們寄送一份副本給您 您可以要求對這些限制做出例外處理 如需例外處理的詳細資訊, 請參閱問題 11 若您住在療養院或其他長期護理機構, 且需要不在藥物清單上的藥物, 或您不易取得所需藥物, 我們可提供協助 我們可提供協助 我們會針對您所需要的藥物給付 31 天的緊急供應量 ( 除非您的處方天數較短 ), 無論您是否為 CareMore Cal MediConnect Plan 這樣一來, 您就有時間與醫師或其他處方醫師討論 醫師可協助您決定藥物清單上是否有類似藥物可用, 或是否要求例外處理 如需例外處理的詳細資訊, 請參閱問題 您如何得知想使用的藥物適用某些限制, 或是否需完成特定行動措施才可取得藥物 第 9 頁的給付藥物清單中, 有一欄為 必要行動措施 限額或使用限制 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 4

6 7. 若我們更動給付部分藥物的規定, 會如何 例如, 若我們新增藥物事先授權 ( 核准 ) 藥量限制及/ 或漸進式療法限制 若我們新增藥物事先授權 藥量限制及 / 或漸進式療法限制, 我們會告知您 我們會在新增限制前至少 60 天, 或您下次要求藥房再領取藥物時告知您 然後, 您可在給付規定變動前, 領取 60 天份的藥物 這樣一來, 您就有時間和醫師或其他處方醫師討論接下來該怎麼做 8. 如何查詢藥物清單中的藥物 查詢藥物的方式有兩種.. 您可以按字母順序搜尋 ( 如果您知道藥物的拼法 ), 或者 按病情搜尋 若要依字母順序搜尋, 請前往 按字母順序排列 一節 您可以使用藥物名稱的第一個字母找到 若要按病情搜尋, 請到第 9 頁尋找 依病情列出藥物清單 一節 本節中的藥物根據用於治療病情的類型, 被歸類到不同的類別 例如, 若您有心臟疾病, 應到 CARDIOVASCULAR, HYPERTENSION / LIPIDS 類別中搜尋 您可這裡可以找到治療心臟疾病的藥物 9. 如果藥物清單上沒有您想要使用的藥物, 該怎麼辦 若您沒有在藥物清單上找到所需藥物, 請於週一至週五上午 8 點至下午 8 致電會員服務部詢問, 電話 (TTY 711) 若您得知 CareMore Cal MediConnect Plan 不給付該藥物, 可採取以下幾種做法 : 向會員服務部索取與您所需藥物類似的藥物清單 然後向醫師或其他處方醫師出示此清單 醫師可以針對您所需的藥物, 改開藥物清單上的類似藥物處方 或者 您可以要求醫療保險計畫對您的藥物予以例外給付 如需例外處理的詳細資訊, 請參閱問題 如果您是 CareMore Cal MediConnect Plan 的新會員, 且藥物清單上沒有您所需的藥物, 或取得藥物有困難, 該怎麼辦 我們能為您提供協助 我們可能可以在您成為 CareMore Cal MediConnect Plan 會員之後的前 90 天內, 給付 30 天的暫時性藥物供應 這樣一來, 您就有時間與醫師或其他處方醫師討論 醫師可協助您決定藥物清單上是否有類似藥物可用, 或是否要求例外處理 若符合以下條件, 我們會給付 30 天份的供藥量 : 您正在使用的藥物不在我們的藥物清單上, 或者 醫療保險計畫規定不讓您取得處方醫師開立的藥量, 或者 藥物需要獲得 CareMore Cal MediConnect Plan 的事先授權, 或者 您正在使用的藥物是漸進式療法限制的一部分 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 5

7 若您住在療養院或其他長期護理機構, 您的處方最多可再領取 天份的藥物 在您參與計畫的前 90 天 內, 您可以多次再領取藥物 這樣一來, 處方醫師就有時間將您的藥物變更為藥物清單上的藥物, 或要求例外處理 如果您遇到所取得的醫療保健等級的改變, 需要您從一個機構或治療中心轉換到另一個時, 您可能有資格獲得您現有處方的一次性暫時供藥量 例如, 如果您出院並且給予根據醫院處方之出院清單的藥物, 您可能可以取得一次性的藥物供應 您可以獲得暫時的一次性例外藥物供應, 無論您是否是在加入計畫之後的前 90 天內 請您的處方醫師致電聯絡我們, 以取得更多詳情 11. 您能否要求藥物例外給付 是 您可以要求 CareMore Cal MediConnect Plan 針對不在藥物清單上的藥物給予例外給付 亦可要求我們更動您所需藥物的規定 例如,CareMore Cal MediConnect Plan 可能會限制我們給付藥物的藥量 假如您的藥物有某些限制, 您可以要求我們更改限制並給付更多的數量 其他範例 : 您可以要求我們捨棄漸進式療法的限制, 或事先核准的要求 12. 獲得例外處理需要多久時間 首先, 我們必須取得您的處方醫師支持您提出例外處理要求的聲明 我們取得聲明後, 會在 72 小時內對您的例外處理要求做出決定 若您或處方醫師認為等候 72 小時才做出決定可能損及您的健康, 您可要求快速例外處理 這是指加快做出決定 若處方醫師支持您的要求, 我們會在取得處方醫師支持聲明後 24 小時內做出決定 13. 您如何要求例外處理 要求例外處理時, 請致電會員服務部 會員服務部會和您及您的醫療服務提供者合作, 以幫助您提出例外處理的要求 14. 什麼是一般藥物 一般藥物的組成成分與原廠藥物相同 但通常費用低於原廠藥物, 且一般藥物的藥名通常比較不為人知 一般藥物已獲得食品藥物管理局核准 CareMore Cal MediConnect Plan 會給付原廠藥及一般藥物 15. 什麼是 OTC 藥物 OTC 代表 非處方 的意思 當您的醫療服務提供者為您開具處方藥物時, CareMore Cal MediConnect Plan 會給付某些 OTC 藥物 您不用為藥物清單上給付的 OTC 藥物支付費用 您可以參閱 CareMore Cal MediConnect Plan 的藥物清單, 以了解哪些 OTC 藥物可獲得給付 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 6

8 16. CareMore Cal MediConnect Plan 是否給付 OTC 非藥物產品 當您的醫療服務提供者為您開具處方藥物時, CareMore Cal MediConnect Plan 會給付某些 OTC 非藥物產品 您可以參閱 CareMore Cal MediConnect Plan 的藥物清單, 以了解哪些 OTC 非藥物產品可以獲得給付 17. 您的共付費用是多少 身為 CareMore Cal MediConnect Plan 的會員, 只要您遵循 CareMore Cal MediConnect Plan 的規則, 就不須為處方藥物或 OTC 藥物支付共付費用 住在療養院或其他長期護理機構的 CareMore Cal MediConnect Plan Drug List 會員, 不需支付共付費用 在社區中取得長期護理的部分會員, 也不需支付共付費用 18. 何謂藥物等級 等級是藥物清單上的藥物群組 全部等級皆無共付費用 第 1 級藥物為一般藥物 第 2 級藥物是原廠藥 第 3 級藥物是 Medi-Cal 給付的處方藥物 第 4 級藥物 Medi-Cal 給付的非處方藥物 (OTC) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 7

9 給付藥物清單 以下給付藥物清單為您提供了 CareMore Cal MediConnect Plan 給付的藥物相關的資訊 假如您在清單中搜尋藥物時有困難, 請翻到從第 126 頁開始的索引 表格的第一欄列出藥物名稱 原廠藥的名稱為大寫 ( 例如, NOVOLOG); 一般藥物則為小寫斜體字 ( 例如,enalapril) 必要行動措施 限額或使用限制 欄位中的資訊, 會告知您 CareMore Cal MediConnect Plan 是否有任何藥物給付規定 這裡是我們使用的縮寫列表 : 縮寫說明解釋 B/D Part B 與.Part D 的判定 根據實際狀況, 這種處方藥物由 Medicare Part B 或 Part D 給付 可能需要呈交藥物使用和背景的資訊, 以進行判定 HI 居家靜脈注射 這種處方藥物可能會在我們的醫療福利給付之下 如需更多資訊, 請於週一到週五上午 8 點到下午 8 點致電 (TTY 711) 聯絡會員服務部 LA 限制供應 這種處方藥物可能只能在特定的藥房取得 如需更多資訊, 請於週一到週五上午 8 點到下午 8 點致電 (TTY 711) 聯絡會員服務部 郵購藥物 這種處方藥物是可以透過我們的郵購服務, 以及透過我們的零售網路內藥房取得 請考慮使用郵購取得您的長期性 ( 維持性 ) 藥物 ( 如高血壓藥物 ) 零售網路內藥房可能較適合取得短期性處方藥物 ( 如抗生素 ) 非延長天數供藥 這種藥物不符合延長供藥天數的規定 您可以到您的藥房取得處 方藥物, 一次最多 31 天份的供藥量 PAR 需事先授權 計畫要求您或您的醫師取得某些處方藥物的事先授權 這意味著您 需要在領取藥物前先取得核准 如果您沒有取得核准, 我們可能 不會給付此藥物 QLL 供藥量限制對于某些藥物, 計畫會限制我們給付藥物的數量 注意 : 藥物旁的 asterisk (*) 代表此藥物並非 Part D 藥物 這些藥物您不需支付共付費用 這些藥物亦適用不同的上訴規定 上訴是在您認為我們有錯誤的情況下, 要求我們審查我們對您的給付福利做出之決定, 並要求我們做出變更的一種正式的方式 例如, 我們可能決定不給付您想要採用的某種藥物, 且 Medicare 或 Medi-Cal 不再給付該藥物 若您或醫師不同意我們的決定, 即可提出上訴 如果您有任何疑問, 請於週一至週五上午 8 點至下午 8 點致電 (TTY 711) 聯絡會員服務部 您也可以參閱會員手冊, 瞭解如何提出上訴 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 8

10 依病情列出的藥物清單 本節中的藥物根據用於治療病情的類型, 被歸類到不同的類別 例如, 若您有心臟疾病, 應到心血管疾病, 高血壓 / 血酯類別中搜尋 您在這裡可以找到治療心臟疾病的藥物 藥物名稱藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET B/D; PAR; HI; AMBISOME B/D; PAR; amphotericin b B/D; PAR; CANCIDAS B/D; PAR; clotrimazole mucous membrane ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 50 MG PAR; HI; PAR; fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml ; HI HI; flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION QLL (600 per 30 days); nystatin oral suspension nystatin oral tablet terbinafine hcl oral QLL (30 per 30 days); voriconazole intravenous 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/2016 9

11 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 PAR; QLL (300 per 30 days); voriconazole oral tablet 200 mg PAR; QLL (60 per 30 days); voriconazole oral tablet 50 mg PAR; QLL (120 per 30 days); ANTIVIRALS abacavir QLL (60 per 30 days); abacavir-lamivudine-zidovudine QLL (60 per 30 days); acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution B/D; PAR; HI; adefovir PAR; amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE QLL (120 per 30 days); APTIVUS ORAL SOLUTION QLL (390 per 30 days); ATRIPLA QLL (30 per 30 days); BARACLUDE ORAL SOLUTION PAR; QLL (600 per 30 days); COMPLERA QLL (30 per 30 days); CRIXIVAN ORAL CAPSULE 200 MG QLL (360 per 30 days); CRIXIVAN ORAL CAPSULE 400 MG QLL (180 per 30 days); DESCOVY QLL (30 per 30 days) didanosine oral capsule,delayed release(dr/ec) 125 mg QLL (90 per 30 days); didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg QLL (60 per 30 days); QLL (30 per 30 days); EDURANT QLL (30 per 30 days); EMTRIVA ORAL CAPSULE QLL (30 per 30 days); EMTRIVA ORAL SOLUTION QLL (870 per 30 days); entecavir PAR; QLL (30 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 10

12 voriconazole oral suspension for reconstitution EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET moderiba nevirapine oral suspension ; QLL (960 per 30 days) QLL (30 per 30 days); QLL (30 per 30 days); QLL (60 per 30 days); QLL (21 per 7 days); B/D; PAR QLL (60 per 30 days); B/D; PAR; QLL (30 per 30 days); PAR; QLL (28 per 28 days); QLL (120 per 30 days); QLL (60 per 30 days); QLL (480 per 30 days); QLL (300 per 30 days); QLL (120 per 30 days); QLL (120 per 30 days); QLL (180 per 30 days); QLL (720 per 30 days); QLL (480 per 30 days); QLL (300 per 30 days); QLL (120 per 30 days); QLL (900 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); QLL (60 per 30 days); QLL (1800 per 30 days); QLL (120 per 30 days); QLL (1200 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

13 nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg QLL (60 per 30 days); QLL (30 per 30 days); QLL (360 per 30 days); QLL (480 per 30 days); QLL (360 per 30 days); QLL (30 per 30 days) PAR; QLL (30 per 30 days) QLL (30 per 30 days); QLL (420 per 30 days); QLL (180 per 30 days); QLL (60 per 30 days); QLL (300 per 30 days); QLL (60 per 180 days); QLL (180 per 30 days); QLL (360 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); PAR; QLL (30 per 30 days) QLL (120 per 30 days); QLL (60 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 12

14 stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU TECHNIVIE TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TYBOST TYZEKA valacyclovir valganciclovir VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule QLL (2400 per 30 days); QLL (30 per 30 days); QLL (120 per 30 days); QLL (360 per 30 days); QLL (30 per 30 days); PAR; ; LA PAR; LA; PAR; QLL (56 per 28 days) QLL (60 per 30 days) QLL (60 per 30 days); QLL (30 per 30 days); ; QLL (60 per 30 days) QLL (30 per 30 days) QLL (30 per 30 days); QLL (30 per 30 days); QLL (30 per 30 days); QLL (1200 per 30 days); ; QLL (1200 per 30 days) PAR; QLL (112 per 28 days); QLL (300 per 30 days); QLL (120 per 30 days); PAR; QLL (240 per 30 days); QLL (30 per 30 days); QLL (30 per 30 days); PAR; QLL (30 per 30 days) QLL (960 per 30 days); QLL (180 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

15 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 zidovudine oral syrup QLL (1920 per 30 days); zidovudine oral tablet QLL (60 per 30 days); CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefazolin injection recon soln 100 gram, 20 gram, 300 g HI; cefazolin intravenous cefdinir cefepime HI; cefoxitin HI; cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ; HI ceftazidime injection recon soln 6 gram HI ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg HI; ceftriaxone intravenous HI; cefuroxime axetil oral tablet CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 14

16 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 cefuroxime sodium intravenous vial injection HI; recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram HI; cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous HI; azithromycin oral clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr QLL (28 per 14 days); ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION QLL (180 per 30 days); ALINIA ORAL TABLET QLL (6 per 30 days); amikacin injection solution 1,000 mg/4 ml amikacin injection solution 500 mg/2 ml ; HI atovaquone PAR; atovaquone-proguanil oral tablet mg AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML HI HI; baciim bacitracin intramuscular BILTRICIDE 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

17 CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN dapsone DARAPRIM ethambutol gentamicin injection solution 20 mg/2 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet PAR; LA; HI; HI; ; HI HI HI; ; HI PAR; HI; PAR; QLL (1680 per 30 days); PAR; QLL (56 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 16

18 mefloquine meropenem intravenous recon soln 1 gram meropenem intravenous recon soln 500 mg metro i.v. metronidazole in nacl (iso-os) metronidazole oral MYCOBUTIN NEBUPENT neomycin paromomycin PASER PENTAM PIN-X ORAL SUSPENSION PIN-X ORAL TABLET,CHEWABLE PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate REESE'S PINWORM MEDICINE rifampin intravenous rifampin oral RIFATER SIRTURO STREPTOMYCIN INTRAMUSCULAR STROMECTOL SYNERCID TOBI tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL XIFAXAN ORAL TABLET 550 MG HI; HI; B/D; PAR; ; PAR; HI; PAR; LA; PAR; QLL (280 per 28 days) HI; HI; PAR; QLL (84 per 28 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

19 PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin sodium injection recon soln 2 gram, 250 mg, 500 mg HI; ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K) HI; HI; dicloxacillin nafcillin injection recon soln 1 gram, 10 gram HI; nafcillin injection recon soln 2 gram nafcillin intravenous recon soln 2 gram oxacillin injection recon soln 1 gram, 2 gram oxacillin injection recon soln 10 gram ; HI oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln 2 gram HI PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 18

20 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml HI ; HI penicillin g sodium HI; penicillin v potassium piperacillin-tazobactam intravenous recon soln 2.25 gram piperacillin-tazobactam intravenous recon soln gram, 4.5 gram, 40.5 gram ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 4.5 GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml HI; QLL (14 per 14 days); QLL (3 per 3 days); levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet QLL (14 per 14 days); ofloxacin oral tablet 400 mg 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

21 SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate intravenous HI; doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg minocycline oral capsule minocycline oral tablet morgidox oral capsule 100 mg tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG methenamine hippurate methenamine mandelate oral tablet 1 gram trimethoprim VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML B/D; PAR VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 1 GRAM/200 ML CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 20

22 VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML, 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin intravenous recon soln 5 gram, 750 mg vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg B/D; PAR HI; B/D; PAR; PAR; QLL (40 per 10 days); PAR; QLL (80 per 10 days); ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium injection recon soln 200 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral mesna MESNEX ORAL XGEVA PAR; PAR; QLL (1.7 per 28 days); ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR AFINITOR DISPERZ ALECENSA ALIMTA INTRAVENOUS RECON SOLN 100 MG PAR; PAR; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

23 ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole ARRANON ARZERRA ASTAGRAF XL AVASTIN azacitidine AZASAN azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleomycin injection recon soln 15 unit bleomycin injection recon soln 30 unit BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS QLL (30 per 30 days); B/D; PAR; PAR; B/D; PAR; B/D; PAR; B/D; PAR PAR; PAR; QLL (30 per 30 days); B/D; PAR; B/D; PAR; PAR; QLL (120 per 30 days); PAR; QLL (30 per 30 days); B/D; PAR PAR; LA; QLL (90 per 30 days); PAR; LA; QLL (30 per 30 days); PAR; LA; QLL (90 per 30 days); PAR; LA; QLL (30 per 30 days); B/D; PAR; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 22

24 cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COSMEGEN COTELLIC CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 160 mg/16 ml (10 mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal B/D; PAR PAR; QLL (56 per 28 days); PAR; QLL (112 per 28 days); PAR; QLL (84 per 28 days); PAR; LA; QLL (90 per 30 days); B/D; PAR; B/D; PAR; B/D; PAR; B/D; PAR; PAR; B/D; PAR; B/D; PAR; B/D; PAR LA; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

25 DROXIA EMCYT EMPLICITI epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERBITUX INTRAVENOUS SOLUTION 200 MG/100 ML ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous solution 1 gram/20 ml, 5 gram/100 ml, 500 mg/10 ml fluorouracil intravenous solution 2.5 gram/50 ml flutamide FOLOTYN GAZYVA B/D; PAR; PAR; PAR; PAR; QLL (30 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (30 per 30 days); PAR; QLL (4 per 365 days) ; QLL (1 per 28 days) B/D; PAR; B/D; PAR; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 24

26 gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml ISTODAX B/D; PAR; B/D; PAR B/D; PAR; PAR; QLL (30 per 30 days); PAR; QLL (240 per 30 days) PAR; QLL (60 per 30 days) PAR; PAR; QLL (30 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (30 per 30 days); PAR; QLL (240 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (120 per 30 days); PAR; QLL (240 per 30 days); PAR; QLL (120 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

27 IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT LUPRON DEPOT (3 NTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG LYNPARZA LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG PAR; QLL (150 per 30 days); PAR; QLL (100 per 30 days); PAR; QLL (75 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (300 per 30 days); PAR PAR; PAR; QLL (30 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (90 per 30 days); QLL (30 per 30 days); PAR; PAR; QLL (1 per 28 days); PAR; QLL (1 per 84 days); PAR; QLL (480 per 30 days); PAR; QLL (90 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 26

28 MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium (pf) methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution octreotide acetate injection syringe ODOMZO OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PAR; QLL (30 per 30 days); B/D; PAR; B/D; PAR; PAR; LA; QLL (120 per 30 days); QLL (30 per 30 days); PAR; QLL (3 per 28 days); B/D; PAR; PAR; PAR; PAR; LA; QLL (30 per 30 days); PAR; PAR; PAR; QLL (120 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (30 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

29 PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG B/D; PAR; PAR; B/D; PAR; LA; QLL (60 per 30 days); LA; QLL (30 per 30 days); LA; QLL (150 per 30 days); PAR B/D; PAR; B/D; PAR B/D; PAR; B/D; PAR; QLL (30 per 30 days); PAR; QLL (120 per 30 days); QLL (90 per 30 days); QLL (30 per 30 days); B/D; PAR; PAR; QLL (120 per 30 days); PAR; LA; QLL (60 per 30 days); PAR; LA; QLL (30 per 30 days); QLL (30 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 28

30 TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml QLL (90 per 30 days); PAR PAR; QLL (60 per 30 days); QLL (112 per 28 days); LA; QLL (20 per 21 days); QLL (30 per 30 days); QLL (60 per 30 days); QLL (1 per 168 days) QLL (1 per 84 days) QLL (1 per 168 days) QLL (1 per 28 days) LA; QLL (180 per 30 days); PAR; PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (84 per 365 days) B/D; PAR; B/D; PAR 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

31 vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT XALKORI XTANDI YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 200 MG/8 ML (25 MG/ML) ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA B/D; PAR; QLL (120 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (120 per 30 days); PAR; PAR; PAR; QLL (240 per 30 days); QLL (120 per 30 days); B/D; PAR; PAR; QLL (60 per 30 days); PAR; QLL (150 per 30 days); PAR; QLL (120 per 30 days); AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION PAR; QLL (2400 per 30 days); PAR; QLL (480 per 30 days); PAR; QLL (240 per 30 days); PAR PAR; QLL (600 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 30

32 BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG PAR; QLL (600 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (240 per 30 days); PAR; QLL (120 per 30 days); QLL (1200 per 30 days); QLL (600 per 30 days); QLL (300 per 30 days); QLL (4800 per 30 days); QLL (2400 per 30 days); QLL (1200 per 30 days); QLL (600 per 30 days); QLL (300 per 30 days); QLL (480 per 30 days); QLL (240 per 30 days); QLL (180 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

33 ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG QLL (720 per 30 days) QLL (30 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); QLL (45 per 30 days); QLL (1080 per 30 days); QLL (360 per 30 days); QLL (270 per 30 days); QLL (2160 per 30 days); QLL (2160 per 30 days) QLL (180 per 30 days); QLL (120 per 30 days); QLL (180 per 30 days); QLL (120 per 30 days); QLL (180 per 30 days); QLL (120 per 30 days); QLL (90 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 32

34 LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone QLL (60 per 30 days); QLL (720 per 30 days); QLL (360 per 30 days); QLL (240 per 30 days); QLL (900 per 30 days); PAR; QLL (480 per 30 days); PAR; QLL (120 per 30 days); PAR; QLL (60 per 30 days); QLL (480 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); QLL (3000 per 30 days); QLL (120 per 30 days); QLL (800 per 30 days); QLL (741 per 30 days); QLL (400 per 30 days); QLL (370 per 30 days); QLL (200 per 30 days); QLL (185 per 30 days); QLL (123 per 30 days); ; QLL (90 per 30 days) ; QLL (270 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

35 roweepra SABRIL LA; QLL (180 per 30 days); SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG PAR; QLL (60 per 30 days) PAR; QLL (120 per 30 days) tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg QLL (480 per 30 days); topiramate oral tablet 200 mg QLL (240 per 30 days); topiramate oral tablet 25 mg QLL (1920 per 30 days); topiramate oral tablet 50 mg QLL (960 per 30 days); TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) VIMPAT INTRAVENOUS QLL (1200 per 30 days); VIMPAT ORAL SOLUTION QLL (1200 per 30 days); VIMPAT ORAL TABLET 100 MG QLL (120 per 30 days); VIMPAT ORAL TABLET 150 MG, 200 MG QLL (60 per 30 days); VIMPAT ORAL TABLET 50 MG QLL (240 per 30 days); zonisamide ANTIPARKINSONISM AGENTS APOKYN PAR; LA; AZILECT benztropine oral bromocriptine carbidopa-levodopa CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 34

36 entacapone LODOSYN NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone trihexyphenidyl PAR; ; QLL (30 per 30 days) QLL (180 per 30 days); MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR MIGRANAL rizatriptan sumatriptan succinate oral zolmitriptan ZOMIG NASAL ; QLL (8 per 28 days) ; QLL (12 per 30 days) QLL (9 per 30 days); ; QLL (9 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg donepezil oral tablet 5 mg GILENYA glatopa memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR PAR; LA; QLL (60 per 30 days); PAR; QLL (30 per 30 days) PAR; QLL (12 per 28 days) QLL (30 per 30 days); PAR; QLL (30 per 30 days); PAR; QLL (30 per 30 days); QLL (300 per 30 days); QLL (60 per 30 days); QLL (90 per 30 days); ; QLL (56 per 365 days) ; QLL (30 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

37 NUEDEXTA QLL (60 per 30 days); rivastigmine QLL (30 per 30 days); tetrabenazine oral tablet 12.5 mg PAR; QLL (240 per 30 days); tetrabenazine oral tablet 25 mg PAR; QLL (120 per 30 days); TYSABRI PAR; LA; XENAZINE ORAL TABLET 12.5 MG PAR; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG PAR; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASDIC THERAPY AMRIX PAR baclofen dantrolene MESTINON ORAL SYRUP pyridostigmine bromide oral tablet tizanidine oral tablet NARCOTIC ANALGESICS ABSTRAL PAR; ; QLL (120 per 30 days) acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml) acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml QLL (4500 per 30 days) ; QLL (4500 per 30 days) QLL (4500 per 30 days); acetaminophen-codeine oral tablet mg QLL (390 per 30 days); acetaminophen-codeine oral tablet mg QLL (360 per 30 days); acetaminophen-codeine oral tablet mg QLL (180 per 30 days); buprenorphine hcl injection solution QLL (90 per 30 days); buprenorphine hcl injection syringe QLL (150 per 30 days); buprenorphine hcl sublingual tablet 2 mg PAR; QLL (240 per 30 days); buprenorphine hcl sublingual tablet 8 mg PAR; QLL (60 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 36

38 butalbital-acetaminop-caf-cod oral capsule mg duramorph (pf) endocet oral tablet mg, mg, mg fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 400 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 300 MCG/SPRAY levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg lortab lortab lortab methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg QLL (180 per 30 days); QLL (180 per 30 days); QLL (360 per 30 days); PAR; QLL (120 per 30 days); QLL (15 per 30 days); PAR; QLL (120 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (360 per 30 days) ; QLL (50 per 30 days) QLL (360 per 30 days); QLL (180 per 30 days); PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days); QLL (180 per 30 days); ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (360 per 30 days) QLL (150 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (900 per 30 days) ; QLL (1800 per 30 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

39 methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine intravenous cartridge 2 mg/ml RPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous solution 10 mg/ml RPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg NORCO oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 5 mg oxycodone oral tablet 15 mg, 20 mg, 30 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin ; QLL (30 per 30 days) QLL (180 per 30 days) ; QLL (180 per 30 days) ; QLL (30 per 30 days) B/D; PAR; QLL (180 per 30 days) QLL (270 per 30 days); QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) QLL (2700 per 30 days); QLL (1350 per 30 days); QLL (360 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); ; QLL (360 per 30 days) QLL (360 per 30 days); QLL (180 per 30 days); QLL (1800 per 30 days); QLL (360 per 30 days); QLL (180 per 30 days); QLL (1800 per 30 days) QLL (360 per 30 days); QLL (360 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 38

40 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 1,200 MCG (600 MCG/SPRAY X 2) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 1,600 MCG (800 MCG/SPRAY X 2) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY PAR; LA; QLL (120 per 30 days); PAR; LA; QLL (120 per 30 days) PAR; QLL (120 per 30 days) NON-NARCOTIC ANALGESICS ACEPHEN RECTAL SUPPOSITORY 650 MG ; ACETAMINOPHEN EXTRA STRENGTH ORAL CAPSULE 500 MG ACETAMINOPHEN EXTRA STRENGTH ORAL LIQUID 500 MG/15 ML ACETAMINOPHEN EXTRA STRENGTH ORAL SUSPENSION 160 MG/5 ML ; ; ACETAMINOPHEN LIQUID ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML ORAL SUSPENSION 160 MG/5 ML (5 ML) ACETAMINOPHEN PAIN RELIEF acetaminophen rectal suppository 650 mg ADDED STRENGTH PAIN RELIEVER ADULT LOW DOSE ASPIRIN ; ALL DAY RELIEF ; ASPIRIN LOW DOSE ; ASPIRIN ORAL 81MG aspirin oral tablet ; ASPIRIN ORAL TABLET 325 MG aspirin oral tablet,chewable ; ASPIRIN ORAL TABLET,DELAYED RELEASE (DR/EC) 325 MG aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg ; ; ASPIR-LOW ; BAYER ADVANCED 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

41 BAYER ASPIRIN BETATEMP buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection butorphanol tartrate nasal celecoxib oral capsule 100 mg, 200 mg, 50 mg celecoxib oral capsule 400 mg ASPIRIN LOW DOSE, CHEWABLE ACETAMINOPHEN ORAL SUSP 160 MG/5 ML (5 ML) diclofenac potassium diclofenac sodium oral diflunisal ECOTRIN LOW STRENGTH ENTERIC COATED ASPIRIN EXTRA STRENGTH BAYER fenoprofen oral tablet FEVER REDUCER AN PAIN RELIEVER ORAL SUSPENSION FEVERALL RECTAL SUPPOSITORY 650 MG FLANAX (NAPROXEN) flurbiprofen HEADACHE RELIEF (ASA-ACET-CAF) IBUPROFEN IB ORAL TABLET ibuprofen oral capsule ibuprofen oral suspension ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML ; PAR; ; QLL (360 per 30 days) PAR; ; QLL (90 per 30 days) QLL (5 per 28 days); PAR; QLL (60 per 30 days); PAR; QLL (30 per 30 days); ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 40

42 I-PRIN MAPAP EXTRA STRENGTH MASOPHEN ORAL TABLET 500 MG meclofenamate oral MEDIPROXEN meloxicam oral suspension meloxicam oral tablet MENSTRUAL RELIEF MIGRAINE FORMULA MIGRAINE RELIEF nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection solution naloxone injection syringe 0.4 mg/ml naloxone injection syringe 1 mg/ml naltrexone naproxen oral tablet naproxen sodium oral capsule naproxen sodium oral tablet 220 mg NON-ASPIRIN ORAL SUSPENSION NON-ASPIRIN PAIN RELIEF ORAL TABLET 500 MG oxaprozin PAIN AND FEVER ORAL TABLET 500 MG PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEF ORAL TABLET PAIN RELIEVER (ACETAM-ASPIRIN) PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER ORAL CAPSULE PAIN RELIEVER ORAL TABLET 500 MG PAIN RELIEVER PLUS ; ; QLL (300 per 30 days) QLL (30 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); ; ; ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

43 PAIN-OFF PAMPRIN MAX PEDIACARE FEVER REDUCER PHARBETOL ORAL TABLET 500 MG piroxicam PROVIL Q-PAP EXTRA STRENGTH ; Q-PAP ORAL TABLET 500 MG ; sulindac oral SUPER PAIN RELIEF tramadol oral tablet QLL (240 per 30 days); tramadol-acetaminophen QLL (40 per 30 days); VOLTAREN TOPICAL ; QLL (1000 per 30 days) IBUPROFEN ORAL 200 MG NAPROXEN ORAL 220 MG PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING ADASUVE QLL (1 per 28 days); ; QLL (1 per 28 days) QLL (1 per 28 days); alprazolam oral tablet QLL (120 per 30 days); amitriptyline amoxapine aripiprazole oral solution QLL (900 per 30 days); aripiprazole oral tablet 10 mg QLL (90 per 30 days); aripiprazole oral tablet 15 mg QLL (60 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 42

44 aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg, 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg buspirone chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg clomipramine clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg clozapine oral tablet 50 mg clozapine oral tablet,disintegrating 100 mg QLL (450 per 30 days); QLL (30 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); PAR; QLL (1.6 per 30 days); PAR; QLL (2.4 per 30 days); PAR; QLL (3.2 per 30 days); QLL (135 per 30 days); QLL (180 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); QLL (90 per 30 days); QLL (30 per 30 days); ; QLL (600 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) QLL (270 per 30 days); QLL (120 per 30 days); QLL (1080 per 30 days); QLL (540 per 30 days); QLL (270 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

45 clozapine oral tablet,disintegrating 12.5 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG CLOZAPINE ORAL TABLET,DISINTEGRATING 200 MG clozapine oral tablet,disintegrating 25 mg desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral solution 5 mg/5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg diazepam oral tablet 5 mg QLL (2160 per 30 days); QLL (180 per 30 days); QLL (120 per 30 days); QLL (1080 per 30 days); ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) QLL (120 per 30 days) QLL (240 per 30 days) PAR; QLL (180 per 30 days); PAR; QLL (90 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); QLL (240 per 30 days); ; QLL (240 per 30 days) QLL (1200 per 30 days); QLL (1200 per 30 days) QLL (120 per 30 days); QLL (600 per 30 days); QLL (240 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 44

46 doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG, 12 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTEGRATING 100 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG FAZACLO ORAL TABLET,DISINTEGRATING 25 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG fluoxetine oral capsule 10 mg QLL (180 per 30 days); QLL (120 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); QLL (600 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); QLL (120 per 30 days); QLL (720 per 30 days); QLL (60 per 30 days); QLL (360 per 30 days); QLL (180 per 30 days); QLL (120 per 30 days); QLL (90 per 30 days); QLL (16 per 365 days); QLL (270 per 30 days) QLL (2160 per 30 days) QLL (1080 per 30 days) PAR; QLL (56 per 365 days); PAR; QLL (30 per 30 days); PAR; QLL (180 per 30 days); PAR; QLL (90 per 30 days); QLL (240 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

47 fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution fluphenazine decanoate fluphenazine hcl fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULAR guanfacine oral tablet extended release 24 hr GUANIDINE haloperidol haloperidol decanoate haloperidol lactate HETLIOZ imipramine hcl INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML QLL (120 per 30 days); QLL (60 per 30 days); QLL (600 per 30 days); ; QLL (90 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days); QLL (0.75 per 28 days); QLL (1 per 28 days); QLL (1.5 per 28 days); QLL (0.25 per 28 days); QLL (0.5 per 28 days); QLL (0.875 per 90 days); QLL (1.315 per 90 days); QLL (1.75 per 90 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 46

48 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 120 MG, 60 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 80 MG lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol lorazepam oral tablet loxapine succinate LUNESTA maprotiline oral tablet 25 mg maprotiline oral tablet 50 mg maprotiline oral tablet 75 mg MARPLAN methylphenidate oral tablet methylphenidate oral tablet extended release mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg mirtazapine oral tablet 45 mg mirtazapine oral tablet 7.5 mg mirtazapine oral tablet,disintegrating 15 mg mirtazapine oral tablet,disintegrating 30 mg mirtazapine oral tablet,disintegrating 45 mg modafinil oral tablet 100 mg modafinil oral tablet 200 mg molindone nefazodone oral tablet 100 mg nefazodone oral tablet 150 mg QLL (2.625 per 90 days); QLL (120 per 30 days); QLL (240 per 30 days); QLL (30 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); ; QLL (90 per 30 days) QLL (90 per 30 days); ; QLL (30 per 30 days) QLL (270 per 30 days); QLL (135 per 30 days); ; QLL (90 per 30 days) ; QLL (90 per 30 days) QLL (90 per 30 days); QLL (45 per 30 days); QLL (30 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (45 per 30 days); QLL (30 per 30 days); PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) QLL (180 per 30 days); QLL (120 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

49 nefazodone oral tablet 200 mg nefazodone oral tablet 250 mg nefazodone oral tablet 50 mg nortriptyline NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 20 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg olanzapine oral tablet,disintegrating 20 mg olanzapine oral tablet,disintegrating 5 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg PAXIL ORAL SUSPENSION perphenazine phenelzine QLL (90 per 30 days); QLL (72 per 30 days); QLL (360 per 30 days); PAR; QLL (60 per 30 days); QLL (60 per 30 days); QLL (60 per 30 days); QLL (40 per 30 days); QLL (240 per 30 days); QLL (30 per 30 days); QLL (120 per 30 days); QLL (80 per 30 days); QLL (60 per 30 days); QLL (40 per 30 days); QLL (30 per 30 days); QLL (120 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (60 per 30 days); QLL (45 per 30 days); QLL (900 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 48

50 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG protriptyline quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG REXULTI ORAL TABLET 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ROZEREM QLL (120 per 30 days); QLL (480 per 30 days); QLL (240 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); QLL (960 per 30 days); QLL (80 per 30 days); QLL (60 per 30 days); QLL (480 per 30 days); PAR; QLL (60 per 30 days); PAR; QLL (30 per 30 days); QLL (2 per 28 days); QLL (480 per 30 days); QLL (1920 per 30 days); QLL (960 per 30 days); QLL (480 per 30 days); QLL (240 per 30 days); QLL (150 per 30 days); QLL (120 per 30 days); QLL (1920 per 30 days); QLL (960 per 30 days); QLL (480 per 30 days); QLL (240 per 30 days); QLL (150 per 30 days); QLL (120 per 30 days); QLL (30 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

51 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg SLEEP AID (DOXYLAMINE) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG SURNTIL temazepam oral capsule 15 mg, 30 mg thioridazine thiothixene tranylcypromine trazodone trifluoperazine trimipramine TRINTELLIX ORAL TABLET 10 MG QLL (60 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); ; QLL (150 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) QLL (300 per 30 days); QLL (60 per 30 days); QLL (240 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); PAR; ; QLL (30 per 30 days) PAR; QLL (60 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 50

52 TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG ULTRA SLEEP (DOXYLAMINE SUCC) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet 75 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg VERSACLOZ VIIBRYD ORAL TABLET 10 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK XYREM zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg, 80 mg QLL (30 per 30 days) QLL (120 per 30 days) QLL (60 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (113 per 30 days); QLL (450 per 30 days); QLL (300 per 30 days); QLL (225 per 30 days); QLL (150 per 30 days); QLL (60 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (600 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); PAR; QLL (30 per 30 days); PAR; QLL (14 per 365 days) PAR; LA; QLL (540 per 30 days); QLL (60 per 30 days); QLL (30 per 30 days); PAR; ; QLL (180 per 30 days) PAR; ; QLL (90 per 30 days) QLL (240 per 30 days); QLL (120 per 30 days); QLL (60 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

53 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG QLL (2 per 28 days); ; LA; QLL (2 per 28 days) LA; QLL (2 per 28 days) CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution B/D; PAR; amiodarone intravenous syringe B/D; PAR amiodarone oral tablet 100 mg amiodarone oral tablet 200 mg, 400 mg dofetilide flecainide lidocaine (pf) intravenous solution lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) mexiletine MULTAQ ; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone oral tablet quinidine sulfate oral tablet sorine sotalol af oral tablet 120 mg sotalol af oral tablet 160 mg, 80 mg sotalol oral tablet 120 mg CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 52

54 sotalol oral tablet 160 mg, 240 mg, 80 mg TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride-hydrochlorothiazide amlodipine besylate oral tablet 10 mg, 2.5 mg ; QLL (30 per 30 days) amlodipine besylate oral tablet 5 mg ; QLL (45 per 30 days) atenolol atenolol-chlorthalidone benazepril BENICAR HCT ; QLL (30 per 30 days) BENICAR ORAL TABLET 20 MG, 40 MG ; QLL (30 per 30 days) BENICAR ORAL TABLET 5 MG ; QLL (60 per 30 days) betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide bumetanide BYSTOLIC captopril-hydrochlorothiazide cartia xt carvedilol chlorothiazide clonidine hcl oral tablet clonidine transdermal patch ; QLL (4 per 28 days) DEMSER diltiazem hcl intravenous solution diltiazem hcl oral capsule, extended release 120 mg, 240 mg, 300 mg diltiazem hcl oral capsule, extended release 180 mg, 360 mg diltiazem hcl oral capsule,ext release degradable 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

55 diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release 24hr 180 mg diltiazem hcl oral tablet dilt-xr doxazosin enalapril maleate enalapril-hydrochlorothiazide eplerenone eprosartan felodipine fosinopril fosinopril-hydrochlorothiazide furosemide injection solution furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet hydralazine injection hydralazine oral hydrochlorothiazide indapamide irbesartan labetalol intravenous solution labetalol oral lisinopril lisinopril-hydrochlorothiazide losartan oral tablet 100 mg losartan oral tablet 25 mg, 50 mg losartan-hydrochlorothiazide ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 54

56 methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral nadolol nadolol-bendroflumethiazide nicardipine oral nifedical xl nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr pindolol propranolol intravenous propranolol oral solution propranolol oral tablet quinapril quinapril-hydrochlorothiazide ramipril spironolactone spironolacton-hydrochlorothiaz taztia xt telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg terazosin timolol maleate oral torsemide oral trandolapril ; QLL (30 per 30 days) ; QLL (60 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

57 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 triamterene-hydrochlorothiazid UPTRAVI ORAL TABLET PAR; LA; QLL (60 per 30 days); UPTRAVI ORAL TABLETS,DOSE PACK PAR; LA; QLL (400 per 365 days); valsartan oral tablet 160 mg ; QLL (60 per 30 days) valsartan oral tablet 320 mg ; QLL (30 per 30 days) valsartan oral tablet 40 mg, 80 mg ; QLL (90 per 30 days) valsartan-hydrochlorothiazide ; QLL (30 per 30 days) verapamil intravenous solution verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 120 mg verapamil oral tablet extended release 180 mg, 240 mg CARDIAC GLYCOSIDES digox oral tablet 125 mcg digoxin injection solution DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 125 mcg LANOXIN INJECTION LANOXIN ORAL TABLET 125 MCG, 62.5 MCG COAGULATION THERAPY aspirin-dipyridamole ; QLL (60 per 30 days) BRILINTA QLL (60 per 30 days); cilostazol clopidogrel oral tablet 300 mg ; QLL (1 per 30 days) clopidogrel oral tablet 75 mg ; QLL (30 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 56

58 EFFIENT ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution HEPARIN FLUSH heparin lock flush intravenous kit 100 unit/ml heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml heparin lock flush intravenous syringe 10 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 100 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) HEPARIN, PORCINE (PF) INTRAVENOUS SYRINGE 1 UNIT/ML $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) QLL (30 per 30 days); QLL (60 per 30 days); QLL (74 per 30 days); QLL (84 per 28 days); QLL (28 per 28 days); QLL (22.4 per 28 days); QLL (8.4 per 28 days); QLL (11.2 per 28 days); QLL (16.8 per 28 days); QLL (24 per 30 days); QLL (15 per 30 days); QLL (12 per 30 days); QLL (18 per 30 days); B/D; PAR; ; HI B/D; PAR; ; HI B/D; PAR; HI; ; B/D; PAR; ; B/D; PAR; ; B/D; PAR; ; B/D; PAR; B/D; PAR; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

59 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 heparin, porcine (pf) intravenous syringe 10 $0 (Tier 3) B/D; PAR; ; unit/ml, 100 unit/ml jantoven MEPHYTON $0 (Tier 3) ; NOJECT PREFILL (PF) $0 (Tier 3) B/D; PAR; NOJECT PREFILL ADVANCED (PF) $0 (Tier 3) B/D; PAR; ; pentoxifylline PRADAXA QLL (60 per 30 days); PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG PAR; LA; QLL (30 per 30 days); PROMACTA ORAL TABLET 50 MG PAR; LA; QLL (60 per 30 days); tranexamic acid intravenous warfarin XARELTO ORAL TABLET 10 MG, 20 MG QLL (30 per 30 days); XARELTO ORAL TABLET 15 MG QLL (42 per 30 days); XARELTO ORAL TABLETS,DOSE PACK QLL (102 per 365 days); LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin ; QLL (30 per 30 days) cholestyramine (with sugar) cholestyramine light oral powder cholestyramine light oral powder in packet colestipol oral granules colestipol oral packet colestipol oral tablet fenofibrate micronized oral capsule 134 mg, 67 mg QLL (30 per 30 days); fenofibrate nanocrystallized 48 mg, 145 mg fenofibrate oral tablet 160 mg, 54 mg QLL (30 per 30 days); gemfibrozil oral JUXTAPID PAR; LA; QLL (30 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 58

60 KYNAMRO PAR; LA; QLL (4 per 28 days); lovastatin oral tablet 10 mg, 20 mg ; QLL (30 per 30 days) lovastatin oral tablet 40 mg ; QLL (60 per 30 days) niacin oral capsule, extended release 250 mg, 500 mg ; niacin oral tablet 100 mg, 50 mg, 500 mg ; NIACIN ORAL TABLET 250 MG ; niacin oral tablet extended release 24 hr 1,000 mg, 750 mg ; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg ; QLL (30 per 30 days) niacin oral tablet extended release 250 mg, 750 mg ; NIACOR omega-3 acid ethyl esters omega-3 fatty acids oral capsule ; PRALUENT PEN PAR; QLL (2 per 28 days) PRALUENT SYRINGE PAR; QLL (2 per 28 days) pravastatin ; QLL (30 per 30 days) prevalite REPATHA SURECLICK PAR; QLL (3 per 28 days) REPATHA SYRINGE PAR; QLL (3 per 28 days) simvastatin ; QLL (30 per 30 days) ZETIA QLL (30 per 30 days); MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA VECAMYL NITRATES isosorbide dinitrate oral tablet isosorbide mononitrate nitro-bid nitroglycerin intravenous B/D; PAR nitroglycerin transdermal patch 24 hour 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

61 NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC ANTI-DANDRUFF calcipotriene scalp QLL (60 per 30 days); calcipotriene topical QLL (120 per 30 days); calcitriol topical selenium sulfide topical lotion SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG BURN THERAPY silver sulfadiazine ssd KERATOLYTICS SALICYLIC ACID TOPICAL LIQUID 3 % SCALP RELIEF HYDROCORTISONE TOPICAL LIQUID 3 % MISCELLANEOUS DERMATOLOGICALS 8-P PAR; AMLACTIN TOPICAL LOTION ; ammonium lactate 12% lotion (otc) ammonium lactate 12% lotion fragrance free (otc) ammonium lactate topical cream ammonium lactate topical lotion 12 % AMNIUM LACTATE TOPICAL LOTION 12 % AMNIUM LACTATE TOPICAL LOTION 5 % ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 60

62 AQUA CARE ; calamine CALAMINE-ZINC OXIDE TOPICAL LOTION 8-8 % ; diclofenac sodium topical gel 3 % PAR; QLL (100 per 30 days); ELIDEL PAR; QLL (100 per 90 days); fluorouracil topical cream 5 % GORMEL ; GORMEL TEN imiquimod methoxsalen rapid PAR PANRETIN PICATO podofilox SKIN TREATMENT tacrolimus topical PAR; ; QLL (100 per 90 days) urea topical cream 10 %, 20 % ; urea topical lotion 10 % UREACIN-20 ; UVADEX VALCHLOR THERAPY FOR ACNE ACNE TREATMENT (BENZOYL PEROX) TOPICAL GEL ACNE-CLEAR BENZOYL PEROXIDE GEL 10 %, 5 % benzoyl peroxide topical gel 10 %, 5 % ; claravis clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab DIFFERIN TOPICAL GEL 0.3 % 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

63 DIFFERIN TOPICAL GEL WITH PUMP ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin with ethanol topical swab erythromycin-benzoyl peroxide metronidazole topical cream metronidazole topical gel 0.75 % metronidazole topical lotion PERSA-GEL rosadan topical cream TAZORAC tretinoin topical cream QLL (45 per 30 days); tretinoin topical gel 0.01 %, % QLL (45 per 30 days); TOPICAL ANESTHETICS lidocaine (pf) injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 40 mg/ml (4 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 10 mg/ml (1 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane lidocaine hcl urethral lidocaine topical adhesive patch,medicated PAR; QLL (90 per 30 days); lidocaine topical ointment lidocaine viscous lidocaine-prilocaine topical cream TOPICAL ANTIBACTERIALS CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 62

64 ANTIBIOTIC (NEOMY-BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) bacitracin topical ointment BACITRACIN TOPICAL PACKET BACITRACIN ZINC TOPICAL PACKET bacitracin-polymyxin b topical ointment bacitracin-polymyxin b topical packet BACITRAYCIN PLUS TOPICAL OINTMENT 500 UNIT/GRAM DOUBLE ANTIBIOTIC gentamicin topical mupirocin topical ointment NEOSPORIN PLUS PAINRELIEF(BAC) POLY BACITRACIN sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET TRI-BIOZENE TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC TOPICAL OINTMENT TRIPLE ANTIBIOTIC TOPICAL OINTMENT IN PACKET TRIPLE ANTIBIOTIC-PAIN RELIEF ; ; ; ; TOPICAL ANTIFUNGALS AF ANTIFUNGAL (CLOTRIMAZOLE) ANTIFUNGAL (TOLNAFTATE) TOPICAL AEROSOL,SPRAY ANTIFUNGAL (TOLNAFTATE) TOPICAL CREAM ANTIFUNGAL MICONAZOLE CREAM ANTI-FUNGAL MICONAZOLE POWDER TOPICAL POWDER 2 % 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

65 ANTIFUNGAL SPRAY ATHLETE'S FOOT (TERBINAFINE) ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF BAZA ANTIFUNGAL ; ciclodan topical solution PAR; ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution PAR; ciclopirox topical suspension clotrimazole 1% cream (otc) clotrimazole 1% cream clotrimazole 1% cream foot care (otc) clotrimazole 1% cream grx clotrimazole 1% cream usp (otc) clotrimazole 1% solution (otc) CLOTRIMAZOLE AF CLOTRIMAZOLE ANTIFUNGAL clotrimazole topical cream 1 % clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream cvs clotrimazole 1% cream (otc) DESENEX TOPICAL POWDER ; TOLNAFTATE AEROSOL POWDER, TOPICAL FUNGOID-D INZO ANTIFUNGAL JOCK ITCH JOCK ITCH (CLOTRIMAZOLE) JOCK ITCH (TERBINAFINE) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 64

66 ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo LAMISIL AT TOPICAL CREAM ; LOTRIMIN AF TOPICAL CREAM ; LOTRIMIN AF TOPICAL POWDER ; MICATIN miconazole nitrate topical cream ; MICONAZORB AF MICRO-GUARD ; nyamyc nystatin topical nystop ODOR CONTROL FOOT-SNEAKER pv clotrimazole 1% cream (otc) qc clotrimazole 1% cream (otc) RINGWORM SECURA ANTIFUNGAL ; SECURA ANTIFUNGAL EXTRA THICK sm clotrimazole af 1% cream (otc) terbinafine hcl topical ; TINACTIN TOPICAL AEROSOL POWDER ; tolnaftate topical aerosol powder tolnaftate topical cream ZEASORB (MICONAZOLE) ; TOPICAL ANTIVIRALS ABREVA ; acyclovir topical QLL (30 per 30 days); DENAVIR QLL (5 per 30 days); TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

67 amcinonide ANTI-ITCH (HC) TOPICAL CREAM ANTI-ITCH (HC) TOPICAL OINTMENT AVEENO ANTI-ITCH (HYDROCORTSN) BETA-HC betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical lotion betamethasone, augmented topical ointment CAPEX clobetasol scalp clobetasol topical gel clobetasol-emollient topical cream cormax scalp CORTISONE (HYDROCORTISONE) TOPICAL CREAM CORTIZONE-10 PLUS CORTIZONE-10 TOPICAL CREAM CORTIZONE-10 TOPICAL OINTMENT cvs hydrocortisone 1% cream maximum strength (otc) cvs hydrocortisone 1% oint maximum strength (otc) desonide desoximetasone topical cream desoximetasone topical gel ECZEMA ANTI-ITCH eq hydrocortisone 1% cream maximum strength (otc) ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 66

68 fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical cream fluticasone topical ointment gnp hydrocortisone 1% cream max str, w/aloe (otc) gnp hydrocortisone 1% ointment maximum strength (otc) halobetasol propionate HALOG hm hydrocortisone 1% cream max str, w/aloe (otc) hm hydrocortisone 1% cream plus 12 moisturizers (otc) hydrocortisone 1% cream (otc) hydrocortisone 1% cream anti-itch (otc) hydrocortisone 1% cream carton (otc) hydrocortisone 1% cream max str w/aloe (otc) hydrocortisone 1% cream max str w/oatmeal (otc) hydrocortisone 1% cream max str, w/aloe (otc) hydrocortisone 1% cream maximum strength (otc) hydrocortisone 1% cream u-d, 48's, foil (otc) hydrocortisone 1% cream w/aloe (otc) hydrocortisone 1% cream w/aloe, max strength (otc) hydrocortisone 1% cream w/aloe,max strength (otc) hydrocortisone 1% cream w/colloidal oatmeal (otc) hydrocortisone 1% ointment (otc) hydrocortisone 1% ointment carton (otc) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

69 hydrocortisone 1% ointment max str (otc) hydrocortisone 1% ointment maximum strength (otc) hydrocortisone acetate topical HYDROCORTISONE PLUS hydrocortisone plus 1% cream moisturizer,max. str (otc) hydrocortisone topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 1 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate hydrocortisone-min oil-wht pet HYDROCREAM HYDROSKIN TOPICAL LOTION lokara mometasone topical NEOSPORIN ANTI-ITCH NOBLE FORMULA HC TOPICAL CREAM pv hydrocortisone 1% cream (otc) pv hydrocortisone 1% cream maximum strength (otc) pv hydrocortisone 1% ointment maximum strength (otc) qc hydrocortisone 1% cream maximum strength (otc) ra hydrocortisone 1% cream maximum strength (otc) ra hydrocortisone 1% cream plus 12 moisturizers (otc) ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 68

70 ra hydrocortisone 1% cream plus 12,maximum str (otc) ra hydrocortisone 1% cream w/aloe,max strength (otc) RECORT PLUS sb hydrocortisone 1% cream max str, w/aloe (otc) sb hydrocortisone 1% ointment maximum strength (otc) SCALP RELIEF HYDROCORTISONE TOPICAL SOLUTION 1 % SCALPICIN ANTI-ITCH ; sm hydrocortisone 1% cream max str, w/aloe (otc) sm hydrocortisone 1% ointment maximum strength (otc) SOOTHING CARE (HYDROCORTISONE) triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triderm topical cream TOPICAL ENZYMES SANTYL QLL (30 per 30 days); TOPICAL SCABICIDES / PEDICULICIDES COMPLETE LICE TREATMENT LICE BEDDING SPRAY LICE COMPLETE KIT LICE CREAM RINSE LICE KILLING LICE KILLING (PERMETHRIN) LICE PYRINYL SHAMPOO LICE SOLUTION LICE TREATMENT (PERMETHRIN) LICE TREATMENT TOPICAL LIQUID 1 % LICE TREATMENT TOPICAL SHAMPOO 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

71 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 lindane topical shampoo permethrin topical cream permethrin topical liquid ; RID COMPLETE LICE ELIM KIT TOPICAL STOP LICE DIAGNOSTICS / MISCELLANEOUS AGENTS ANOREXIANTS ALLI ; benzphetamine oral tablet 50 mg $0 (Tier 3) PAR; ; phentermine $0 (Tier 3) PAR; ; ANTIDOTES acetylcysteine intravenous IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN alendronate oral tablet 40 mg QLL (30 per 30 days); anagrelide ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG PAR; ; LA ARALAST NP INTRAVENOUS RECON SOLN 500 MG PAR; LA; BUPHENYL ORAL TABLET PAR; CARBAGLU PAR; LA; cevimeline CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 70

72 CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE D10 %-0.45 % SODIUM CHLORIDE d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DEX4 GLUCOSE ORAL TABLET,CHEWABLE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE DEXTROSE 10 % AND 0.2 % NACL dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) dextrose oral gel dextrose with sodium chloride disulfiram EXJADE FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET GLUCO BURST B/D; PAR; HI B/D; PAR; HI B/D; PAR; HI HI HI; HI; HI; ; HI HI; HI; HI; HI; HI; HI; PAR; LA; PAR PAR; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

73 GLUCOSE GEL glucose oral tablet,chewable 4 gram GLUTOSE 15 GLUTOSE 45 INCRELEX INSTA-GLUCOSE kionex levocarnitine (with sugar) levocarnitine oral tablet midodrine NORTHERA ORAL CAPSULE 100 MG NORTHERA ORAL CAPSULE 200 MG NORTHERA ORAL CAPSULE 300 MG ORFADIN ORAL CAPSULE pilocarpine hcl oral RAVICTI RENVELA ORAL POWDER IN PACKET 0.8 GRAM RENVELA ORAL POWDER IN PACKET 2.4 GRAM RENVELA ORAL TABLET riluzole sodium chloride 0.9 % intravenous parenteral solution sodium chloride 0.9 % intravenous piggyback sodium chloride irrigation sodium polystyrene (sorb free) sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension sodium polystyrene sulfonate rectal enema 30 gram/120 ml ; ; ; PAR; LA; ; B/D; PAR; PAR; QLL (540 per 30 days); PAR; QLL (270 per 30 days); PAR; QLL (180 per 30 days); LA PAR; QLL (525 per 30 days); QLL (180 per 30 days); QLL (90 per 30 days); QLL (270 per 30 days); HI; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 72

74 SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sps oral sps rectal SYPRINE VELPHORO ; QLL (180 per 30 days) water for irrigation, sterile ZEMAIRA PAR; LA zoledronic acid 5 mg/100 ml infusion bottle (ml) SKING DETERRENTS buproban QLL (60 per 30 days); CHANTIX PAR; QLL (60 per 30 days); CHANTIX CONTINUING NTH BOX PAR; QLL (56 per 28 days); CHANTIX STARTING NTH BOX PAR; QLL (106 per 365 days); NICORELIEF ; NICORETTE BUCCAL LOZENGE 2 MG ; nicotine (polacrilex) ; NICOTINE TRANSDERMAL nicotine transdermal system transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal system transdermal patch, td daily, sequential mg/24 hr ; ; NICOTROL NS QLL (120 per 30 days); QUIT 2 QUIT 4 BUCCAL GUM STOP SKING AID EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON-AEROSOL ; QLL (30 per 25 days) azelastine nasal aerosol,spray QLL (30 per 25 days); chlorhexidine gluconate mucous membrane ipratropium bromide nasal QLL (30 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

75 NASAL MIST oralone paroex oral rinse periogard STERILE SALINE NASAL triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS acetic acid otic acetic acid-aluminum acetate carbamide peroxide fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S neomycin-polymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORNES ACTHAR H.P. cortisone dexamethasone oral elixir dexamethasone oral solution dexamethasone oral tablet dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection solution 10 mg/ml PAR CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 74

76 dexamethasone sodium phosphate injection solution 4 mg/ml dexamethasone sodium phosphate injection syringe fludrocortisone hydrocortisone oral methylprednisolone methylprednisolone acetate methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml) prednisolone sodium phosphate oral solution 5 mg base/5 ml (6.7 mg/5 ml) prednisone intensol prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil DIABETES THERAPY acarbose oral tablet 100 mg ; QLL (90 per 30 days) acarbose oral tablet 25 mg ; QLL (360 per 30 days) acarbose oral tablet 50 mg ; QLL (180 per 30 days) ALCOHOL PADS BYDUREON QLL (4 per 28 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

77 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CONDOMS, LATEX, LUBRICATED DEVICE CONDOMS, LATEX, NON-LUBRICATED DEVICE CYCLOSET FREESTYLE INSULINX STRIP FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST GAUZE PADS 2 X 2 glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1 ML, 1/2 ML INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG QLL (2.4 per 30 days); QLL (1.2 per 30 days); QLL (180 per 30 days); ; ; ; ; ; ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (240 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 76

78 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG JARDIANCE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg MICROLIFE PEAK FLOW METER NEEDLES, INSULIN DISP.,SAFETY NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL pioglitazone oral tablet 15 mg pioglitazone oral tablet 30 mg pioglitazone oral tablet 45 mg PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (150 per 30 days) ; QLL (90 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; ; QLL (90 per 30 days) ; QLL (45 per 30 days) ; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

79 SYMLINPEN 120 QLL (11 per 30 days); SYMLINPEN 60 QLL (6 per 30 days); TOUJEO SOLOSTAR CONDOMS, LATEX, LUBRICATED VICTOZA 2-PAK ; QLL (9 per 30 days) VICTOZA 3-PAK ; QLL (9 per 30 days) MISCELLANEOUS HORNES ALDURAZYME PAR; ANADROL-50 PAR; ANDRODERM ; QLL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) QLL (150 per 30 days); QLL (112.5 per 30 days); QLL (150 per 30 days); androxy PAR; AXIRON ; QLL (180 per 30 days) cabergoline calcitonin (salmon) QLL (4 per 30 days); calcitriol intravenous solution 1 mcg/ml B/D; PAR; calcitriol oral capsule B/D; PAR; CEREZYME INTRAVENOUS RECON SOLN 400 UNIT PAR danazol oral desmopressin injection desmopressin nasal aerosol,spray desmopressin nasal spray,non-aerosol desmopressin oral ELAPRASE PAR; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 78

80 FABRAZYME INTRAVENOUS RECON SOLN 35 MG FABRAZYME INTRAVENOUS RECON SOLN 5 MG KORLYM KUVAN ORAL TABLET,SOLUBLE MIACALCIN INJECTION MYOZYME NAGLAZYME NATPARA oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate SENSIPAR ORAL TABLET 30 MG, 60 MG SENSIPAR ORAL TABLET 90 MG SOMAVERT STIMATE SYNAREL TESTIM testosterone cypionate testosterone enanthate testosterone transdermal gel in packet VPRIV ZAVESCA zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML PAR; PAR; PAR PAR; B/D; PAR; PAR; LA; PAR; LA; QLL (2 per 28 days); QLL (60 per 30 days); QLL (120 per 30 days); B/D; PAR; QLL (60 per 30 days); QLL (120 per 30 days); PAR; PAR; ; QLL (300 per 30 days) QLL (300 per 30 days); PAR; PAR; LA; THYROID HORNES levothyroxine oral levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

81 liothyronine oral SYNTHROID unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASDICS ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML BISMATROL ORAL SUSPENSION 525 MG/15 ML ; BISMATROL ORAL TABLET,CHEWABLE BISMUTH BISMUTH MAXIMUM STRENGTH DIARRHEA RELIEF (BISMUTH SUBS) dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet DIOTAME diphenoxylate-atropine glycopyrrolate oral KAOPECTATE (BISMUTH SUBSALICY) ; KAOPECTATE EX STR (BISMUTH SS) KAO-TIN (BISMUTH SUBSALICYLAT) K-PEC ANTIDIARRHEAL (BISM SUB) loperamide oral capsule loperamide oral liquid 1 mg/5 ml ; PEPTIC RELIEF CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 80

82 PEPTO-BISL ORAL TABLET,CHEWABLE ; PEPTO-BISL TO-GO PINK BISMUTH MAXIMUM STRENGTH PINK BISMUTH ORAL SUSPENSION PINK BISMUTH ORAL TABLET PINK BISMUTH ORAL TABLET,CHEWABLE ; SOOTHE (BISMUTH SUBSALICYLATE) SOOTHE REGULAR STRENGTH STOMACH RELIEF STOMACH RELIEF MAX STRENGTH STOMACH RELIEF ORIGINAL MISCELLANEOUS GASTROINTESTINAL AGENTS ACID GONE ANTACID E.STRENGTH ADVANCED ANTACID-ANTIGAS ALOPHEN alosetron QLL (60 per 30 days); ALUMINA AND MAGNESIUM ANTACID ORAL SUSPENSION MG/15 ML ALUMINA AND MAGNESIUM ANTACID ORAL TABLET,CHEWABLE MG ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION ORAL SUSPENSION MG/5 ML, MG/5 ML aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml ; ANTACID ANTACID ANTI-GAS ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXTRA-STRENGTH ORAL SUSPENSION MG/5 ML ANTACID LIQUID ANTACID M 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

83 ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI-GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ANTACID-SIMETHICONE APRISO ASACOL HD balsalazide BISAC-EVAC bisacodyl oral bisacodyl rectal BISA-LAX BISCOLAX budesonide oral CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL SUSPENSION MG/5 ML, MG/5 ML CALCIUM CARBONATE AND MAGNESIA ANTACID ORAL TABLET,CHEWABLE MG CANASA CITRATE OF MAGNESIA CITROMA CLEARLAX colocort COL-RITE COMFORT GEL COMFORT GEL EXTRA STRENGTH compro constulose CREON ; ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 82

84 CYSTADANE DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC) DIOCTO ORAL LIQUID DIOCTO ORAL SYRUP DIOCTYL DIPENTUM DOC-Q-LACE DOCU DOCUPRENE docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral capsule 250 mg docusate sodium oral liquid docusate sodium oral tablet DOCUSIL DOK ORAL CAPSULE 100 MG DOK ORAL CAPSULE 250 MG DOK ORAL TABLET DRAMAMINE LESS DROWSY dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK enulose FLANAX ANTACID ; ; ; ; ; ; ; ; ; B/D; PAR; QLL (120 per 30 days); B/D; PAR; ; QLL (120 per 30 days) ; B/D; PAR; ; QLL (5 per 30 days) B/D; PAR; ; QLL (1 per 28 days) B/D; PAR; ; QLL (10 per 30 days) B/D; PAR; ; QLL (15 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

85 FLEET GLYCERIN (ADULT) FLEET LAXATIVE GAS RELIEF 80 GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAVILAX ORAL POWDER gavilyte-c gavilyte-g gavilyte-n generlac GENTLE LAXATIVE GENTLELAX GERI-LANTA GERI-X ANTACID-ANTIGAS glycerin (adult) GLYCOLAX ORAL POWDER HEALTHYLAX HEARTBURN ANTACID HEARTBURN RELIEF hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema KAO-TIN (DOCUSATE CALCIUM) lactulose oral solution 10 gram/15 ml lactulose oral solution 10 gram/15 ml (15 ml), 20 gram/30 ml LAXA CLEAR LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) LAXATIVE (BISACODYL) RECTAL LAXATIVE PEG 3350 ORAL POWDER ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 84

86 LINZESS LIQUID ANTACID MAALOX MAXIMUM STRENGTH MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate oral solution MASANTI DOUBLE STRENGTH meclizine 12.5 mg caplet (otc) meclizine 12.5 mg caplet caplet (otc) meclizine 12.5 mg tablet (otc) meclizine 12.5 mg tablet meclizine 12.5 mg tablet inner meclizine 12.5 mg tablet outer meclizine 25 mg tablet (otc) meclizine 25 mg tablet meclizine 25 mg tablet inner meclizine 25 mg tablet outer meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable MEDI-MECLIZINE mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID GAS RELIEF MILK OF MAGNESIA MILK OF MAGNESIA CONCENTRATED MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY ORAL MINERAL OIL LAXATIVE mineral oil oral ; ; ; ; ; ; ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

87 mineral oil rectal MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX ORAL POWDER IN PACKET TION RELIEF (MECLIZINE) TION SICKNESS (MECLIZINE) TION SICKNESS II TION SICKNESS RELIEF(MECLIZ) VIPREP MYTAB GAS MYTAB GAS MAXIMUM STRENGTH ondansetron ondansetron hcl (pf) ondansetron hcl intravenous ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ORAL SALINE LAXATIVE ORAL LIQUID PANCREAZE peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram peg-electrolyte soln PENTASA PHOSPHATE LAXATIVE ORAL LIQUID polyethylene glycol 3350 oral powder 17 gram/dose polyethylene glycol 3350 oral powder in packet 17 gram ; ; ; ; B/D; PAR; QLL (90 per 30 days); B/D; PAR; QLL (30 per 30 days); B/D; PAR; QLL (90 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 86

88 polyethylene glycol 3350 powd (otc) polyethylene glycol 3350 powd polyethylene glycol 3350 powd 14 day (otc) polyethylene glycol 3350 powd 14 once-daily doses (otc) polyethylene glycol 3350 powd 15 once-daily doses (otc) polyethylene glycol 3350 powd 17 grams pkt,inner (otc) polyethylene glycol 3350 powd 17 grams pkts,outer (otc) polyethylene glycol 3350 powd 30 once-daily doses (otc) polyethylene glycol 3350 powd 31 once-daily doses (otc) polyethylene glycol 3350 powd 50 day (otc) polyethylene glycol 3350 powd 7 once-daily doses (otc) polyethylene glycol 3350 powd inner,s/f (otc) polyethylene glycol 3350 powd outer,s/f (otc) polyethylene glycol 3350 powd u-d, 17gm packet (otc) POWDERLAX prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc PROLAXIN PURELAX READY-TO-USE ENEMA (MIN OIL) RELISTOR SUBCUTANEOUS SOLUTION REMICADE RI-GEL ; ; ; ; ; PAR; PAR; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

89 RI-GEL II RI-X SANI-SUPP (ADULT) sb polyethylene glycol once-daily doses (otc) sb polyethylene glycol once-daily doses (otc) sb polyethylene glycol once-daily doses (otc) SILACE ORAL LIQUID SILACE ORAL SYRUP SIMETHICONE ORAL CAPSULE 125 MG, 180 MG simethicone oral capsule 180 mg simethicone oral tablet,chewable SIMETHICONE ORAL TABLET,CHEWABLE 125 MG, 80 MG SOTHLAX SOF-LAX STOOL SOFTENER ORAL CAPSULE 100 MG, 240 MG, 250 MG STOOL SOFTENER ORAL CAPSULE 50 MG STOOL SOFTENER ORAL LIQUID STOOL SOFTENER ORAL SYRUP STOOL SOFTENER ORAL TABLET sulfasalazine SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK THE MAGIC BULLET TRANSDERM-SCOP TRAVEL SICKNESS (MECLIZINE) ; ; ; ; ; ; QLL (4 per 12 days); ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 88

90 ursodiol WOMAN'S LAXATIVE ORAL TABLET,DELAYED RELEASE (DR/EC) WOMEN'S GENTLE LAXATIVE(BISAC) WOMEN'S LAXATIVE (BISACODYL) ORAL TABLET,DELAYED RELEASE (DR/EC) ULCER THERAPY ACID CONTROL (RANITIDINE) ORAL TABLET 150 MG ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) DEXILANT ; QLL (30 per 30 days) eq ranitidine 150 mg tablet maximum strength (otc) esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg ; QLL (30 per 30 days); ; QLL (30 per 30 days) famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine 20 mg tablet famotidine 20 mg tablet f/c famotidine 20 mg tablet inner famotidine 20 mg tablet outer famotidine intravenous famotidine oral tablet 10 mg ; famotidine oral tablet 20 mg, 40 mg HEARTBURN PREVENTION HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) hm famotidine 20 mg tablet maximum strength (otc) lansoprazole oral capsule,delayed release(dr/ec) 15 mg ; misoprostol 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

91 omeprazole oral capsule,delayed release(dr/ec) OMEPRAZOLE ORAL TABLET,DELAYED RELEASE (DR/EC) ; pantoprazole intravenous pantoprazole oral PEPCID AC ORAL TABLET 20 MG ; PROTONIX INTRAVENOUS pub famotidine 20 mg tablet (otc) pub famotidine 20 mg tablet max strength (otc) pub ranitidine 150 mg tablet (otc) ; ranitidine 150 mg tablet (otc) ; ranitidine 150 mg tablet ; ranitidine 150 mg tablet federal supply ; ranitidine 150 mg tablet inner ; ranitidine 150 mg tablet maximum strength (otc) ; ranitidine 150 mg tablet outer ; ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg ; sucralfate oral tablet RANITIDINE HCL ORAL TABLET RANITIDINE HCL ORAL TABLET ZANTAC MAXIMUM STRENGTH ; ZANTAC ORAL TABLET 150 MG ; IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE PAR; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 90

92 ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 300 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML ARCALYST AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR PEN INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE KIT BETASERON SUBCUTANEOUS KIT GENOTROPIN GENOTROPIN MINIQUICK HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT) ILARIS (PF) INTRON A INJECTION LEUKINE INJECTION RECON SOLN ZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUPOGEN NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) PEGASYS PAR; QLL (4 per 28 days); PAR; QLL (1.6 per 28 days); PAR; QLL (2 per 28 days); PAR; QLL (1.2 per 28 days); PAR; QLL (1.68 per 28 days); PAR; QLL (2.4 per 28 days); PAR; QLL (4 per 28 days); PAR; PAR; QLL (4 per 28 days); PAR; QLL (4 per 28 days); PAR; QLL (4 per 28 days); PAR; PAR; PAR; PAR PAR; LA; PAR PAR; PAR; QLL (2 per 28 days); PAR; PAR PAR; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

93 PEGASYS PROCLICK PAR; PEGINTRON PAR; PEGINTRON REDIPEN PAR; QLL (4 per 28 days); PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/2 ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROLEUKIN PAR; QLL (12 per 28 days); PAR; ; QLL (12 per 28 days) PAR; QLL (24 per 28 days); REBIF (WITH ALBUMIN) PAR; REBIF REBIDOSE PAR REBIF TITRATION PACK PAR; SYLATRON PAR; ZORBTIVE PAR VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE ATGAM B/D; PAR BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM PAR; PAR; CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 92

94 ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HIBERIX (PF) IVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION IPOL INJECTION SUSPENSION IXIARO (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) M-M-R II (PF) PEDVAX HIB (PF) PROQUAD (PF) QUADRACEL (PF) B/D; PAR; B/D; PAR; B/D; PAR; PAR PAR; PAR; PAR; PAR 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

95 RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE B/D; PAR; B/D; PAR; B/D; PAR; ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR SYRINGE TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD THYGLOBULIN B/D; PAR; TICE BCG TRUMENBA TWINRIX (PF) INTRAMUSCULAR SUSPENSION TWINRIX (PF) INTRAMUSCULAR SYRINGE TYPHIM VI VAQTA (PF) INTRAMUSCULAR SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE VARIVAX (PF) VARIZIG INTRAMUSCULAR SOLUTION YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol colchicine oral colchicine-probenecid CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 94

96 probenecid OSTEOPOROSIS THERAPY alendronate oral tablet 10 mg, 5 mg QLL (30 per 30 days); alendronate oral tablet 35 mg, 70 mg QLL (4 per 28 days); BONIVA INTRAVENOUS B/D; PAR; FORTEO PAR; QLL (3 per 28 days); PROLIA PAR; QLL (2 per 365 days); raloxifene QLL (30 per 30 days); OTHER RHEUMATOLOGICALS ACTEMRA INTRAVENOUS VIAL PAR BENLYSTA PAR DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN PAR; QLL (8 per 28 days); ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) PAR; QLL (4.08 per 28 days); PAR; QLL (8 per 28 days); ENBREL SURECLICK PAR; QLL (8 per 28 days); HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) PAR; QLL (6 per 365 days) PAR; QLL (12 per 365 days) HUMIRA PEN PAR; QLL (3.2 per 28 days) HUMIRA PEN CROHN'S-UC-HS START PAR; QLL (12 per 365 days) HUMIRA PEN PSORIASIS STARTER PAR; QLL (3.2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PAR; QLL (2 per 28 days); PAR; QLL (3.2 per 28 days); KINERET PAR; QLL (28 per 28 days); leflunomide ORENCIA PAR; QLL (4 per 28 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

97 ORENCIA (WITH MALTOSE) PAR; RIDAURA SAVELLA ORAL TABLET 100 MG ; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG ; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG ; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG ; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK ; QLL (110 per 365 days) OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila deblitane DEPO-PROVERA INTRAMUSCULAR SOLUTION errin ESTRACE VAGINAL estradiol oral ESTRING ; QLL (1 per 90 days) heather hydroxyprogesterone caproate jencycla jolivette lyza medroxyprogesterone intramuscular suspension medroxyprogesterone intramuscular syringe medroxyprogesterone oral MENEST nora-be norethindrone (contraceptive) norethindrone acetate CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 96

98 norlyroc PREMARIN PREMPHASE PREMPRO sharobel VAGIFEM VIVELLE-DOT ; QLL (8 per 28 days) MISCELLANEOUS OB/GYN 3-DAY VAGINAL ; clindamycin phosphate vaginal CLOTRIMAZOLE 3 DAY clotrimazole vaginal cream ; CLOTRIMAZOLE-3 CLOTRIMAZOLE-7 metronidazole vaginal MICONAZOLE 3 DAY VAGINAL CREAM MICONAZOLE 7 ; miconazole nitrate vaginal comb pack,prefill appl, cream miconazole nitrate vaginal cream ; miconazole nitrate vaginal suppository MICONAZOLE-3 VAGINAL KIT miconazole-3 vaginal suppository QLL (6 per 30 days); NUVARING terconazole tranexamic acid oral VAGINAL CONTRACEPTIVE FOAM VAGISTAT-3 ORAL CONTRACEPTIVES / RELATED AGENTS AFTERA altavera (28) alyacen 1/35 (28) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

99 alyacen 7/7/7 (28) apri aranelle (28) aubra aviane azurette (28) balziva (28) briellyn caziant (28) cryselle (28) cyclafem 7/7/7 (28) dasetta 7/7/7 (28) delyla (28) desog-e.estradiol/e.estradiol drospirenone-ethinyl estradiol oral tablet mg ECONTRA EZ elinest ELLA enpresse FALLBACK SOLO falmina (28) gildagia gildess 1.5/30 (21) gildess fe 1.5/30 (28) gildess fe 1/20 (28) jolessa junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 98

100 junel fe 24 kariva (28) kelnor 1/35 (28) kurvelo larin 1.5/30 (21) larin fe 1/20 (28) lessina levonest (28) levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month levonorg-eth estrad triphasic low-ogestrel (28) lutera (28) marlissa microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) MIRCETTE (28) mono-linyah mononessa (28) MY WAY myzilra necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEXT CHOICE ONE DOSE norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg nortrel 0.5/35 (28) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

101 nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) OPCICON ONE-STEP orsythia philith pimtrea (28) pirmella portia previfem reclipsen (28) sprintec (28) sronyx syeda TAKE ACTION tarina fe 1/20 (28) tri-estarylla tri-linyah trinessa (28) tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) viorele (28) vyfemla (28) zarah zenchent (28) zovia 1/35e (28) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 100

102 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 zovia 1/50e (28) OPHTHALLOGY ANTIBIOTICS bacitracin ophthalmic bacitracin-polymyxin b ophthalmic ciprofloxacin hcl ophthalmic erythromycin ophthalmic gentak ophthalmic ointment gentamicin ophthalmic NATACYN neomycin-bacitracin-polymyxin neomycin-polymyxin-gramicidin neo-polycin ofloxacin ophthalmic polycin polymyxin b sulf-trimethoprim tobramycin VIGAX ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS betaxolol ophthalmic carteolol levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

103 CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops MISCELLANEOUS OPHTHALLOGICS ADVANCED EYE RELIEF ; AKWA TEARS (POLYVINYL ALCOHOL) ; ALAWAY ; ALLERGY EYE (KETOTIFEN) ARTIFICIAL TEARS (PETRO/MIN) ; ARTIFICIAL TEARS (PF) OPHTHALMIC DROPPERETTE % ARTIFICIAL TEARS (POLYVIN ALC) ; ARTIFICIAL TEARS(GLYCERIN-PEG) ARTIFICIAL TEARS(PG-HYPM-GLYC) ARTIFICIAL TEARS(PVALCH-POVID) azelastine ophthalmic BION TEARS (PF) ; COLLYRIUM ; cromolyn ophthalmic CYSTARAN DRY EYE RELIEF EYE DROP TEARS EYE IRRIGATING SOLUTION ; EYE ITCH RELIEF ; EYE STREAM ; EYE WASH EYE WASH STERILE ITCHY EYE DROPS KETOTIFEN FUM 0.025% EYE DROPS ketotifen fumarate ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 102

104 LIQUITEARS ; LUBRICANT EYE (PG-PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) LUBRICATING PLUS MEDIWASH MEDIWASH EYE IRRIGANT ISTURE DROPS NATURAL TEARS (PF) OCUSOFT IRRIGATING OPHTH SOLN ; olopatadine ophthalmic PATADAY PAZEO polyvinyl alcohol RESTASIS QLL (60 per 30 days); REVIVE PLUS STERILE EYE WASH TEARS AGAIN (PVA) ; TEARS NATURALE FREE (PF) ; ULTRA FRESH NON-STEROIDAL ANTI-INFLAMMATORY AGENTS flurbiprofen ophthalmic drops ILEVRO ketorolac ophthalmic NEVANAC ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS AZOPT 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

105 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % TRAVATAN Z travoprost (benzalkonium) STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic neo-polycin hc tobramycin-dexamethasone opthalmic suspension STEROIDS dexamethasone sodium phosphate ophthalmic DUREZOL fluorometholone prednisolone acetate prednisolone sodium phosphate ophthalmic STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE S.O.P. sulfacetamide-prednisolone SULFONAMIDES sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 104

106 brimonidine ophthalmic drops 0.2 % VASOCONSTRICTOR DECONGESTANTS LUBRICANT REDNESS RELIEVER OPHTHALMIC DROPS % MAXIMUM REDNESS RELIEF naphazoline REDNESS RELIEVER LUBRICANT STERILE EYE DROPS OPHTHALMIC DROPS %, % RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 12 HOUR COLD RELIEF ACTA-TABS PE ADULT ROBITUSSIN PEAK COLD DM ; ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ALA-HIST DM ; ALAVERT ; ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY (CETIRIZINE) ORAL TABLET ; QLL (30 per 30 days) ALL DAY ALLERGY RELIEF(CETIR) ; QLL (30 per 30 days) ALLERCLEAR ALLER-G-TIME ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY MEDICATION ALLERGY MEDICINE ALLERGY RELIEF (CETIRIZINE) ORAL TABLET ALLERGY RELIEF (CLEMASTINE) ; ALLERGY RELIEF (LORATADINE) ORAL TABLET ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

107 ALLERGY RELIEF (LORATADINE) ORAL TABLET,DISINTEGRATING ALLERGY RELIEF(DIPHENHYDRAMIN) ALLER-TEC AP-HIST DM APRODINE arbinoxa BANOPHEN ALLERGY BANOPHEN ORAL CAPSULE 25 MG BANOPHEN ORAL CAPSULE 50 MG BANOPHEN ORAL LIQUID BANOPHEN ORAL TABLET benzonatate oral capsule 100 mg, 200 mg BIOCOTRON brompheniramin-phenylephrin-dm oral liquid mg/5 ml cetirizine oral tablet CHERATUSSIN AC PSEUDOEPHEDRINE ORAL LIQ, 15 MG/5 MLS DIPHENHYDRAMINE ORAL, ALLERGY clemastine oral tablet 1.34 mg clemastine oral tablet 2.68 mg codeine-guaifenesin COLD AND ALLERGY COLD AND ALLERGY PE COMPLETE ALLERGY COMPLETE ALLERGY MEDICINE COUGH CONTROL (GUAIFENESIN) COUGH CONTROL DM ORAL LIQUID COUGH SYRUP $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; QLL (30 per 30 days) ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 106

108 cyproheptadine oral tablet DAYHIST ALLERGY DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN-DM DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIABETIC TUSSIN EX DIPHEDRYL ALLERGY DIPHEDRYL ORAL CAPSULE DIPHEDRYL ORAL LIQUID DIPHEDRYL ORAL TABLET DIPHENHIST ORAL CAPSULE DIPHENHIST ORAL LIQUID DIPHENHIST ORAL TABLET 25 MG diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral elixir diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet 25 mg DIPHENHYDRAMINE ORAL CAPSULE 25 MG, 50 MG DIPHENHYDRAMINE ORAL ELIXIR 12.5 MG/5 ML DIPHENHYDRAMINE ORAL LIQUID 12.5 MG/5 ML DIPHENHYDRAMINE ORAL SYRUP 12.5 MG/5 ML ED A-HIST ORAL TABLET ED A-HIST PSE ENTRE-HIST PSE EPIPEN 2-PAK EPIPEN JR 2-PAK EXPECTORANT COUGH SYRUP ; ; ; ; ; ; ; ; QLL (2 per 28 days); QLL (2 per 28 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

109 EXPECTORANT ORAL LIQUID GERI-TUSSIN G-TRON GUAIFENESIN AC guaifenesin oral liquid GUAIFENESIN ORAL SOLN GUAIFENESIN-DM hydrocodone-chlorpheniramine hydrocodone-homatropine oral syrup mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP MG/5 ML (5 ML) hydrocodone-homatropine oral tablet HYDROMET hydroxyzine hcl oral tablet IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR levocetirizine oral tablet LOHIST-DM LORADAMED loratadine oral tablet loratadine oral tablet,disintegrating M-CLEAR WC NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET EXTENDED RELEASE NIGHTIME SLEEP $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) ; ; ; ; PAR; ; ; ; QLL (30 per 30 days); ; ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 108

110 NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET NON-DROWSY ALLERGY phenadoz PHENYLEPHRINE HCL/DIPHENHYDRAMINE HCL promethazine oral tablet PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm promethazine-phenyleph-codeine promethegan rectal suppository 12.5 mg PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg PSEUDOEPHEDRINE HCL ORAL TABLET EXTENDED RELEASE pseudoephedrine hcl oral tablet extended release PSEUDOEPHEDRINE HCL/CHLORPHENIRAMINE MALEATE ORAL TABLET 4-10 MG, 4-60 MG PSEUDOEPHEDRINE HCL/TRIPROLIDINE HCL ORAL TABLET Q-DRYL ORAL CAPSULE Q-DRYL ORAL LIQUID Q-TUSSIN QUENALIN RELCOF C REST SIMPLY NIGHTTIME SLEEP RESTFULLY SLEEP RI-TUSSIN ROBAFEN $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) $0 (Tier 3) PAR; ; ; ; ; ; ; ; ; ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

111 ROBAFEN DM COUGH RYDEX SCOT-TUSSIN EXPECTORANT SILADRYL SA SILTUSSIN DM DAS SILTUSSIN SA SINUS 12 HOUR SINUS AND ALLERGY PE SINUS-ALLERGY (PHENYLEPHRINE) SLEEP SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET SLEEP AID MAX STR (DIPHENHYDR) SLEEP II SLEEP TABLET (DIPHENHYDRAMINE) SLEEP-TABS SORBUGEN NR SUDOGEST SUDOGEST 12-HOUR SUDOGEST COLD AND ALLERGY SUDOGEST SINUS AND ALLERGY SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY TUSNEL DIABETIC ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 110

112 TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSIGON $0 (Tier 3) TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM COUGH AND CHEST ORAL LIQUID MG/5 ML TUSSIN DM ORAL LIQUID TUSSIN EXPECTORANT TUSSIN HONEY TUSSIN ORAL LIQUID UNISOM SLEEPGELS VALU-DRYL ALLERGY ORAL CAPSULE VICKS QLEARQUIL ALLERGY VICKS QLEARQUIL NIGHTTIME RLF VIRTUSSIN AC DIPHENHYDRAMINE ORAL, ALLERGY LORATADINE ORAL, ALLERGY PSEUDOEPHEDRINE HCL ORAL TABLET EXTENDED RELEASE PHENYLEPHRINE ORAL DIPHENHYDRAMINE CAPSULE CETIRIZINE ORAL, ALLERGY ; ; PULNARY AGENTS acetylcysteine ADEMPAS ADVAIR DISKUS ADVAIR HFA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml albuterol sulfate inhalation solution for nebulization 5 mg/ml B/D; PAR; PAR; LA; ; QLL (60 per 30 days) ; QLL (12 per 30 days) B/D; PAR; QLL (360 per 30 days); B/D; PAR; ; QLL (60 per 30 days) B/D; PAR; QLL (60 per 30 days); 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

113 albuterol sulfate oral ANORO ELLIPTA ATROVENT HFA BREO ELLIPTA budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml CINRYZE COMBIVENT RESPIMAT cromolyn inhalation DALIRESP DULERA ESBRIET FIRAZYR FLONASE ALLERGY RELIEF FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal FORADIL AEROLIZER ipratropium bromide inhalation ipratropium-albuterol KALYDECO ORAL TABLET ; QLL (60 per 30 days) QLL (26 per 30 days); QLL (60 per 30 days); B/D; PAR; ; QLL (120 per 30 days) PAR; ; QLL (8 per 30 days) B/D; PAR; QLL (240 per 30 days); PAR; QLL (30 per 30 days); ; QLL (13 per 30 days) PAR; QLL (270 per 30 days); ; QLL (60 per 30 days); QLL (240 per 30 days); QLL (12 per 30 days); QLL (24 per 30 days); QLL (11 per 30 days); QLL (75 per 30 days); QLL (16 per 30 days); ; QLL (60 per 30 days) B/D; PAR; B/D; PAR; ; QLL (540 per 30 days) PAR; QLL (60 per 30 days); CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 112

114 LETAIRIS levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml metaproterenol montelukast NASACORT NASALCROM OFEV ORKAMBI PROAIR HFA PROAIR RESPICLICK PULZYME QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION SEREVENT DISKUS sildenafil oral sodium chloride inhalation solution for nebulization 0.9 %, 3 % SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT terbutaline oral terbutaline subcutaneous theophylline oral tablet extended release theophylline oral tablet extended release 12 hr TRACLEER TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION $0 (Tier 3) PAR; LA; QLL (30 per 30 days); B/D; PAR; ; QLL (270 per 30 days) B/D; PAR; ; QLL (540 per 30 days) QLL (30 per 30 days); ; ; PAR; QLL (60 per 30 days); PAR; QLL (120 per 30 days); QLL (18 per 30 days); ; QLL (2 per 30 days) B/D; PAR; QLL (9 per 30 days); ; QLL (18 per 30 days) QLL (60 per 30 days); PAR; QLL (90 per 30 days); ; ; QLL (4 per 30 days) ; QLL (30 per 30 days) ; QLL (4 per 30 days) PAR; LA; QLL (60 per 30 days); ; QLL (1 per 30 days) 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

115 TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) QLL (1 per 30 days) VENTAVIS PAR; QLL (270 per 30 days) VENTOLIN HFA QLL (36 per 30 days); VOSPIRE ER XOLAIR PAR; LA; QLL (6 per 28 days) zafirlukast QLL (60 per 30 days); UROLOGICALS ANTICHOLINERGICS / ANTISPASDICS darifenacin QLL (30 per 30 days) MYRBETRIQ QLL (30 per 30 days); oxybutynin chloride oral syrup QLL (600 per 30 days); oxybutynin chloride oral tablet QLL (120 per 30 days); oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg QLL (60 per 30 days); QLL (30 per 30 days); tolterodine oral capsule,extended release 24hr ; QLL (30 per 30 days) tolterodine oral tablet QLL (60 per 30 days); TOVIAZ QLL (30 per 30 days); VESICARE ; QLL (30 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin dutasteride QLL (30 per 30 days); dutasteride-tamsulosin ; QLL (30 per 30 days) finasteride oral tablet 5 mg tamsulosin QLL (60 per 30 days); CHOLINERGIC STIMULANTS CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 114

116 bethanechol chloride MISCELLANEOUS UROLOGICALS CYSTAGON LA; potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) URINARY ANESTHETICS URINARY PAIN RELIEF ORAL TABLET 95 MG URINARY TRACT VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES ALCALAK ANTACID (CALCIUM CARBONATE) ANTACID EXT STR (CALCIUM CARB) ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG (420 MG), 300 MG (750 MG) CALCI-CHEW ; CALCIONATE ; CALCITRATE ; CALCIUM 500 CALCIUM D (D3) CALCIUM D ORAL TABLET 500 MG(1,250MG) -200 UNIT CALCIUM D ORAL TABLET 500 MG(1,250MG) -400 UNIT CALCIUM D ORAL TABLET,CHEWABLE ; ; CALCIUM 500 WITH D ; CALCIUM 600 CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) UNIT ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

117 CALCIUM 600 WITH VITAMIN D3 ORAL TABLET calcium acetate oral capsule calcium acetate oral tablet 667 mg CALCIUM ANTACID ORAL TABLET,CHEWABLE 200 MG CALCIUM (500 MG) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG), 400 MG (1,000 MG) CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate - d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 500 mg(1,250mg) -400 unit, 500mg (1,250mg) -600 unit calcium carbonate - d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit calcium carbonate - d3 oral tablet,chewable 500 mg(1,250mg) -400 unit CALCIUM CARBONATE - D3 ORAL TABLET,CHEWABLE MG-UNIT CALCIUM CARBONATE ANTACID ORAL TABLET,CHEWABLE 400 MG (1,000 MG) CALCIUM CARBONATE ORAL SUSPENSION calcium carbonate oral tablet 500 mg calcium (1,250 mg), 600 mg (1,500 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg), 500 mg calcium (1,250 mg) CALCIUM CITRATE + D calcium citrate oral tablet 200 mg (950 mg) CALCIUM CITRATE ORAL TABLET 250 MG CALCIUM ; ; ; ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 116

118 calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, 250 mg calcium- 200 unit calcium citrate-vitamin d3 oral tablet mgunit, mg-unit CALCIUM GLUCONATE ORAL TABLET 45 MG (500 MG) CALCIUM GLUCONATE ORAL TABLET 60 MG (650 MG) CALCIUM LACTATE ORAL TABLET 84 MG (648 MG) CALCIUM WITH VITAMIN D calcium-magnesium-zinc oral tablet CALCIUM-MAGNESIUM-ZINC ORAL TABLET MG CAL-GEST ANTACID CERASPORT ORAL LIQUID CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT dextrose-kcl-nacl HI-CAL PLUS VIT D klor-con 10 klor-con 8 klor-con m10 klor-con m15 klor-con m20 lactated ringers intravenous MAGNESIUM OXIDE ORAL CAPSULE 500 MG magnesium sulfate in water intravenous parenteral solution magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution ; ; ; ; ; ; HI; HI; ; HI 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

119 magnesium sulfate injection syringe NORSOL-R NORSOL-R IN 5 % DEXTROSE OYSCO 500/D ORAL TABLET OYSCO D OYSCO-500 OYST-CAL-500 OYSTER SHELL + D3 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D3 OYSTERCAL-D potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 30 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml potassium chloride intravenous piggyback 10 meq/50 ml potassium chloride intravenous piggyback 20 meq/50 ml, 30 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release POTASSIUM CHLORIDE ORAL LIQUID HI; HI ; ; ; ; ; ; HI; HI HI; HI; HI; HI; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 118

120 potassium chloride oral tablet extended release 10 meq, 20 meq potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl HI; potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l HI; HI; potassium chloride-d5-0.9%nacl HI; ringers intravenous B/D; PAR; HI; SOTH ANTACID sodium chloride 0.45 % intravenous parenteral solution sodium chloride 0.45 % intravenous piggyback HI; sodium chloride 3 % ; HI sodium chloride 5 % HI sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride intravenous parenteral solution 4 meq/ml ; HI SUPER CALCIUM TPN ELECTROLYTES HI; TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) ; ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 % B/D; PAR AMINOSYN 8.5 %-ELECTROLYTES B/D; PAR; HI; AMINOSYN II 10 % B/D; PAR; HI; AMINOSYN II 7 % B/D; PAR; HI; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

121 藥物名稱 藥物費用 ( 等級 ) 必要行動措施 限額或使用限制 AMINOSYN II 8.5 % B/D; PAR; HI; AMINOSYN II 8.5 %-ELECTROLYTES B/D; PAR; HI; AMINOSYN M 3.5 % B/D; PAR AMINOSYN-HBC 7% B/D; PAR; HI; AMINOSYN-PF 10 % B/D; PAR; HI; AMINOSYN-PF 7 % (SULFITE-FREE) B/D; PAR; HI; CLINIMIX 5%/D15W SULFITE FREE B/D; PAR; HI CLINIMIX 5%/D25W SULFITE-FREE B/D; PAR; HI CLINIMIX 2.75%/D5W SULFIT FREE B/D; PAR; HI CLINIMIX 4.25%/D10W SULF FREE B/D; PAR; HI CLINIMIX 4.25%-D20W SULF-FREE B/D; PAR; HI CLINIMIX 4.25%-D25W SULF-FREE B/D; PAR; HI CLINIMIX 5%-D20W(SULFITE-FREE) B/D; PAR; HI CLINIMIX E 4.25%/D25W SUL FREE B/D; PAR; HI CLINIMIX E 4.25%/D5W SULF FREE B/D; PAR; HI CLINIMIX E 5%/D15W SULFIT FREE B/D; PAR; HI CLINIMIX E 5%/D20W SULFIT FREE B/D; PAR; HI CLINIMIX E 5%/D25W SULFIT FREE B/D; PAR; HI CLINISOL SF 15 % B/D; PAR; ; HI freamine iii 10 % B/D; PAR HEPATAMINE 8% B/D; PAR; HI intralipid intravenous emulsion 20 % B/D; PAR; HI; NORSOL-M IN 5 % DEXTROSE HI NORSOL-R PH 7.4 HI PLASMA-LYTE 148 HI PLASMA-LYTE-56 IN 5 % DEXTROSE HI travasol 10 % B/D; PAR; ; HI TROPHAMINE 10 % B/D; PAR; ; HI TROPHAMINE 6% B/D; PAR; HI VITAMINS / HEMATINICS CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 120

122 ascorbic acid (vitamin c) oral capsule, extended release ascorbic acid (vitamin c) oral tablet 1,000 mg B-12 DOTS C-500 ORAL TABLET C-500 ORAL TABLET,CHEWABLE CALCIUM MINERALS calcium carbonate-vit d3-min oral tablet CALCIUM CARBONATE-VIT D3-MIN ORAL TABLET,CHEWABLE 600 MG (1,500 MG)-400 UNIT CALCIUM FOR WOMEN CALCIUM SOFT CHEW ORAL TABLET,CHEWABLE MG-UNIT- MCG, MG-UNIT-MCG calcium-vitamin d3-vitamin k oral tablet,chewable mg-unit-mcg cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral capsule 2,000 unit, 400 unit cholecalciferol (vitamin d3) oral drops 400 unit/ml cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit, 5,000 unit cholecalciferol (vitamin d3) oral tablet 400 unit CLASSIC PRENATAL cyanocobalamin (vitamin b-12) injection cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg, 100 mcg, 500 mcg cyanocobalamin (vitamin b-12) oral tablet extended release cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg cyanocobalamin (vitamin b-12) sublingual tablet 2,500 mcg D DAILY PRENATAL $0 (Tier 3) ; ; ; ; ; ; ; ; ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

123 DELTA D3 DIALYVITE 800 DIALYVITE VITAMIN D D-VI-SOL D-VITA ergocalciferol (vitamin d2) oral capsule ergocalciferol (vitamin d2) oral tablet 400 unit EZFE 200 FEOSOL ORAL TABLET 325 MG (65 MG IRON) FERATE ORAL TABLET 240 MG (27 MG IRON) FEROSUL ORAL TABLET FERRETTS FERREX 150 FERRO-TIME ferrous gluconate oral tablet 240 mg (27 mg iron) ferrous gluconate oral tablet 256 mg (28 mg iron) FERROUS GLUCONATE ORAL TABLET 324 MG (36 MG IRON), 324 MG (37.5 MG IRON), 324 MG (38 MG IRON), 325 MG (36 MG IRON) ferrous sulfate oral tablet 325 mg (65 mg iron) FERROUS SULFATE ORAL TABLET,DELAYED RELEASE (DR/EC) 324 MG (65 MG IRON) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) FERROUSUL folic acid 1,000 mcg tablet p/f,s/f (otc) folic acid oral tablet 1 mg folic acid oral tablet 400 mcg, 800 mcg FULL SPECTRUM B-VITAMIN C HIGH POTENCY IRON $0 (Tier 3) $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 122

124 IFEREX 150 IRON (DRIED) IRON (FERROUS SULFATE) IRON HIGH POTENCY IRON ORAL TABLET 325 MG (65 MG IRON) KPN MYFERON 150 ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG-MG OYSTER SHELL CALCIUM WITH D POLY-IRON polysaccharide iron complex POLY-VITA POLY-VITAMIN PRENATAL FORMULA ORAL TABLET 28 MG IRON- 800 MCG PRENATAL ONE DAILY PRENATAL TABLET PRENATAL VITAMIN ORAL TABLET, MG PRENATAL VITAMIN ORAL TABLET ORAL CAPSULE MG prenatal vitamin oral tablet PRENATAL VITAMIN ORAL TABLET ORAL TABLET 27 MG IRON- 800 MCG prenatal vitamin oral tablet oral tablet 28 mg iron- 800 mcg PRENATAL VITAMIN ORAL TABLET ORAL TABLET 28 MG IRON- 800 MCG pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg RENA-VITE RISACAL-D SLOW RELEASE IRON ORAL TABLET EXTENDED RELEASE 160 MG (50 MG IRON), 47.5 MG IRON ; ; ; ; ; ; ; ; 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

125 sodium fluoride oral tablet sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg) STRAWBERRY C THERA-D thiamine hcl (vitamin b1) oral tablet 100 mg, 250 mg, 50 mg thiamine mononitrate (vit b1) VITAMIN A PALMITATE ORAL CAPSULE VITAMIN A PALMITATE ORAL TABLET 10,000 UNIT vitamin a palmitate oral tablet 15,000 unit VITAMIN B-1 VITAMIN B-1 (NONITRATE) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 MCG, 500 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 1,000 MCG VITAMIN B-12 ORAL TABLET EXTENDED RELEASE 2,000 MCG VITAMIN B-12 SUBLINGUAL TABLET 2,500 MCG VITAMIN B-2 VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG VITAMIN C ORAL CAPSULE, EXTENDED RELEASE VITAMIN C ORAL TABLET 1,000 MG, 250 MG, 500 MG VITAMIN C ORAL TABLET,CHEWABLE 250 MG, 500 MG VITAMIN C WITH ROSE HIPS ORAL TABLET VITAMIN D2 $0 (Tier 3) ; ; ; ; ; ; ; ; ; ; ; CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 124

126 VITAMIN D3 ORAL CAPSULE 1,000 UNIT, 2,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 1,000 UNIT, 400 UNIT VITAMIN D3 ORAL TABLET 2,000 UNIT, 5,000 UNIT VITAMIN E (DL, ACETATE) ORAL CAPSULE 100 UNIT vitamin e oral capsule 1,000 unit, 200 unit, 400 unit ; ; ; ; vitamin e oral capsule 100 unit 參閱第 8 頁, 您可以找到此表中的符號和縮寫的資訊 更新日期 08/08/

127 索引 1 12 HOUR COLD RELIEF DAY VAGINAL P A abacavir abacavir-lamivudinezidovudine ABELCET... 9 ABILIFY MAINTENA. 42 ABRAXANE ABREVA ABSTRAL acamprosate acarbose acebutolol ACEPHEN acetaminophen ACETAMINOPHEN EXTRA STRENGTH 39 ACETAMINOPHEN LIQUID ACETAMINOPHEN ORAL SUSPENSION 160 MG/5 ML... 39, 40 ACETAMINOPHEN PAIN RELIEF acetaminophen-codeine.. 36 acetazolamide acetazolamide sodium acetic acid acetic acid-aluminum acetate acetylcysteine... 70, 111 ACID CONTROL (RANITIDINE) ACID GONE ANTACID E.STRENGTH ACID REDUCER (FATIDINE) ACID REDUCER (RANITIDINE) ACNE TREATMENT (BENZOYL PEROX) 61 ACNE-CLEAR ACTA-TABS PE ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIMMUNE acyclovir... 10, 65 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN ADASUVE ADDED STRENGTH PAIN RELIEVER adefovir ADEMPAS ADULT LOW DOSE ASPIRIN ADULT ROBITUSSIN PEAK COLD DM ADULT TUSSIN CHEST CONGESTION ADULT TUSSIN COUGH CONGEST DM ADVAIR DISKUS ADVAIR HFA ADVANCED ANTACID- ANTIGAS ADVANCED EYE RELIEF AF afeditab cr AFINITOR AFINITOR DISPERZ AFTERA AKWA TEARS (POLYVINYL ALCOHOL) ala-cort ALA-HIST DM ALAVERT ALAWAY ALBENZA albuterol sulfate , 112 ALCALAK alclometasone ALCOHOL PADS ALDURAZYME ALECENSA alendronate... 70, 95 alfuzosin ALIMTA... 21, 22 ALINIA ALKA-SELTZER PLUS ALLERGY ALL DAY ALLERGY (CETIRIZINE) ALL DAY ALLERGY RELIEF(CETIR) ALL DAY RELIEF ALLERCLEAR ALLER-G-TIME ALLERGY (DIPHENHYDRAMINE) ALLERGY AND SINUS RELIEF ALLERGY EYE (KETOTIFEN) ALLERGY MEDICATION ALLERGY MEDICINE ALLERGY RELIEF (CETIRIZINE) ALLERGY RELIEF (CLEMASTINE) ALLERGY RELIEF (LORATADINE) , 106 ALLERGY RELIEF(DIPHENHYDR AMIN) ALLER-TEC ALLI allopurinol ALOPHEN alosetron ALPHAGAN P CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 126

128 alprazolam altavera (28) ALUMINA AND MAGNESIUM ANTACID ALUMINA, MAGNESIA, SIMETHICONE SUSPENSION aluminum hydroxide gel 81 alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl AMBISOME... 9 amcinonide amifostine crystalline amikacin amiloride amiloridehydrochlorothiazide AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 %. 120 AMINOSYN-HBC 7% 120 AMINOSYN-PF 10 %. 120 AMINOSYN-PF 7 % (SULFITE-FREE) amiodarone amitriptyline AMLACTIN amlodipine besylate ammonium lactate AMNIUM LACTATE amoxapine amoxicillin amoxicillin-pot clavulanate amphotericin b... 9 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA AMRIX ANADROL anagrelide anastrozole ANDRODERM ANDROGEL androxy ANORO ELLIPTA ANTACID ANTACID (CALCIUM CARBONATE) ANTACID ANTI-GAS.. 81 ANTACID ANTI-GAS DOUBLE STR ANTACID EXST (MAG CARB-AL HYD) ANTACID EXT STR (CALCIUM CARB). 115 ANTACID EXTRA- STRENGTH... 81, 115 ANTACID LIQUID ANTACID M ANTACID MAXIMUM STRENGTH ANTACID PLUS ANTI- GAS ANTACID REGULAR STRENGTH ANTACID WITH SIMETHICONE ANTACID-ANTIGAS ANTACID- SIMETHICONE ANTIBIOTIC (NEOMY- BACIT-POLYM) ANTIBIOTIC-PAIN RELIEF (BACIT) ANTI-DANDRUFF ANTI-DIARRHEAL (LOPERAMIDE) ANTIFUNGAL (CLOTRIMAZOLE).. 63 ANTIFUNGAL (TOLNAFTATE) ANTIFUNGAL MICONAZOLE CREAM ANTI-FUNGAL MICONAZOLE POWDER ANTIFUNGAL SPRAY 64 ANTI-ITCH (HC) AP-HIST DM APOKYN apraclonidine apri APRISO APRODINE APTIOM APTIVUS AQUA CARE ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) arbinoxa ARCALYST aripiprazole... 42, 43 ARISTADA ARRANON ARTIFICIAL TEARS (PETRO/MIN) ARTIFICIAL TEARS (PF) ARTIFICIAL TEARS (POLYVIN ALC) ARTIFICIAL TEARS(GLYCERIN- PEG) ARTIFICIAL TEARS(PG- HYPM-GLYC) ARTIFICIAL TEARS(PVALCH- POVID) ARZERRA ASACOL HD ascorbic acid (vitamin c) aspirin ASPIRIN ASPIRIN LOW DOSE ASPIRIN LOW DOSE, CHEWABLE ASPIRIN ORAL 81MG. 39 aspirin-dipyridamole ASPIR-LOW ASTAGRAF XL ASTEPRO atenolol CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 127

129 atenolol-chlorthalidone.. 53 ATGAM ATHLETE'S FOOT (TERBINAFINE) ATHLETE'S FOOT (TOLNAFTATE) ATHLETE'S FOOT AF. 64 atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine... 80, 102 ATROVENT HFA aubra AVASTIN AVEENO ANTI-ITCH (HYDROCORTSN) aviane AVONEX AVONEX (WITH ALBUMIN) AXIRON azacitidine AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) AZASAN azathioprine azathioprine sodium azelastine... 73, 102 AZILECT azithromycin AZOPT azurette (28) B B-12 DOTS baciim bacitracin... 15, 63, 101 BACITRACIN BACITRACIN ZINC bacitracin-polymyxin b. 63, 101 BACITRAYCIN PLUS. 63 baclofen balsalazide balziva (28) BANOPHEN BANOPHEN ALLERGY BANZEL BARACLUDE BAYER ADVANCED BAYER ASPIRIN BAZA ANTIFUNGAL.. 64 BCG VACCINE, LIVE (PF) BELEODAQ benazepril BENDEKA BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide BENZOYL PEROXIDE GEL 10 %, 5 % benzphetamine benztropine BETA-HC betamethasone dipropionate betamethasone valerate.. 66 betamethasone, augmented BETASERON BETATEMP betaxolol... 53, 101 bethanechol chloride bexarotene BEXSERO (PF) bicalutamide BICILLIN C-R BICNU BILTRICIDE BIOCOTRON BION TEARS (PF) BISAC-EVAC bisacodyl BISA-LAX BISCOLAX BISMATROL BISMUTH BISMUTH MAXIMUM STRENGTH bisoprolol fumarate bisoprololhydrochlorothiazide bleomycin BLEPHAMIDE S.O.P BLINCYTO BONIVA BOOSTRIX TDAP BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine BRIVIACT... 30, 31 bromocriptine brompheniraminphenylephrin-dm budesonide... 82, 112 bumetanide BUPHENYL buprenorphine hcl buprenorphine-naloxone 40 buproban bupropion hcl buspirone BUSULFEX butalbital-acetaminop-cafcod butorphanol tartrate BYDUREON BYETTA BYSTOLIC C C cabergoline CABOMETYX calamine CALAMINE-ZINC OXIDE CALCI-CHEW CALCIONATE calcipotriene calcitonin (salmon) CALCITRATE calcitriol... 60, 78 CALCIUM CALCIUM D CALCIUM D (D3) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 128

130 CALCIUM 500 WITH D CALCIUM CALCIUM D(3) 115 CALCIUM MINERALS CALCIUM 600 WITH VITAMIN D calcium acetate CALCIUM ANTACID 116 CALCIUM ANTACID TROPICAL CALCIUM ANTACID ULTRA MAX ST calcium carbonate CALCIUM CARBONATE calcium carbonate - d CALCIUM CARBONATE - D CALCIUM CARBONATE AND MAGNESIA ANTACID CALCIUM CARBONATE ANTACID calcium carbonate-vit d3- min CALCIUM CARBONATE-VIT D3- MIN calcium citrate CALCIUM CITRATE. 116 CALCIUM CITRATE + D calcium citrate-vitamin d CALCIUM FOR WOMEN CALCIUM GLUCONATE CALCIUM LACTATE 117 CALCIUM SOFT CHEW CALCIUM WITH VITAMIN D calcium-magnesium-zinc CALCIUM- MAGNESIUM-ZINC calcium-vitamin d3-vitamin k CAL-GEST ANTACID117 camila CANASA CANCIDAS... 9 CAPASTAT CAPEX CAPRELSA captoprilhydrochlorothiazide CARBAGLU carbamazepine carbamide peroxide carbidopa-levodopa carboplatin CARIMUNE NF NANOFILTERED carteolol cartia xt carvedilol CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (isoos) cefdinir cefepime cefoxitin cefoxitin in dextrose, isoosm cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,isoos cefuroxime axetil cefuroxime sodium intravenous vial celecoxib CELLCEPT INTRAVENOUS CELONTIN cephalexin CERASPORT CEREZYME CERVARIX VACCINE (PF) cetirizine cevimeline CHANTIX CHANTIX CONTINUING NTH BOX CHANTIX STARTING NTH BOX CHERATUSSIN AC CHILDREN'S PAIN- FEVER RELIEF CHILDREN'S WAL- DRYL ALLERGY chloramphenicol sod succinate chlorhexidine gluconate. 73 chloroquine phosphate chlorothiazide chlorpromazine cholecalciferol (vitamin d3) cholestyramine (with sugar) cholestyramine light ciclodan ciclopirox cilostazol CINRYZE CIPRODEX ciprofloxacin (mixture).. 19 ciprofloxacin hcl... 19, 101 ciprofloxacin lactate cisplatin citalopram CITRATE OF MAGNESIA CITROMA CITRUS CALCIUM cladribine claravis clarithromycin CLASSIC PRENATAL121 CLEARLAX clemastine clindamycin hcl CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 129

131 clindamycin phosphate.. 16, CLOTRIMAZOLE AF.. 64 CORTISONE 61, 97 CLOTRIMAZOLE (HYDROCORTISONE) CLINIMIX 5%/D15W ANTIFUNGAL SULFITE FREE CLOTRIMAZOLE CORTIZONE CLINIMIX 5%/D25W CLOTRIMAZOLE CORTIZONE-10 PLUS. 66 SULFITE-FREE clotrimazole- COSMEGEN CLINIMIX 2.75%/D5W betamethasone COTELLIC SULFIT FREE clozapine... 43, 44 COUGH CONTROL CLINIMIX 4.25%/D10W CLOZAPINE (GUAIFENESIN) SULF FREE COARTEM COUGH CONTROL DM CLINIMIX 4.25%/D5W codeine-guaifenesin SULFIT FREE colchicine COUGH SYRUP CLINIMIX 4.25%-D20W colchicine-probenecid CREON SULF-FREE COLD AND ALLERGY CRIXIVAN CLINIMIX 4.25%-D25W cromolyn , 112 SULF-FREE COLD AND ALLERGY cryselle (28) CLINIMIX 5%- PE CUBICIN D20W(SULFITE-FREE) colestipol cyanocobalamin (vitamin colistin (colistimethate na) b-12) CLINIMIX E cyclafem 7/7/7 (28) %/D10W SUL COLLYRIUM CYCLOPHOSPHAMIDE FREE colocort CLINIMIX E 2.75%/D5W COL-RITE CYCLOSET SULF FREE COLY-MYCIN S cyclosporine CLINIMIX E COMBIGAN cyclosporine modified %/D25W SUL COMBIVENT RESPIMAT cyproheptadine FREE CYRAMZA CLINIMIX E 4.25%/D5W COMETRIQ CYSTADANE SULF FREE COMFORT GEL CYSTAGON CLINIMIX E 5%/D15W COMFORT GEL EXTRA CYSTARAN SULFIT FREE STRENGTH cytarabine CLINIMIX E 5%/D20W COMPLERA cytarabine (pf) SULFIT FREE COMPLETE ALLERGY D CLINIMIX E 5%/D25W D10 %-0.45 % SODIUM SULFIT FREE COMPLETE ALLERGY CHLORIDE CLINISOL SF 15 % MEDICINE d2.5 %-0.45 % sodium clobetasol COMPLETE LICE chloride clobetasol-emollient TREATMENT D CLOLAR compro d5 % and 0.9 % sodium clomipramine CONDOMS, LATEX, chloride clonazepam LUBRICATED... 76, 78 d5 %-0.45 % sodium clonidine hcl CONDOMS, LATEX, chloride clonidine transdermal patch NON-LUBRICATED 76 dacarbazine constulose DACOGEN clopidogrel COPAXONE DAILY PRENATAL clorazepate dipotassium. 43 cormax DALIRESP clotrimazole... 9, 64, 65, 97 cortisone danazol CLOTRIMAZOLE 3 DAY dantrolene dapsone CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 130

132 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM darifenacin DARZALEX dasetta 7/7/7 (28) daunorubicin DAYHIST ALLERGY 107 deblitane decitabine DELTA D delyla (28) DELZICOL demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA DESCOVY DESENEX desipramine desmopressin desog-e.estradiol/e.estradiol desonide desoximetasone DESVENLAFAXINE DESVENLAFAXINE FUMARATE DEX4 GLUCOSE DEX4 GLUCOSE POUCH PACK DEX4 GLUCOSE QUICK DISSOLVE dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 74, 75, 104 DEXILANT dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose DEXTROSE 10 % AND 0.2 % NACL dextrose 10 % in water (d10w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride dextrose-kcl-nacl DIABETIC SILTUSSIN DAS-NA DIABETIC SILTUSSIN- DM DIABETIC TUSSIN DM DIABETIC TUSSIN EX DIALYVITE DIALYVITE VITAMIN D DIARRHEA RELIEF (BISMUTH SUBS) diazepam... 31, 44 diazepam intensol diclofenac potassium diclofenac sodium... 40, 61 dicloxacillin dicyclomine didanosine DIFFERIN... 61, 62 diflunisal digox digoxin DIGOXIN DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS 31 diltiazem hcl... 53, 54 dilt-xr DIOCTO DIOCTYL DIOTAME DIPENTUM DIPHEDRYL DIPHEDRYL ALLERGY DIPHENHIST DIPHENHYDRAMINE diphenhydramine hcl DIPHENHYDRAMINE ORAL, ALLERGY diphenoxylate-atropine disulfiram divalproex DOCEFREZ docetaxel DOC-Q-LACE DOCU DOCUPRENE docusate calcium docusate sodium DOCUSIL dofetilide DOK donepezil dorzolamide dorzolamide-timolol DOUBLE ANTIBIOTIC 63 doxazosin doxepin doxorubicin doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate DRAMAMINE LESS DROWSY dronabinol CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 131

133 drospirenone-ethinyl estradiol DROXIA DRY EYE RELIEF DSS DUCODYL DULCOLAX STOOL SOFTENER (DSS) DULERA duloxetine duramorph (pf) DUREZOL dutasteride dutasteride-tamsulosin. 114 D-VI-SOL D-VITA E ECONTRA EZ ECOTRIN LOW STRENGTH ECZEMA ANTI-ITCH.. 66 ED A-HIST ED A-HIST PSE EDURANT EFFIENT ELAPRASE ELIDEL elinest ELIQUIS ELITEK ELLA EMCYT EMEND EMPLICITI EMSAM EMTRIVA enalapril maleate enalaprilhydrochlorothiazide ENBREL ENBREL SURECLICK. 95 endocet ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse entacapone entecavir ENTERIC COATED ASPIRIN ENTRE-HIST PSE enulose EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin epitol EPIVIR eplerenone eprosartan EPZICOM EQUETRO ERAXIS(WATER DILUENT)... 9 ERBITUX ergocalciferol (vitamin d2) ergoloid ERGOMAR ERIVEDGE errin ERWINAZE ery pads ery-tab ERYTHROCIN erythromycin erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium ESTRACE estradiol ESTRING ethambutol ethosuximide ETOPOPHOS etoposide EVOMELA EVOTAZ exemestane EXJADE EXPECTORANT EXPECTORANT COUGH SYRUP EXTRA STRENGTH BAYER EYE DROP TEARS EYE IRRIGATING SOLUTION EYE ITCH RELIEF EYE STREAM EYE WASH EYE WASH STERILE 102 EZFE F FABRAZYME FALLBACK SOLO falmina (28) famciclovir famotidine... 89, 90 famotidine (pf) famotidine (pf)-nacl (isoos) FANAPT FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine fenofibrate fenofibrate micronized fenofibrate nanocrystallized 48 mg, 145 mg fenoprofen fentanyl fentanyl citrate FENTORA FEOSOL FERATE FEROSUL FERRETTS FERREX FERRIPROX FERRO-TIME ferrous gluconate FERROUS GLUCONATE ferrous sulfate FERROUS SULFATE. 122 FERROUSUL FETZIMA CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 132

134 FEVER REDUCER AN PAIN RELIEVER FEVERALL finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE 24 FLANAX (NAPROXEN) FLANAX ANTACID FLEBOGAMMA DIF flecainide FLEET GLYCERIN (ADULT) FLEET LAXATIVE FLONASE ALLERGY RELIEF FLOVENT DISKUS FLOVENT HFA fluconazole... 9 fluconazole in dextrose(isoo)... 9 fluconazole in nacl (isoosm)... 9 flucytosine... 9 fludarabine fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap fluocinonide fluocinonide-e fluorometholone fluorouracil... 24, 61 fluoxetine... 45, 46 fluphenazine decanoate.. 46 fluphenazine hcl flurbiprofen flurbiprofen ophthalmic drops flutamide fluticasone... 67, 112 fluvoxamine folic acid FOLOTYN fondaparinux FORADIL AEROLIZER FORTEO foscarnet fosinopril fosinoprilhydrochlorothiazide fosphenytoin FRAGMIN freamine iii 10 % FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LANCETS FREESTYLE LITE STRIPS FREESTYLE TEST FULL SPECTRUM B- VITAMIN C FUNGOID-D furosemide FUSILEV FUZEON FYCOMPA G gabapentin GABITRIL GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) GAS RELIEF GAS RELIEF ULTRA STRENGTH GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD GAVILAX gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 16, 63, 101 gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) GENTAMICIN SULFATE (PF) GENTLE LAXATIVE GENTLELAX GENVOYA GEODON GERI-LANTA GERI-X ANTACID- ANTIGAS GERI-TUSSIN gildagia gildess 1.5/30 (21) gildess fe 1.5/30 (28) gildess fe 1/20 (28) GILENYA GILOTRIF glatopa GLEEVEC GLEOSTINE glimepiride glipizide GLUCAGEN HYPOKIT 76 GLUCAGON EMERGENCY KIT (HUMAN) GLUCO BURST glucose GLUCOSE GEL GLUTOSE GLUTOSE glycerin (adult) GLYCOLAX glycopyrrolate GORMEL GORMEL TEN griseofulvin microsize... 9 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 133

135 griseofulvin ultramicrosize... 9 G-TRON guaifenesin GUAIFENESIN AC GUAIFENESIN ORAL SOLN GUAIFENESIN-DM guanfacine GUANIDINE H HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) HEADACHE RELIEF (ASA-ACET-CAF) HEALTHYLAX HEARTBURN ANTACID HEARTBURN PREVENTION HEARTBURN RELIEF. 84 HEARTBURN RELIEF (FATIDINE) HEARTBURN RELIEF (RANITIDINE) heather heparin (porcine) heparin (porcine) in 5 % dex HEPARIN (PORCINE) IN 5 % DEX HEPARIN FLUSH heparin lock flush HEPARIN LOCK FLUSH HEPARIN LOCKFLUSH(PORCIN E)(PF) heparin, porcine (pf). 57, 58 HEPARIN, PORCINE (PF) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HIBERIX (PF) HI-CAL PLUS VIT D HIGH POTENCY IRON HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMIRA PEN PSORIASIS STARTER hydralazine hydrochlorothiazide hydrocodoneacetaminophen hydrocodonechlorpheniramine hydrocodone-homatropine HYDROCODONE- HOMATROPINE hydrocodone-ibuprofen.. 37 hydrocortisone... 66, 67, 68, 69, 75, 84 hydrocortisone acetate HYDROCORTISONE PLUS hydrocortisone valerate.. 68 hydrocortisone-acetic acid hydrocortisone-min oil-wht pet HYDROCREAM HYDROMET hydromorphone HYDROSKIN hydroxychloroquine hydroxyprogesterone caproate hydroxyurea hydroxyzine hcl I IBRANCE ibuprofen IBUPROFEN IB IBUPROFEN ORAL 200 MG ICLUSIG idarubicin IFEREX ifosfamide ILARIS (PF) ILEVRO imatinib IMBRUVICA imipenem-cilastatin imipramine hcl imiquimod IVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) INLYTA INSTA-GLUCOSE INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U INTELENCE intralipid INTRON A INVANZ INVEGA SUSTENNA.. 46 INVEGA TRINZA... 46, 47 INVIRASE INVOKANA INZO ANTIFUNGAL IOPHEN C-NR IOPHEN DM-NR IOPHEN-NR IPOL ipratropium bromide... 73, 112 ipratropium-albuterol I-PRIN irbesartan IRESSA irinotecan IRON IRON (DRIED) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 134

136 IRON (FERROUS kelnor 1/35 (28) LETAIRIS SULFATE) KEPIVANCE letrozole IRON HIGH POTENCY ketoconazole... 9, 65 leucovorin calcium ketorolac LEUKERAN ISENTRESS KETOTIFEN FUM LEUKINE isoniazid % EYE DROPS leuprolide isosorbide dinitrate levalbuterol hcl isosorbide mononitrate ketotifen fumarate LEVEMIR ISTODAX KEYTRUDA LEVEMIR FLEXTOUCH ITCHY EYE DROPS KHEDEZLA itraconazole... 9 KINERET levetiracetam IXEMPRA kionex levobunolol IXIARO (PF) klor-con levocarnitine J klor-con levocarnitine (with sugar) JAKAFI klor-con m jantoven klor-con m levocetirizine JANUMET klor-con m levofloxacin JANUMET XR... 76, 77 KORLYM levonest (28) JANUVIA K-PEC levonorgestrel-ethinyl JARDIANCE ANTIDIARRHEAL estrad jencycla (BISM SUB) levonorg-eth estrad JEVTANA KPN triphasic JOCK ITCH kurvelo levorphanol tartrate JOCK ITCH KUVAN levothyroxine (CLOTRIMAZOLE).. 64 KYNAMRO levoxyl JOCK ITCH L LEXIVA (TERBINAFINE) labetalol LICE BEDDING SPRAY jolessa lactated ringers... 70, jolivette lactulose LICE COMPLETE KIT 1- junel 1.5/30 (21) LAMISIL AT junel 1/20 (21) lamivudine LICE CREAM RINSE junel fe 1.5/30 (28) lamivudine-zidovudine.. 11 LICE KILLING junel fe 1/20 (28) lamotrigine LICE KILLING junel fe LANOXIN (PERMETHRIN) JUXTAPID lansoprazole LICE PYRINYL K LANTUS SHAMPOO KADCYLA LANTUS SOLOSTAR.. 77 LICE SOLUTION KALETRA larin 1.5/30 (21) LICE TREATMENT KALYDECO larin fe 1/20 (28) LICE TREATMENT KAOPECTATE latanoprost (PERMETHRIN) (BISMUTH LATUDA lidocaine SUBSALICY) LAXA CLEAR lidocaine (pf)... 52, 62 KAOPECTATE EX STR LAXATIVE lidocaine hcl (BISMUTH SS) (BISACODYL) lidocaine viscous KAO-TIN (BISMUTH LAXATIVE PEG lidocaine-prilocaine SUBSALICYLAT) LAZANDA lindane KAO-TIN (DOCUSATE leflunomide linezolid CALCIUM) LENVIMA LINZESS kariva (28) lessina liothyronine CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 135

137 LIQUID ANTACID LIQUITEARS lisinopril lisinoprilhydrochlorothiazide lithium carbonate lithium citrate LODOSYN LOHIST-DM lokara LONSURF loperamide LORADAMED loratadine lorazepam lorazepam intensol lorcet (hydrocodone) lorcet hd lorcet plus lortab lortab lortab losartan losartanhydrochlorothiazide LOTRIMIN AF lovastatin low-ogestrel (28) loxapine succinate LUBRICANT EYE (PG- PEG 400) LUBRICANT EYE DROPS LUBRICANT EYE DROPS (GLYC-PG) 103 LUBRICANT REDNESS RELIEVER LUBRICATING PLUS 103 LUMIGAN LUNESTA LUPRON DEPOT LUPRON DEPOT (3 NTH) lutera (28) LYNPARZA LYRICA... 32, 33 LYSODREN lyza M MAALOX MAXIMUM STRENGTH MACRODANTIN MAG-AL PLUS MAG-AL PLUS EXTRA STRENGTH magnesium citrate MAGNESIUM OXIDE 117 magnesium sulfate 117, 118 magnesium sulfate in water MAPAP EXTRA STRENGTH maprotiline marlissa MARPLAN MASANTI DOUBLE STRENGTH MASOPHEN MATULANE MAXIMUM REDNESS RELIEF M-CLEAR WC meclizine meclofenamate MEDI-MECLIZINE MEDIPROXEN MEDIWASH MEDIWASH EYE IRRIGANT medroxyprogesterone mefloquine megestrol MEKINIST... 26, 27 meloxicam melphalan hcl memantine MENACTRA (PF) MENEST MENHIBRIX (PF) MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W- 135 (PF) MENSTRUAL RELIEF. 41 MENVEO A-C-Y-W-135- DIP (PF) MEPHYTON mercaptopurine meropenem mesalamine mesalamine with cleansing wipe mesna MESNEX MESTINON metaproterenol metformin methadone methadone intensol methadose methazolamide methenamine hippurate.. 20 methenamine mandelate. 20 methimazole methotrexate sodium methotrexate sodium (pf) 27 methoxsalen rapid methyclothiazide methyldopa methyldopahydrochlorothiazide methyldopate methylphenidate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol tartrate metro i.v metronidazole... 17, 62, 97 metronidazole in nacl (isoos) mexiletine MIACALCIN MI-ACID GAS RELIEF 85 MICATIN MICONAZOLE 3 DAY VAGINAL CREAM.. 97 MICONAZOLE miconazole nitrate... 65, 97 miconazole CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 136

138 MICONAZOLE MICONAZORB AF microgestin 1.5/30 (21).. 99 microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28). 99 MICRO-GUARD MICROLIFE PEAK FLOW METER midodrine MIGRAINE FORMULA41 MIGRAINE RELIEF MIGRANAL MILK OF MAGNESIA. 85 MILK OF MAGNESIA CONCENTRATED mineral oil... 85, 86 MINERAL OIL EXTRA HEAVY MINERAL OIL HEAVY85 MINERAL OIL LAXATIVE minocycline minoxidil MINTOX MINTOX MAXIMUM STRENGTH MINTOX PLUS MIRALAX MIRCETTE (28) mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) modafinil moderiba ISTURE DROPS molindone mometasone NOJECT PREFILL (PF) NOJECT PREFILL ADVANCED (PF) mono-linyah mononessa (28) montelukast morgidox morphine RPHINE morphine (pf) morphine concentrate TION RELIEF (MECLIZINE) TION SICKNESS (MECLIZINE) TION SICKNESS II 86 TION SICKNESS RELIEF(MECLIZ) VIPREP ZOBIL MULTAQ mupirocin topical ointment MUSTARGEN MY WAY MYCOBUTIN mycophenolate mofetil mycophenolate sodium.. 27 MYFERON MYOZYME MYRBETRIQ MYTAB GAS MYTAB GAS MAXIMUM STRENGTH myzilra N nabumetone nadolol nadololbendroflumethiazide.. 55 nafcillin NAGLAZYME nalbuphine naloxone naltrexone NAMENDA XR naphazoline naproxen NAPROXEN ORAL 220 MG naproxen sodium NASACORT NASAL DECONGESTANT (PSEUDOEPH) NASAL MIST NASALCROM NATACYN NATPARA NATURAL TEARS (PF) NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone... 47, 48 neomycin neomycin-bacitracin-polyhc neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc 74, 104 neo-polycin neo-polycin hc NEOSPORIN ANTI-ITCH NEOSPORIN PLUS PAINRELIEF(BAC).. 63 NEULASTA NEUPOGEN NEUPRO NEVANAC nevirapine... 11, 12 NEXAVAR NEXT CHOICE ONE DOSE niacin NIACIN NIACOR nicardipine NICORELIEF NICORETTE nicotine (polacrilex) CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 137

139 NICOTINE TRANSDERMAL nicotine transdermal system NICOTROL NS nifedical xl nifedipine NIGHTIME SLEEP NIGHTTIME SLEEP AID (DIPHEN) NILANDRON NINLARO NIPENT nitro-bid nitroglycerin NITROSTAT NOBLE FORMULA HC 68 NON-ASPIRIN NON-ASPIRIN PAIN RELIEF NON-DROWSY ALLERGY nora-be NORCO NORDITROPIN FLEXPRO norethindrone (contraceptive) norethindrone acetate norethindrone-e.estradioliron norgestimate-ethinyl estradiol norlyroc NORSOL-M IN 5 % DEXTROSE NORSOL-R NORSOL-R IN 5 % DEXTROSE NORSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN. 77 NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... 9 NUEDEXTA NULOJIX NUPLAZID NUVARING nyamyc nystatin... 9, 65 nystop O ocella octreotide acetate OCUSOFT IRRIGATING OPHTH SOLN ODEFSEY ODOMZO ODOR CONTROL FOOT- SNEAKER OFEV ofloxacin... 19, 74, 101 ogestrel (28) olanzapine olopatadine OLYSIO omega-3 acid ethyl esters 59 omega-3 fatty acids omeprazole OMEPRAZOLE ondansetron ondansetron hcl ondansetron hcl (pf) ONE DAILY PRENATAL ONFI OPCICON ONE-STEP 100 OPDIVO ORAL SALINE LAXATIVE oralone ORAP ORENCIA ORENCIA (WITH MALTOSE) ORFADIN ORKAMBI orsythia oxacillin oxaliplatin oxandrolone oxaprozin oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin OYSCO 500/D OYSCO D OYSCO OYST-CAL OYSTER SHELL + D3 118 OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM OYSTER SHELL CALCIUM WITH D 123 OYSTER SHELL CALCIUM-VIT D OYSTERCAL-D P pacerone paclitaxel PAIN AND FEVER PAIN RELIEF PAIN RELIEF (ACETAMIN-ASP-CAF) PAIN RELIEF EXTRA STRENGTH PAIN RELIEVER PAIN RELIEVER (ACETAM-ASPIRIN) 41 PAIN RELIEVER EXTRA STRENGTH PAIN RELIEVER PLUS 41 PAIN-OFF paliperidone pamidronate PAMPRIN MAX PANCREAZE CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 138

140 PANRETIN phenytoin sodium potassium chloride in lr-d5 pantoprazole phenytoin sodium extended paroex oral rinse potassium chloride-0.45 % paromomycin philith nacl paroxetine hcl PHOSPHATE LAXATIVE potassium chloride-d5- PASER %nacl PATADAY PHOSPHOLINE IODIDE potassium chloride-d5- PAXIL %nacl PAZEO PICATO potassium chloride-d5- PEDIACARE FEVER pilocarpine hcl %nacl REDUCER pimtrea (28) potassium citrate PEDVAX HIB (PF) pindolol POTIGA peg 3350-electrolytes PINK BISMUTH POWDERLAX PEGANONE PINK BISMUTH PRADAXA PEGASYS MAXIMUM PRALUENT PEN PEGASYS PROCLICK. 92 STRENGTH PRALUENT SYRINGE 59 peg-electrolyte soln PIN-X pramipexole PEGINTRON pioglitazone pravastatin PEGINTRON REDIPEN 92 piperacillin-tazobactam.. 19 prednisolone PENICILLIN G POT IN pirmella prednisolone acetate DEXTROSE... 18, 19 piroxicam prednisolone sodium penicillin g potassium PLASMA-LYTE phosphate... 75, 104 penicillin g procaine PLASMA-LYTE-56 IN 5 prednisone penicillin g sodium % DEXTROSE prednisone intensol penicillin v potassium podofilox PREMARIN PENTAM POLY BACITRACIN PREMPHASE PENTASA polycin PREMPRO pentoxifylline polyethylene glycol , PRENATAL FORMULA PEPCID AC , PEPTIC RELIEF POLY-IRON PRENATAL ONE DAILY PEPTO-BISL polymyxin b sulf PEPTO-BISL TO-GO trimethoprim PRENATAL TABLET polysaccharide iron PRENATAL VITAMIN periogard complex PERJETA polyvinyl alcohol prenatal vitamin oral tablet permethrin POLY-VITA perphenazine POLY-VITAMIN PRENATAL VITAMIN PERSA-GEL POMALYST ORAL TABLET PHARBETOL portia prevalite phenadoz PORTRAZZA previfem phenelzine potassium chlorid-d5- PREZCOBIX phenobarbital %nacl PREZISTA phentermine potassium chloride 118, 119 PRIFTIN PHENYLEPHRINE POTASSIUM CHLORIDE PRIMAQUINE HCL/DIPHENHYDRA primidone MINE HCL potassium chloride in PRISTIQ PHENYLEPHRINE ORAL 0.9%nacl PROAIR HFA potassium chloride in 5 % PROAIR RESPICLICK 113 phenytoin dex probenecid CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 139

141 procainamide prochlorperazine prochlorperazine edisylate prochlorperazine maleate 87 PROCRIT procto-pak proctosol hc proctozone-hc PROGLYCEM PROGRAF PROLEUKIN PROLIA PROMACTA promethazine PROMETHAZINE VC- CODEINE promethazine-codeine promethazine-dm promethazine-phenylephcodeine promethegan PROLAXIN propafenone propranolol propylthiouracil PROQUAD (PF) PROTONIX protriptyline PROVIL PSEUDOEPHEDRINE 120 MG ER pseudoephedrine hcl PSEUDOEPHEDRINE HCL ORAL TABLET EXTENDED RELEASE , 111 PSEUDOEPHEDRINE HCL/CHLORPHENIRA MINE MALEATE PSEUDOEPHEDRINE HCL/TRIPROLIDINE HCL ORAL TABLET PSEUDOEPHEDRINE ORAL LIQ, 15 MG/5 MLS PULZYME PURELAX PURIXAN pyrazinamide pyridostigmine bromide. 36 pyridoxine (vitamin b6) 123 Q Q-DRYL Q-PAP Q-PAP EXTRA STRENGTH Q-TUSSIN QUADRACEL (PF) QUENALIN quetiapine quinapril quinaprilhydrochlorothiazide quinidine sulfate quinine sulfate QUIT QUIT QVAR R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl... 89, 90 RANITIDINE HCL ORAL TABLET RAPAMUNE RAVICTI READY-TO-USE ENEMA (MIN OIL) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK reclipsen (28) RECOMBIVAX HB (PF) RECORT PLUS REDNESS RELIEVER LUBRICANT REESE'S PINWORM MEDICINE RELCOF C RELENZA DISKHALER RELISTOR REMICADE RENA-VITE RENVELA repaglinide REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR REST SIMPLY NIGHTTIME SLEEP RESTASIS RESTFULLY SLEEP RETROVIR REVIVE PLUS REVLIMID REXULTI REYATAZ ribasphere ribavirin RID COMPLETE LICE ELIM KIT RIDAURA rifampin RIFATER RI-GEL RI-GEL II riluzole rimantadine RI-X ringers... 70, 119 RINGWORM RISACAL-D RISPERDAL CONSTA. 49 risperidone RI-TUSSIN RITUXAN rivastigmine rizatriptan ROBAFEN ROBAFEN DM COUGH ropinirole rosadan ROTARIX ROTATEQ VACCINE.. 94 roweepra ROZEREM CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 140

142 RYDEX SLEEP SPIRIVA WITH S SLEEP AID HANDIHALER SABRIL (DIPHENHYDRAMINE) spironolactone SALICYLIC ACID spironolacton- SANDIMMUNE SLEEP AID hydrochlorothiaz SANI-SUPP (ADULT).. 88 (DOXYLAMINE) sprintec (28) SANTYL SLEEP AID MAX STR SPRITAM SAPHRIS (BLACK (DIPHENHYDR) SPRYCEL CHERRY) SLEEP II sps SAVELLA SLEEP TABLET sronyx SCALP RELIEF (DIPHENHYDRAMINE) ssd HYDROCORTISONE60, stavudine... 12, SLEEP-TABS STERILE EYE DROPS 105 SCALPICIN ANTI-ITCH SLOW RELEASE IRON STERILE EYE WASH STERILE SALINE SCOT-TUSSIN SOTH ANTACID STIMATE EXPECTORANT SOTHLAX STIOLTO RESPIMAT 113 SECURA ANTIFUNGAL sodium chloride... 72, 113, STIVARGA STOMACH RELIEF SECURA ANTIFUNGAL sodium chloride 0.45 % 119 STOMACH RELIEF MAX EXTRA THICK sodium chloride 0.9 % STRENGTH selegiline hcl sodium chloride 3 % STOMACH RELIEF selenium sulfide sodium chloride 5 % ORIGINAL SELZENTRY sodium fluoride STOOL SOFTENER SENSIPAR sodium polystyrene (sorb STOP LICE SEREVENT DISKUS free) STOP SKING AID.. 73 SEROQUEL XR sodium polystyrene STRATTERA sertraline sulfonate STRAWBERRY C sharobel SODIUM STREPTOMYCIN SIGNIFOR POLYSTYRENE STRIBILD SILACE SULFONATE STROMECTOL SILADRYL SA SOF-LAX SUBSYS sildenafil SOLTAX sucralfate SILTUSSIN DM DAS. 110 SOMATULINE DEPOT 28 SUDOGEST SILTUSSIN SA SOMAVERT SUDOGEST 12-HOUR 110 silver sulfadiazine SOOTHE (BISMUTH SUDOGEST COLD AND simethicone SUBSALICYLATE).. 81 ALLERGY SIMETHICONE SOOTHE REGULAR SUDOGEST SINUS AND SIMULECT STRENGTH ALLERGY simvastatin SOOTHING CARE sulfacetamide sodium SINUS 12 HOUR (HYDROCORTISONE) sulfacetamide sodium (acne) SINUS AND ALLERGY PE SORBUGEN NR sulfacetamide-prednisolone SINUS-ALLERGY SORIATANE (PHENYLEPHRINE) sorine sulfadiazine sotalol... 52, 53 sulfamethoxazolesirolimus sotalol af trimethoprim SIRTURO SOVALDI SULFAMYLON SKIN TREATMENT SPIRIVA RESPIMAT. 113 sulfasalazine CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 141

143 sulindac sumatriptan succinate SUPER CALCIUM SUPER PAIN RELIEF.. 42 SUPHEDRIN SUPHEDRIN 12 HOUR SUPHEDRINE SUPHEDRINE 12 HOUR SUPHEDRINE PE COLD AND ALLERGY SUPHEDRINE PE SINUS ANDALLERGY SUPPOSITORY ADULT SUPREP BOWEL PREP KIT SURFAK SURNTIL SUSTIVA SUTENT syeda SYLATRON SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus... 28, 61 TAFINLAR TAGRISSO TAKE ACTION TAMIFLU tamoxifen tamsulosin TARCEVA... 28, 29 TARGRETIN tarina fe 1/20 (28) TASIGNA TAZORAC taztia xt TEARS AGAIN (PVA) 103 TEARS NATURALE FREE (PF) TECENTRIQ TECHNIVIE TEFLARO telmisartan temazepam TENIVAC (PF) terazosin terbinafine hcl... 9, 65 terbutaline terconazole TESTIM testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID THE MAGIC BULLET. 88 theophylline THERA-D thiamine hcl (vitamin b1) thiamine mononitrate (vit b1) thioridazine thiotepa thiothixene THYGLOBULIN tiagabine TICE BCG TIKOSYN timolol maleate... 55, 101 TINACTIN TIVICAY tizanidine TOBI tobramycin tobramycin sulfate tobramycin-dexamethasone opthalmic suspension 104 tolcapone tolnaftate TOLNAFTATE AEROSOL POWDER, TOPICAL tolterodine topiramate toposar topotecan TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER tramadol tramadol-acetaminophen 42 trandolapril tranexamic acid... 58, 97 TRANSDERM-SCOP tranylcypromine travasol 10 % TRAVATAN Z TRAVEL SICKNESS (MECLIZINE) travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) 29 TREXALL triamcinolone acetonide 69, 74, 75 triamterenehydrochlorothiazid TRI-BIOZENE triderm tri-estarylla trifluoperazine trifluridine trihexyphenidyl TRILEPTAL tri-linyah trimethoprim trimipramine trinessa (28) TRINTELLIX... 50, 51 CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 142

144 TRIPLE ANTIBIOTIC.. 63 TRIPLE ANTIBIOTIC (PRAM) EXTRA TRIPLE ANTIBIOTIC PLUS TRIPLE ANTIBIOTIC- PAIN RELIEF tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ trivora (28) TRIZIVIR TROPHAMINE 10 % TROPHAMINE 6% TRUMENBA TRUVADA TUDORZA PRESSAIR113, 114 TUMS ULTRA TUSNEL DIABETIC TUSSI PRES-B TUSSIGON TUSSIN TUSSIN CHEST CONGESTION TUSSIN COUGH-CHEST CONGESTION TUSSIN DM TUSSIN DM COUGH AND CHEST TUSSIN EXPECTORANT TUSSIN HONEY TWINRIX (PF) TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYZEKA U ULTRA FRESH ULTRA SLEEP (DOXYLAMINE SUCC) ULTRA STRENGTH ANTACID ULTRA STRENGTH CALCIUM ANTACID UNISOM SLEEPGELS 111 unithroid UNITUXIN UPTRAVI urea UREACIN URINARY PAIN RELIEF URINARY TRACT ursodiol UVADEX V VAGIFEM VAGINAL CONTRACEPTIVE FOAM VAGISTAT valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartanhydrochlorothiazide VALU-DRYL ALLERGY vancomycin VANCOMYCIN IN 0.9% SODIUM CL VANCOMYCIN IN DEXTROSE 5 %. 20, 21 VAQTA (PF) VARIVAX (PF) VARIZIG VECAMYL VECTIBIX VELCADE velivet triphasic regimen (28) VELPHORO VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTAVIS VENTOLIN HFA verapamil VERSACLOZ VESICARE VICKS QLEARQUIL ALLERGY VICKS QLEARQUIL NIGHTTIME RLF VICTOZA 2-PAK VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIGAX VIIBRYD VIMPAT vinblastine vincasar pfs... 29, 30 vincristine vinorelbine viorele (28) VIRACEPT VIRAZOLE VIREAD VIRTUSSIN AC vitamin a palmitate VITAMIN A PALMITATE VITAMIN B VITAMIN B-1 (NONITRATE) VITAMIN B VITAMIN B VITAMIN B VITAMIN C VITAMIN C WITH ROSE HIPS VITAMIN D VITAMIN D vitamin e VITAMIN E (DL, ACETATE) VITEKTA VIVELLE-DOT VOLTAREN CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 143

145 voriconazole... 9, 10, 11 VOSPIRE ER VOTRIENT VPRIV VRAYLAR vyfemla (28) W WAL-ITIN WAL-SOM (DIPHENHYDRAMINE) WAL-ZYR (CETIRIZINE) warfarin water for irrigation, sterile WOMAN'S LAXATIVE 89 WOMEN'S GENTLE LAXATIVE(BISAC). 89 WOMEN'S LAXATIVE (BISACODYL) X XALKORI XARELTO XENAZINE XGEVA XIFAXAN XOLAIR XTANDI XYREM Y YERVOY YF-VAX (PF) YONDELIS Z zafirlukast zaleplon ZALTRAP ZANOSAR ZANTAC ZANTAC MAXIMUM STRENGTH zarah ZAVESCA ZEASORB (MICONAZOLE) ZELBORAF ZEMAIRA zenchent (28) zenzedi ZEPATIER ZETIA ZIAGEN zidovudine... 13, 14 ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid-mannitolwater ZOLINZA zolmitriptan ZOMETA ZOMIG zonisamide ZORBTIVE ZORTRESS ZOSTAVAX (PF) ZOSYN IN DEXTROSE (ISO-OSM) zovia 1/35e (28) zovia 1/50e (28) ZYDELIG ZYKADIA ZYPREXA RELPREVV 52 ZYTIGA CareMore Cal MediConnect Plan 非工作時間每週 7 天, 每天 24 小時全天候, 包含假日皆可留語音訊息 此為免費電話 如需更多資訊, 請瀏覽網站 duals.caremore.com 144

146 如果您有疑問, 請致電 CareMore Cal MediConnect Plan 會員服務部 (TTY 711), 太平洋時間週一至週五上午 8 點至下午 8 點 如需更多資訊, 請瀏覽網站 duals.caremore.com 給付藥物清單 和 / 或網路內藥房和醫療服務提供者可能於全年內隨時變動 在我們做的改變對您造成影響之前, 我們會向您寄送通知 福利 和 / 或共付費用可能於每年 1 月 1 日進行變動 您可以隨時查詢 CareMore Cal MediConnect Plan 最新的給付藥物清單, 請上網至網站 duals.caremore.com 或致電 (TTY 711) 條件及限制可能適用 有關更多資訊, 請致電 CareMore Cal MediConnect Plan 會員服務部, 或查閱 CareMore Cal MediConnect Plan 會員手冊 處方藥物的共付費用可能會根據您所取得的 Extra Help( 額外補助 ) 等級而有所不同 請聯絡本計畫以取得更多詳情 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 是一個同時與 Medicare 和 Medi-Cal 訂立合約的醫療保健計畫, 從而為參保人提供這兩個計畫的福利 CareMore 代表 CareMore 的附屬公司負責執行合約 CareMore 為 CareMore Health System 的註冊商標 H6229_17_19648_T_CT CMS Approved 08/12/2016 Formulary ID: Version: 7 Issued 01/01/2017 [Inventory Code]