List of Covered Drugs

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1 GuildNet Gold Plus FIDA Plan MMP-POS 承保藥物清單 ( 處方集 )2016 年 本處方集上次於 2015 年 8 月 19 日更新 請撥打 ( 聽障 / 語障人士請撥 ) 聯絡計劃以取得最新資訊或查詢其他問題 我們的服務時間為週一至週日每天上午 8 Este 時到晚上 vademécum 8 時 se, actualizó 或請造訪 el 8/8/ Para obtener información más reciente o si tiene otras preguntas, comuníquese con el Plan al o, para usuarios de teléfonos de texto (TTY), al Se atiende de lunes a domingo, 16143v7 H0811_GN252Ch_MEM16_Formulary_Accepted

2 GuildNet Gold Plus FIDA Plan 2016 承保藥物清單 ( 處方一覽表 ) 這是會員可透過 GuildNet Gold Plus FIDA Plan 獲得的藥物清單 GuildNet Gold Plus FIDA Plan 是一種管理式醫療保健計劃, 該計劃與 Medicare 和紐約州衛生 部 (Medicaid) 均簽訂了合約, 以便透過 Fully Integrated Duals Advantage (FIDA) 展示為參與者 提供這兩項計劃 承保藥物清單及 / 或藥店和醫療提供者網絡在全年內可能發生變化 在我們做出影響到您的修改 之前, 我們將向您傳送通知 福利可能在每年的 1 月 1 日發生變化 您總是可線上檢視 GuildNet Gold Plus FIDA Plan 最新藥物清單, 網址是 或致電 GuildNet Gold Plus FIDA Plan 會員服務部, 電話是 TTY/TDD, 請致 電 限制和約束可能適用 欲瞭解更多資訊, 請致電 GuildNet Gold Plus FIDA Plan 會員服務部或 閱讀 GuildNet Gold Plus FIDA Plan 參與者手冊 任何承保藥物無自付費用 您可以免費獲得以其他格式 ( 例如大字印刷 盲文或音訊 ) 編寫的此資訊 請致電 , 或 TTY , 工作時間是週一至週日的早 8 點至晚 8 點 該電話免費 You can get this information for free in other languages. Call or TTY/TDD , Monday through Sunday, 8am to 8pm. The call is free. Usted puede obtener esta información en otros idiomas gratis. Llame al o TTY/TDD al , de lunes a domingo de 8am a 8pm. La llamada es gratis. Queste informazioni sono disponibili gratuitamente in altre lingue. Chiamare il numero verde o mediante un telefono testuale per non udenti (TTY/TDD), da lunedì a domenica, dalle 8 alle 20. La chiamata è gratuita. 您可以免費獲得本信息的其他語言版本 請撥打 或聽障 / 語障人士專線 (TTY/TDD) , 星期一至星期日上午 8 時至晚上 8 時 撥打該電話免費 Вы можете бесплатно получить эту информацию на других языках. Позвоните по телефону и TTY/TDD Служба работает с понедельника? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 i

3 по воскресенье с 08:00 до 20:00 ч. Звонок бесплатный. Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang. Rele nimewo oswa TTY/TDD , lendi jiska dimanch, depi 8am jiska 8pm. Koutfil la gratis. 다른언어로작성된이정보를무료로얻으실수있습니다. 월요일 - 일요일오전 8 시부터오후 8 시사이에 번이나 TTY/TDD 번으로전화주세요. 통화는 무료입니다. 紐約州已制訂了稱作 消費者獨立維權網絡 (ICAN) 的會員監管員計劃, 旨在為會員提供針對 GuildNet Gold Plus FIDA Plan 所承保的任何服務的免費和保密性協助 您可致電免費電話 或瀏覽網站 icannys.org 連絡 ICAN? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 ii

4 常見問題 (FAQ) 如果您對於承保藥物清單有任何疑問, 請在此尋找答案 您可以閱讀所有常見問題 (FAQ) 以瞭解 更多資訊, 或尋找一個問題和答案 1. 承保藥物清單上包含哪些處方藥? ( 我們將承保藥物清單簡稱為藥物清單 ) 從 2 頁開始的承保藥物清單上所列的各種藥物為 GuildNet Gold Plus FIDA Plan 承保藥物 這些藥 物均可在我們網絡藥房內獲得 如果藥房與我們簽訂合作協定並向您提供服務, 則藥房在我們網絡 內 我們把這些藥房稱為 網絡藥房 下列情況中 GuildNet Gold Plus FIDA Plan 將承保藥物清單上的所有藥物 : 您的醫生或其他開藥醫生表示您需要這些藥物以康復或維持健康, 藥物對治療您的病症具有醫療必要性, 以及 您在 GuildNet Gold Plus FIDA Plan 網絡藥房內配藥 GuildNet Gold Plus FIDA Plan 可能在獲得某些藥物上需要採取其他步驟 ( 請檢視以下第 5 個問 題 ) 在一些情況下, 您在獲得藥物之前可能需要做其他事, 例如先嘗試其他藥物 檢視最新承保藥物清單, 您可瀏覽我們的網站 或致電會員服務部, 電話是 TTY/TDD, 請致電 藥物清單是否會變更? 是 一年當中 GuildNet Gold Plus FIDA Plan 可能會新增或移除藥物清單中的某些藥物 通常, 只有在下列情況中藥物清單才會有所變更 : 現在出現了一種新藥物, 其藥效與藥物清單上的藥物效果相同, 或者 我們瞭解到一種藥物並不安全 我們可能也會變更我們的藥物規則 例如, 我們可以 : 決定一種藥物是否需要事先核准 ( 事先核准是指在您可獲得藥物之前, 您需獲得 GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 的許可 ) 新增或變更您可獲得的藥量 ( 稱為 數量限制 )? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 iii

5 增加或變更藥物逐步治療限制 ( 逐步治療指在我們會承保其他藥物之前, 您必須先試用其他藥物 ) ( 有關這些藥物規則的更多資訊, 請參閱第 iv 頁 ) 一旦您正在服用的藥物從藥物清單上除名, 我們將告知您 一旦我們變更藥物的承保規則, 我們將告知您 以下第 3 4 以及 7 個問題就藥物清單變更會發生什麼的問題有更多闡述 您可以隨時線上檢視 GuildNet Gold Plus FIDA Plan 最新藥物清單, 網址為 您可致電會員服務部, 瞭解現行版本的藥物清單, 電話是 TTY/TDD, 請致電 如果現在出現了一種與藥物清單上藥物效果相同且價格更低的新藥, 會發生什麼? 如果現出現了一種與藥物清單上藥物效果相同的新藥 : 您的藥劑師可能在您下次配藥時向您提供較便宜的藥物 如果您和您的提供者認定便宜的藥物對您並不適用, 您的提供者可讓藥劑師繼續向您提供您正在服用的藥物 GuildNet Gold Plus FIDA Plan 可能決定將較貴的藥物從藥物清單上移除 如果我們因為新藥具有相同藥效而將您在服用的一種藥物從藥物清單上移除, 我們將在藥物從藥物清單上移除前至少 60 天前或在您要求續配藥時通知您 隨後您可在藥物清單變更前購買 60 天的藥 您將在變更生效前至少 60 天內收到一封信函 4. 如果我們發現一種藥物並不安全, 會發生什麼? 如果食品和藥品管理局 (FDA) 表示您服用的藥物並不安全, 我們會立即將此藥從藥物清單上移除 我們亦將發函通知您這種不安全的藥物已從藥物清單上移除 如果您收到了這封信函, 您應該致電您的保健管理員或處方醫生, 安排變更處方 5. 藥物承保是否有約束或限制? 或者為獲得某些藥品是否要求採取一些措施? 是, 一些藥物有承保規則或限制您所能獲得的藥量 一些情況下, 您 您的醫生或其他開藥醫生在 獲得藥物之前必須先做某件事情 例如 :? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 iv

6 事先核准 ( 或事先核准 ): 對於一些藥品, 您 您的醫生或其他開藥醫生必須在您配藥之前獲得 GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 的核准 若您未獲得核准, GuildNet Gold Plus FIDA Plan 可能不承保此藥品 數量限制 : 有時,GuildNet Gold Plus FIDA Plan 限制您能獲得的藥量 階段治療 : 有時 GuildNet Gold Plus FIDA Plan 要求您採取逐步治療 這意味著在應對您的醫療病症時, 您將必須按一定順序試用藥物 在我們會承保其他藥物之前, 您可能需要先試用其他藥物 如果您的醫生認為第一種藥物對您並不適用, 之後我們將承保第二種藥物 瞭解您的藥物是否有其他額外要求或限制, 您可從 2 頁開始檢視各表格 您亦可透過瀏覽我們網站瞭解更多資訊, 網址為 我們在網上發佈檔案, 解釋我們的事先核准和逐步治療限制 您也可以要求我們向您傳送一份副本 您可對這些限制要求進行 例外處理 瞭解例外處理的更多資訊, 請檢視第 11 個問題 如果您在護理設施或其他長期護理設施內, 並且需要藥物清單外的一種藥物, 或者如果您獲得所需藥物並不方便, 我們可提供協助 我們將承保一次 31 天急救藥物用量 ( 除非您處方箋上註明的天數較少 ), 不論您是否為 GuildNet Gold Plus FIDA Plan 新會員 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可協助您決定是否採用藥物清單上的相似藥或是否需要要求例外處理 瞭解例外處理的更多資訊, 請檢視第 11 個問題 6. 您將如何得知您想要的藥物是否有限制或獲得藥物是否需要採取行動? 第 2 頁的承保藥物清單有一張柱狀圖, 標題是 7. 如果我們變更了藥物承保方式的規則, 會發生什麼? 例如, 如果我們增加了一種藥物的事先核准 ( 核准 ) 數量限制 以及 / 或者逐步治療 我將向您告知如果我們增加藥物的事先核准 數量限制, 以及 / 或者逐步治療限制 我們將在增加限 制或在您要求下次續配藥之前至少提前 60 天通知您 隨後您可在藥物清單變更前購買 60 天的藥 這將給您與您的醫生或其他開藥醫生商討下一步操作的時間 8. 您如何在藥品清單上尋找一種藥物? 尋找藥物有兩個方法 : 您可按字母尋找 ( 如果您知道藥物名稱如何拼字 ), 或者? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 v

7 您可按醫療病症查詢 按字母查詢, 請翻至第 137 頁檢視字母清單部分 然後在清單上尋找您所需藥物的名稱 按醫療病症查詢, 請翻至第 2 頁檢視 按醫療病症排列藥物清單 隨後尋找您的醫療病症 例如, 如果您心臟有問題, 您應該尋找心血管 高血壓 / 血脂類別 您可在那裏找到應對心臟問題的藥物 9. 如果您想服用的藥品未在藥物清單上, 該怎麼辦? 果您在藥物清單上並未看到您的藥物, 請致電會員服務部詢問情況, 電話為 (TTY/TDD 請致電 ) 如果您瞭解到 GuildNet Gold Plus FIDA Plan 將不會對該藥物進行承保, 您可採取以下一項操作 : 向會員服務部索取一份您想要服用的藥物清單 然後將清單給您的醫生或其他開藥醫生看 他或她可向您開立類似您想要服用且在藥物清單上的藥物 或 您可要求計劃或您的跨學科小組 (IDT) 作例外處理, 承保您的藥物 瞭解例外處理的更多資訊, 請檢視第 11 個問題 10. 如果您新加入 GuildNet Gold Plus FIDA Plan, 並且在藥物清單上找不到或很難找到您的藥物, 該怎麼辦? 我們竭誠相助 我們必須按需要承保在您成為 GuildNet Gold Plus FIDA Plan 會員最初 90 天的藥 物暫時用量 這將給您與您的醫生或其他開藥醫生商討留出時間 他或她可協助您決定是否採用藥 物清單上的相似藥或是否需要要求例外處理 我們將向您承保最多 90 天的暫時藥物用量, 如果 : 您在服用的藥物並不在我們的藥物清單上, 或者 健康計劃規則並不能讓您獲得您的開藥醫生開立的藥量, 或者 藥物需要 GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 事先核准, 或者 您所服用的藥物為逐步治療限制的一部分 如果您在護理設施或其他長期護理設施內, 您可獲得的再次配藥藥量為 至多 98 天 在 90 天期間, 您可以多次續配藥 這給予您的開藥醫生留出時間將您的藥物改為藥物 清單上的藥物或者要求例外處理? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 vi

8 如果您是我們的計劃的現有會員而且您的護理層級發生了變化, 如允許使用或停止使用長期護理設施, 必要時您將能 提早 續配您的用藥, 從而協助您過渡到您的全新護理層級 11. 您是否能夠要求例外處理以承保您的藥物? 是 您可要求 GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 作例外處理, 承保未在藥物清單上的藥物 您亦可要求 GuildNet Gold Plus FIDA Plan 或您的 IDT 變更藥物規則 例如,GuildNet Gold Plus FIDA Plan 可能限制了我們將承保藥物的劑量 如果您的藥物有限制, 您可要求我們或您的跨學科小組 (IDT) 變更限制或承保更多劑量 其他範例 : 您可要求我們或您的跨學科小組 (IDT) 擯棄逐步治療限制或事先核准要求 12. 獲得例外處理需要多少時間? 首先,GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 必須收到來自您的開藥醫生支援您例外處理要求的聲明 您將在我們收到聲明後 72 小時內獲得我們對於您的例外處理要求的決定 如果您或您的開藥醫生認為如果 72 小時的必須等待可能有損您的健康, 您可要求加快例外處理 這就是快速決定 如果您的開藥醫生支援您的要求, 您將在我們收到您的開藥醫生的支援性聲明後 24 小時內獲得決定 13. 您如何要求進行例外處理? 要求例外處理, 您可致電您的保健管理員 您的保健管理員將協助您和您的提供者協助您要求例外處理 14. 什麼是普通藥物? 普通藥物成分與品牌藥物相同 它們通常比品牌藥價格更低且藥名並不被熟知 普通藥獲食品與藥品管理局 (FDA) 核准 GuildNet Gold Plus FIDA Plan 承保品牌藥和普通藥 15. 什麼是非處方 (OTC) 藥物?? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 vii

9 OTC 表示 非處方藥 當非處方藥是由您的提供者開立時,GuildNet Gold Plus FIDA Plan 將承保這些非處方藥 您可閱讀 GuildNet Gold Plus FIDA Plan 藥物清單瞭解哪些非處方藥在承保之列 承保的非處方藥 (OTC) 範例 : 阿司匹林 撲熱息痛 Advil 抗酸劑 抗過敏和感冒藥物 抗生素藥膏 通便劑 尼古丁貼片 口香糖和維生素 16. GuildNet Gold Plus FIDA Plan 是否承保 OTC 非藥產品? 當某些 OTC 非藥產品是由您的提供者作為處方開立時,GuildNet Gold Plus FIDA Plan 將為它們提供承保 您可閱讀 GuildNet Gold Plus FIDA Plan 藥物清單瞭解哪些 OTC 非藥產品在承保之列 例如防曬霜 (SPF 15+) Sebex 局部洗髮水和 A&D 藥膏 可以透過您的 GuildNet Gold Plus FIDA Plan OTC 卡在加盟藥房中獲得其他未包含在藥物清單中的非處方用品 您的 Plan OTC 卡承保的項目包括創口貼 止咳嘀液 牙膏和醫用壓力襪支撐 請閱覽 參與者手冊 的第 4 章, 瞭解更多資訊 17. 什麼是您的自付費用? 藥物清單上的藥物您無需支付自付費用 18. 什麼是藥物層級? 承保藥物清單上的每種藥物均屬於四個層級之一 第 1 層級為 Medicare D 部分的普通藥物第 2 層級為 Medicare D 部分的品牌藥物第 3 層級為 Medicaid 承保的 ( 非 D 部分 ) 處方藥物第 4 層級為非處方 (OTC) 項目 我們的藥物清單上的所有藥物和用品自付費用為 0 美元? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 viii

10 承保藥物清單 從下頁開始的承保藥物清單向您說明 GuildNet Gold Plus FIDA Plan 承保的藥物資訊 如果您在藥物清單上找藥物有困難, 請翻至位於第 137 頁上的索引部分 圖表第一列是藥物名稱 品牌藥品名稱大寫 ( 如 :SYNTHROID), 普通藥品為斜體小寫 ( 如 :atenolol) 柱狀圖向您說明您藥物的 GuildNet Gold Plus FIDA Plan 承保規則 注意 : 藥品邊上的 * 表示此藥並非 D 部分藥品 這些藥品有不同的上訴規則 上訴即要求我們審核並且在您認為存在錯誤的情況下變更承保決定的正式方式 例如,GuildNet Gold Plus FIDA Plan 或您的跨學科小組 (IDT) 可能決定您想要的藥物並未或不再受到 Medicare 或 Medicaid 承保 如果您或您的醫生或其他開藥醫生對該決定有異議, 您可提起上訴 瞭解如何上訴的說明, 請致電會員服務部, 電話是 (TTY/TDD 請致電 ) 或者致電獨立消費者宣導組織 (ICAN), 電話是 (TTY 711) 您亦可閱讀會員手冊, 瞭解如何對決定提起上訴? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 ix

11 ? 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 x

12 下列為可能出現在後續頁面的要求 / 限制欄中的縮寫清單, 向您說明您的藥物是否有任何特殊承保要求 縮寫清單 *: 藥品邊上的 * 表示此藥並非 D 部分藥品 這些藥品有不同的上訴規則 上訴即要求我們審核並且在您認為存在錯誤的情況下變更承保決定的正式方式 例如,GuildNet 或您的跨學科小組 (IDT) 可能決定您想要的藥物並未或不再受到 Medicare 或 Medicaid 承保 如果您或您的醫生或其他開藥醫生對該決定有異議, 您可提起上訴 瞭解如何上訴的說明, 請致電 GuildNet Gold Plus FIDA Plan, 電話是 ;TTY/TDD 或者致電獨立消費者宣導組織 (ICAN), 電話是 您亦可閱讀會員手冊, 瞭解如何對決定提起上訴 B/D PA: 視不同情況而定, 此處方藥可能根據 Medicare B 部分或 D 部進行承保 可能需要提交資訊, 說明此藥品的用途和治療情況, 以便作出決定 LA: 供應受限 該處方可能只允許在一些藥房配藥 有關詳情, 請致電客戶服務部 MO: 郵購藥品 可透過我們的郵購服務和我們的零售網絡藥房獲得此處方藥 您的長期 ( 維持 ) 用藥 ( 如高血壓用藥 ) 可考慮使用郵購服務 零售網絡藥房可能更適用於短期處方藥 ( 如抗生素 ) PA: 事前核准 計劃要求您或您的醫生為某些藥品獲得事前核准 這意味著您獲得處方藥之前需要獲得核准 若您未獲得核准, 我們可能不承保此藥物 QL: 數量限制 對於某些藥品, 計劃限制我們承保的藥量 ST: 分步療法 在某些情況下, 計劃會要求您在其承保治療您所患病症的藥物前先試用其他藥物 例如, 如果藥品 A 和藥品 B 都可治療您的疾病情況, 我們可能會要求您先試用藥品 A, 否則就不承保藥品 B 如果藥品 A 對您無效, 我們將承保藥品 B 醫療狀況藥品清單這一小節中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 如果您心臟有問題, 您應該尋找心血管 高血壓 / 血脂類別 您可在那裏找到應對心臟問題的藥物 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA Plan, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 1

13 抗感染藥 抗真菌劑 ABELCET INTRAVENOUS SUSPENSION 2 $0 B/D PA; MO AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO amphotericin b injection recon soln 1 $0 B/D PA; MO CANCIDAS INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO clotrimazole mucous membrane troche fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml 1 $0 B/D PA fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule ; QL (120 per 30 days) ketoconazole oral tablet NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral tablet ; QL (90 per 365 days) voriconazole intravenous solution 1 $0 B/D PA; MO VORICONAZOLE ORAL SUSPENSION FOR RECONSTITUTION VORICONAZOLE ORAL TABLET 200 MG voriconazole oral tablet 50 mg 抗病毒藥 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 2

14 abacavir oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution 1 $0 B/D PA; MO ADEFOVIR ORAL TABLET amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION 2 $0 ATRIPLA ORAL TABLET BARACLUDE ORAL SOLUTION CIDOFOVIR INTRAVENOUS SOLUTION 2 $0 B/D PA; MO COMPLERA ORAL TABLET CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine oral capsule,delayed release(dr/ec) EDURANT ORAL TABLET EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION ENTECAVIR ORAL TABLET EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ORAL TABLET EVOTAZ ORAL TABLET famciclovir oral tablet 125 mg ; QL (21 per 10 days) famciclovir oral tablet 250 mg ; QL (60 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 3

15 famciclovir oral tablet 500 mg ; QL (21 per 7 days) foscarnet intravenous solution FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln 1 $0 B/D PA; MO HARVONI ORAL TABLET 2 $0 PA; MO; QL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG 2 $0 INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine oral solution lamivudine oral tablet LAMIVUDINE-ZIDOVUDINE ORAL TABLET LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET PREZCOBIX ORAL TABLET PREZISTA ORAL SUSPENSION 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 4

16 PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE ; QL (60 per 180 days) RETROVIR INTRAVENOUS SOLUTION REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribavirin oral capsule 1 $0 PA; MO ribavirin oral tablet 200 mg 1 $0 PA; MO rimantadine oral tablet SELZENTRY ORAL TABLET SOVALDI ORAL TABLET 2 $0 PA; MO; QL (30 per 30 days) stavudine oral capsule stavudine oral recon soln STRIBILD ORAL TABLET SUSTIVA ORAL CAPSULE SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML 2 $0 PA; MO; LA TAMIFLU ORAL CAPSULE 30 MG ; QL (84 per 180 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG ; QL (42 per 180 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY ORAL TABLET TRIUMEQ ORAL TABLET TRUVADA ORAL TABLET TYBOST ORAL TABLET ; QL (600 per 180 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 5

17 TYZEKA ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 6 valacyclovir oral tablet ; QL (30 per 30 days) VALCYTE ORAL RECON SOLN VALGANCICLOVIR ORAL TABLET VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN VIEKIRA PAK ORAL TABLETS,DOSE PACK 2 $0 PA; MO; QL (112 per 28 days) VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE INHALATION RECON SOLN 2 $0 B/D PA; MO VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ORAL TABLET ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet 頭孢菌素 cefaclor oral capsule 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, 2 gram/50 ml 1 $0 B/D PA; MO cefazolin injection recon soln 1 gram, 500 mg 1 $0 B/D PA; MO cefazolin injection recon soln 10 gram 1 $0 B/D PA

18 cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet 200 mg cefepime injection recon soln 1 $0 B/D PA; MO cefixime oral suspension for reconstitution cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 1 $0 B/D PA cefotetan injection recon soln 1 $0 cefotetan intravenous recon soln 1 $0 cefoxitin in dextrose, iso-osm intravenous piggyback 1 $0 B/D PA cefoxitin intravenous recon soln 1 gram 1 $0 B/D PA; MO cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 1 $0 B/D PA cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram 1 $0 1 $0 B/D PA; MO ceftriaxone injection recon soln 10 gram 1 $0 B/D PA ceftriaxone injection recon soln 250 mg, 500 mg 1 $0 B/D PA; MO ceftriaxone intravenous recon soln 1 $0 B/D PA; MO cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg 1 $0 B/D PA; MO cefuroxime sodium intravenous recon soln 1 $0 B/D PA cephalexin oral capsule cephalexin oral suspension for reconstitution 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 7

19 cephalexin oral tablet SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML 2 $0 SUPRAX ORAL TABLET,CHEWABLE TEFLARO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO 紅黴素 / 其他大環內酯類抗生素 azithromycin intravenous recon soln 500 mg 1 $0 B/D PA; MO azithromycin intravenous recon soln 500 mg (2 mg/ml) 1 $0 B/D PA azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr e.e.s. 400 oral tablet ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 B/D PA erythromycin ethylsuccinate oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 8

20 erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet 雜類抗感染藥物 ALBENZA ORAL TABLET ALINIA ORAL SUSPENSION FOR RECONSTITUTION ; QL (180 per 30 days) ALINIA ORAL TABLET ; QL (12 per 30 days) amikacin injection solution 500 mg/2 ml 1 $0 B/D PA; MO ATOVAQUONE ORAL SUSPENSION atovaquone-proguanil oral tablet aztreonam injection recon soln 1 gram baciim intramuscular recon soln 1 $0 B/D PA bacitracin intramuscular recon soln 1 $0 B/D PA; MO CAPASTAT INJECTION RECON SOLN 2 $0 B/D PA CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln ; QL (84 per 28 days) 1 $0 B/D PA chloroquine phosphate oral tablet clindamycin hcl oral capsule clindamycin pediatric oral recon soln 1 $0 clindamycin phosphate intravenous solution 600 mg/4 ml 1 $0 B/D PA; MO COARTEM ORAL TABLET COLISTIN (COLISTIMETHATE NA) INJECTION RECON SOLN 2 $0 B/D PA; MO CUBICIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO CYCLOSERINE ORAL CAPSULE DAPSONE ORAL TABLET DARAPRIM ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 9

21 ethambutol oral tablet gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/50 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 80 MG/100 ML 1 $0 B/D PA; MO 1 $0 2 $0 B/D PA gentamicin injection solution 40 mg/ml 1 $0 B/D PA; MO hydroxychloroquine oral tablet imipenem-cilastatin intravenous recon soln 1 $0 B/D PA; MO INVANZ INJECTION RECON SOLN 2 $0 B/D PA; MO INVANZ INTRAVENOUS RECON SOLN 2 $0 B/D PA isoniazid injection solution 1 $0 isoniazid oral solution isoniazid oral tablet ivermectin oral tablet LINEZOLID INTRAVENOUS PARENTERAL SOLUTION 2 $0 PA LINEZOLID ORAL TABLET 2 $0 PA; MO mefloquine oral tablet meropenem intravenous recon soln 500 mg 1 $0 B/D PA; MO metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule metronidazole oral tablet NEBUPENT INHALATION RECON SOLN 2 $0 B/D PA; MO neomycin oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 10

22 paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION RECON SOLN 2 $0 B/D PA; MO polymyxin b sulfate injection recon soln 1 $0 PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET pyrazinamide oral tablet quinine sulfate oral capsule 1 $0 PA; MO rifabutin oral capsule rifampin intravenous recon soln 1 $0 B/D PA; MO rifampin oral capsule SIRTURO ORAL TABLET ; LA STREPTOMYCIN INTRAMUSCULAR RECON SOLN 2 $0 B/D PA; MO SYNERCID INTRAVENOUS RECON SOLN 2 $0 B/D PA tinidazole oral tablet TOBRAMYCIN IN % NACL INHALATION SOLUTION FOR NEBULIZATION tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml 2 $0 B/D PA; MO tobramycin sulfate injection solution 1 $0 B/D PA; MO TRECATOR ORAL TABLET TYGACIL INTRAVENOUS RECON SOLN XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 PA; MO 2 $0 PA; MO ZYVOX ORAL TABLET 2 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 11

23 青黴素 amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg 1 $0 B/D PA; MO ampicillin sodium intravenous recon soln 1 $0 B/D PA ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 BICILLIN C-R INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO BICILLIN L-A INTRAMUSCULAR SYRINGE dicloxacillin oral capsule NAFCILLIN IN DEXTROSE ISO-OSM INTRAVENOUS PIGGYBACK 1 GRAM/50 ML 2 $0 B/D PA nafcillin injection recon soln 1 gram 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 12

24 NAFCILLIN INJECTION RECON SOLN 10 GRAM 2 $0 B/D PA; MO nafcillin intravenous recon soln 2 gram 2 $0 B/D PA; MO oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml OXACILLIN IN DEXTROSE(ISO-OSM) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML OXACILLIN INJECTION RECON SOLN 10 GRAM 1 $0 B/D PA 2 $0 B/D PA; MO 2 $0 B/D PA; MO oxacillin intravenous recon soln 2 gram 1 $0 B/D PA 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 1 $0 B/D PA; MO 1 $0 B/D PA; MO 1 $0 B/D PA penicillin g sodium injection recon soln 1 $0 B/D PA; MO penicillin v potassium oral recon soln penicillin v potassium oral tablet piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram 喹諾酮 AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1 $0 B/D PA; MO 2 $0 B/D PA; MO ciprofloxacin hcl oral tablet ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon levofloxacin in d5w intravenous piggyback 500 mg/100 ml 1 $0 B/D PA 1 $0 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 13

25 levofloxacin intravenous solution 1 $0 B/D PA; MO levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet ofloxacin oral tablet 400 mg 1 $0 磺胺製劑 / 相關製劑 sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution sulfamethoxazole-trimethoprim oral suspension 1 $0 B/D PA; MO sulfamethoxazole-trimethoprim oral tablet 四環素 demeclocycline oral tablet doxy-100 intravenous recon soln 1 $0 B/D PA; MO doxycycline hyclate intravenous recon soln 1 $0 B/D PA doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet 50 mg 1 $0 doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 24 hr morgidox oral capsule ORACEA ORAL CAPSULE,IR & DELAY REL,BIPHASE 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 14

26 tetracycline oral capsule 尿道製劑 methenamine hippurate oral tablet nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg 1 $0 PA; MO nitrofurantoin monohyd/m-cryst oral capsule 1 $0 PA; MO trimethoprim oral tablet 萬古黴素 vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg VANCOMYCIN INTRAVENOUS RECON SOLN 750 MG 1 $0 B/D PA; MO 1 $0 B/D PA; MO VANCOMYCIN ORAL CAPSULE 抗腫瘤藥 / 免疫抑制劑 輔助劑 AMIFOSTINE CRYSTALLINE INTRAVENOUS RECON SOLN dexrazoxane hcl intravenous recon soln 250 mg ELITEK INTRAVENOUS RECON SOLN 1.5 MG leucovorin calcium injection recon soln 100 mg, 350 mg 2 $0 B/D PA; MO 1 $0 B/D PA 2 $0 B/D PA 1 $0 B/D PA; MO leucovorin calcium oral tablet LEVOLEUCOVORIN CALCIUM INTRAVENOUS SOLUTION 2 $0 B/D PA mesna intravenous solution 1 $0 B/D PA; MO MESNEX ORAL TABLET XGEVA SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO 抗腫瘤藥 / 免疫抑制劑 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 15

27 ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO adrucil intravenous solution 500 mg/10 ml 1 $0 B/D PA; MO AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 $0 PA; MO AFINITOR ORAL TABLET 2 $0 PA; MO ALIMTA INTRAVENOUS RECON SOLN 500 MG 2 $0 B/D PA; MO anastrozole oral tablet ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 2 $0 B/D PA; MO AVASTIN INTRAVENOUS SOLUTION 2 $0 B/D PA; MO AZACITIDINE INJECTION RECON SOLN AZASAN ORAL TABLET 2 $0 B/D PA; MO azathioprine oral tablet 1 $0 B/D PA; MO BELEODAQ INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO bicalutamide oral tablet BICNU INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO bleomycin injection recon soln 30 unit 1 $0 B/D PA; MO BOSULIF ORAL TABLET 2 $0 PA; MO BUSULFEX INTRAVENOUS SOLUTION 2 $0 B/D PA CAPRELSA ORAL TABLET carboplatin intravenous solution 1 $0 B/D PA; MO CELLCEPT INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO cisplatin intravenous solution 1 $0 B/D PA; MO cladribine intravenous solution 1 $0 B/D PA; MO COMETRIQ ORAL CAPSULE 2 $0 PA; MO CYCLOPHOSPHAMIDE ORAL CAPSULE 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 16

28 cyclosporine intravenous solution 1 $0 B/D PA cyclosporine modified oral capsule 1 $0 B/D PA; MO cyclosporine modified oral solution 1 $0 B/D PA; MO cyclosporine oral capsule 1 $0 B/D PA; MO cytarabine injection solution 1 $0 B/D PA; MO dacarbazine intravenous recon soln 200 mg 1 $0 B/D PA; MO daunorubicin intravenous solution 1 $0 B/D PA DAUNOXOME INTRAVENOUS SOLUTION DECITABINE INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO doxorubicin intravenous solution 50 mg/25 ml 1 $0 B/D PA; MO DROXIA ORAL CAPSULE ELIGARD SUBCUTANEOUS SYRINGE 2 $0 PA; MO EMCYT ORAL CAPSULE EPIRUBICIN INTRAVENOUS SOLUTION 50 MG/25 ML 2 $0 B/D PA; MO ERIVEDGE ORAL CAPSULE 2 $0 PA; MO ERWINAZE INTRAMUSCULAR RECON SOLN 2 $0 PA; MO etoposide intravenous solution 1 $0 B/D PA; MO exemestane oral tablet FARESTON ORAL TABLET FARYDAK ORAL CAPSULE 2 $0 PA; MO FASLODEX INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO FLUDARABINE INTRAVENOUS RECON SOLN fluorouracil intravenous solution 2.5 gram/50 ml 2 $0 B/D PA; MO 1 $0 B/D PA; MO flutamide oral capsule GAZYVA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO GEMCITABINE INTRAVENOUS RECON SOLN 1 GRAM 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 17

29 gengraf oral capsule 1 $0 B/D PA; MO gengraf oral solution 1 $0 B/D PA; MO GILOTRIF ORAL TABLET 2 $0 PA; MO GLEEVEC ORAL TABLET 100 MG 2 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 18 GLEEVEC ORAL TABLET 400 MG 2 $0 PA; MO; QL (60 per 30 days) GLEOSTINE ORAL CAPSULE HERCEPTIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO HEXALEN ORAL CAPSULE hydroxyurea oral capsule IBRANCE ORAL CAPSULE 2 $0 PA; MO; QL (21 per 28 days) ICLUSIG ORAL TABLET 2 $0 PA; MO idarubicin intravenous solution 1 $0 B/D PA IFOSFAMIDE INTRAVENOUS RECON SOLN 1 GRAM 2 $0 B/D PA; MO IMBRUVICA ORAL CAPSULE 2 $0 PA; MO INLYTA ORAL TABLET 2 $0 PA; MO IRINOTECAN INTRAVENOUS SOLUTION 100 MG/5 ML 2 $0 B/D PA; MO ISTODAX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG 2 $0 PA; MO JAKAFI ORAL TABLET 25 MG 2 $0 PA; MO; QL (60 per 30 days) KADCYLA INTRAVENOUS RECON SOLN 100 MG 2 $0 B/D PA; MO KEYTRUDA INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO LENVIMA ORAL CAPSULE 2 $0 PA; MO letrozole oral tablet LEUKERAN ORAL TABLET leuprolide subcutaneous kit

30 LOMUSTINE ORAL CAPSULE LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO LYNPARZA ORAL CAPSULE 2 $0 PA; MO LYSODREN ORAL TABLET MATULANE ORAL CAPSULE megestrol oral tablet 1 $0 PA; MO MEKINIST ORAL TABLET 2 $0 PA; MO melphalan hcl intravenous recon soln 1 $0 B/D PA mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln 1 $0 B/D PA methotrexate sodium (pf) injection solution 1 $0 B/D PA; MO methotrexate sodium oral tablet 1 $0 B/D PA; MO mitomycin intravenous recon soln 20 mg 1 $0 B/D PA; MO mitoxantrone intravenous concentrate 1 $0 B/D PA; MO MUSTARGEN INJECTION RECON SOLN 2 $0 B/D PA; MO mycophenolate mofetil oral capsule 1 $0 B/D PA; MO mycophenolate mofetil oral suspension for reconstitution 1 $0 B/D PA; MO mycophenolate mofetil oral tablet 1 $0 B/D PA; MO mycophenolate sodium oral tablet,delayed release (dr/ec) 1 $0 B/D PA; MO NEORAL ORAL CAPSULE 2 $0 B/D PA; MO NEORAL ORAL SOLUTION 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 19

31 NEXAVAR ORAL TABLET 2 $0 PA; MO NILANDRON ORAL TABLET NULOJIX INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO OCTREOTIDE ACETATE INJECTION SOLUTION 1,000 MCG/ML, 500 MCG/ML octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) 2 $0 PA; MO 1 $0 PA; MO 1 $0 PA; MO 2 $0 PA; MO ONCASPAR INJECTION SOLUTION 2 $0 PA; MO OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML OXALIPLATIN INTRAVENOUS SOLUTION 100 MG/20 ML PACLITAXEL INTRAVENOUS CONCENTRATE 2 $0 PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO PERJETA INTRAVENOUS SOLUTION 2 $0 B/D PA; MO POMALYST ORAL CAPSULE 2 $0 PA; MO PURIXAN ORAL SUSPENSION RAPAMUNE ORAL SOLUTION 2 $0 B/D PA; MO RAPAMUNE ORAL TABLET 2 $0 B/D PA; MO REVLIMID ORAL CAPSULE 2 $0 PA; MO; LA RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG (DOSE PACK 12), 2.5 MG (DOSE PACK 16), 2.5 MG (DOSE PACK 20), 2.5 MG (DOSE PACK 8) 2 $0 B/D PA; MO 2 $0 B/D PA RITUXAN INTRAVENOUS CONCENTRATE 2 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 20

32 SANDIMMUNE ORAL CAPSULE 2 $0 B/D PA; MO SANDIMMUNE ORAL SOLUTION 2 $0 B/D PA; MO SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 2 $0 PA; MO SIGNIFOR SUBCUTANEOUS SOLUTION 2 $0 PA; MO SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PA; MO sirolimus oral tablet 1 $0 B/D PA; MO SOLTAMOX ORAL SOLUTION SOMATULINE DEPOT SUBCUTANEOUS SYRINGE SPRYCEL ORAL TABLET 100 MG, 140 MG, 80 MG 2 $0 B/D PA; MO 2 $0 PA; MO; QL (30 per 30 days) SPRYCEL ORAL TABLET 20 MG, 50 MG 2 $0 PA; MO SPRYCEL ORAL TABLET 70 MG 2 $0 PA; MO; QL (60 per 30 days) STIVARGA ORAL TABLET 2 $0 PA; MO SUTENT ORAL CAPSULE 2 $0 PA; MO SYNRIBO SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO TABLOID ORAL TABLET tacrolimus oral capsule 0.5 mg, 1 mg 1 $0 B/D PA; MO TACROLIMUS ORAL CAPSULE 5 MG 2 $0 B/D PA; MO TAFINLAR ORAL CAPSULE 2 $0 PA; MO tamoxifen oral tablet TARCEVA ORAL TABLET 100 MG, 25 MG 2 $0 PA; MO TARCEVA ORAL TABLET 150 MG 2 $0 PA; MO; QL (30 per 30 days) TARGRETIN ORAL CAPSULE 2 $0 PA; MO TARGRETIN TOPICAL GEL TASIGNA ORAL CAPSULE 2 $0 PA; MO THALOMID ORAL CAPSULE 2 $0 PA; MO toposar intravenous solution 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 21

33 TOPOTECAN INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRETINOIN (CHEMOTHERAPY) ORAL CAPSULE 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO TRISENOX INTRAVENOUS SOLUTION 2 $0 B/D PA; MO TYKERB ORAL TABLET 2 $0 PA; MO VELCADE INJECTION RECON SOLN 2 $0 B/D PA; MO VINBLASTINE INTRAVENOUS SOLUTION 2 $0 B/D PA; MO vincasar pfs intravenous solution 1 mg/ml 1 $0 B/D PA vincristine intravenous solution 1 mg/ml 1 $0 B/D PA; MO vinorelbine intravenous solution 50 mg/5 ml 1 $0 B/D PA; MO VOTRIENT ORAL TABLET 2 $0 PA; MO XALKORI ORAL CAPSULE 2 $0 PA; MO XTANDI ORAL CAPSULE 2 $0 PA; MO; QL (120 per 30 days) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) 2 $0 PA; MO 2 $0 B/D PA; MO ZELBORAF ORAL TABLET 2 $0 PA; MO ZOLINZA ORAL CAPSULE ZORTRESS ORAL TABLET 2 $0 B/D PA; MO ZYDELIG ORAL TABLET 2 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 22

34 ZYKADIA ORAL CAPSULE 2 $0 PA; MO; QL (150 per 30 days) ZYTIGA ORAL TABLET 植物神經 / 中樞神經系統藥物 神經病學 / 心理學 抗痙攣劑 APTIOM ORAL TABLET 2 $0 PA; MO BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 2 $0 PA; MO carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 1 $0 PA; MO clonazepam oral tablet,disintegrating 1 $0 PA; MO DIASTAT RECTAL KIT 2 $0 PA; MO diazepam rectal kit 1 $0 PA; MO DILANTIN 30 MG ORAL CAPSULE divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 23

35 fosphenytoin injection solution 100 mg pe/2 ml 1 $0 B/D PA; MO FYCOMPA ORAL TABLET 2 $0 PA; MO gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack 25 mg (35) 1 $0 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 1 $0 B/D PA 1 $0 B/D PA; MO levetiracetam intravenous solution 1 $0 B/D PA; MO levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION 2 $0 PA; MO ONFI ORAL TABLET 10 MG, 20 MG 2 $0 PA; MO oxcarbazepine oral suspension oxcarbazepine oral tablet PEGANONE ORAL TABLET phenobarbital oral elixir 1 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 24

36 phenobarbital oral tablet 100 mg 1 $0 PA phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 $0 PA; MO PHENYTEK ORAL CAPSULE phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule phenytoin sodium intravenous solution 1 $0 B/D PA; MO phenytoin sodium intravenous syringe 1 $0 B/D PA POTIGA ORAL TABLET 2 $0 PA; MO primidone oral tablet SABRIL ORAL POWDER IN PACKET 2 $0 PA; MO SABRIL ORAL TABLET 2 $0 PA; MO TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG tiagabine oral tablet topiramate oral capsule, sprinkle 1 $0 PA; MO TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR 2 $0 PA; MO topiramate oral tablet 1 $0 PA; MO valproate sodium intravenous solution 1 $0 B/D PA; MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule VIMPAT INTRAVENOUS SOLUTION 2 $0 PA VIMPAT ORAL SOLUTION 2 $0 PA; MO VIMPAT ORAL TABLET 2 $0 PA; MO zonisamide oral capsule 1 $0 PA; MO 抗帕金森病藥劑 APOKYN SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO AZILECT ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 25

37 benztropine injection solution 1 $0 B/D PA; MO benztropine oral tablet 1 $0 PA; MO bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet entacapone oral tablet NEUPRO TRANSDERMAL PATCH 24 HOUR 2 $0 PA; MO pramipexole oral tablet pramipexole oral tablet extended release 24 hr mg, 0.75 mg, 1.5 mg ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet tolcapone oral tablet trihexyphenidyl oral elixir 1 $0 PA; MO trihexyphenidyl oral tablet 1 $0 PA; MO 偏頭痛 / 叢集性頭痛治療 dihydroergotamine injection solution migergot rectal suppository sumatriptan nasal spray,non-aerosol 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 26 naratriptan oral tablet ; QL (18 per 28 days) rizatriptan oral tablet ; QL (36 per 30 days) rizatriptan oral tablet,disintegrating ; QL (36 per 30 days)

38 sumatriptan succinate oral tablet ; QL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector ; QL (10 per 30 days) ; QL (10 per 30 days) sumatriptan succinate subcutaneous solution ; QL (10 per 30 days) zolmitriptan oral tablet ; QL (12 per 30 days) zolmitriptan oral tablet,disintegrating ; QL (12 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 2 $0 PA; MO 2 $0 PA; MO; QL (30 per 30 days) 2 $0 PA; MO; QL (12 per 28 days) donepezil oral tablet ; QL (30 per 30 days) donepezil oral tablet,disintegrating ; QL (30 per 30 days) EXELON TRANSDERMAL PATCH 24 HOUR ; QL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr ; QL (30 per 30 days) galantamine oral solution galantamine oral tablet GILENYA ORAL CAPSULE GLATOPA SUBCUTANEOUS SYRINGE 2 $0 PA; MO HORIZANT ORAL TABLET EXTENDED RELEASE NAMENDA ORAL SOLUTION 2 $0 PA; MO NAMENDA ORAL TABLET 2 $0 PA; MO NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK 2 $0 PA; MO NUEDEXTA ORAL CAPSULE rivastigmine tartrate oral capsule 1.5 mg ; QL (240 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 27

39 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 28 rivastigmine tartrate oral capsule 3 mg ; QL (120 per 30 days) rivastigmine tartrate oral capsule 4.5 mg, 6 mg TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) ; QL (60 per 30 days) TYSABRI INTRAVENOUS SOLUTION 2 $0 PA; MO XENAZINE ORAL TABLET 2 $0 PA; MO; LA 肌鬆藥 / 解痙藥治療 baclofen oral tablet cyclobenzaprine oral tablet 1 $0 PA; MO dantrolene oral capsule meprobamate oral tablet 1 $0 PA; MO MESTINON ORAL SYRUP MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE metaxalone oral tablet 1 $0 PA; MO pyridostigmine bromide oral tablet regonol injection solution 2 $0 B/D PA tizanidine oral capsule tizanidine oral tablet 麻醉止痛劑 acetaminophen-codeine oral solution 300 mg- 30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg 1 $0 QL (4500 per 30 days) ; QL (360 per 30 days) acetaminophen-codeine oral tablet mg ; QL (180 per 30 days) buprenorphine hcl injection syringe 1 $0 B/D PA; QL (267 per 30 days) buprenorphine hcl sublingual tablet 2 mg ; QL (300 per 30 days) buprenorphine hcl sublingual tablet 8 mg ; QL (75 per 30 days)

40 butalbital-acetaminop-caf-cod oral capsule 1 $0 PA; MO; QL (360 per 30 days) codeine sulfate oral tablet ; QL (180 per 30 days) diskets oral tablet,soluble 1 $0 QL (30 per 30 days) DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML DURAMORPH (PF) INJECTION SOLUTION 1 MG/ML endocet oral tablet mg, mg, mg 2 $0 B/D PA; MO; QL (4000 per 30 days) 2 $0 B/D PA; QL (2000 per 30 days) ; QL (360 per 30 days) endocet oral tablet mg 1 $0 QL (360 per 30 days) FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1,200 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 1,600 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 200 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 400 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 600 MCG FENTANYL CITRATE BUCCAL LOZENGE ON A HANDLE 800 MCG fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg 2 $0 PA; MO; QL (39 per 30 days) 2 $0 PA; MO; QL (29 per 30 days) 2 $0 PA; MO; QL (120 per 30 days) 2 $0 PA; MO; QL (116 per 30 days) 2 $0 PA; MO; QL (77 per 30 days) 2 $0 PA; MO; QL (58 per 30 days) ; QL (9 per 30 days) ; QL (10 per 30 days) 1 $0 QL (5550 per 30 days) ; QL (5550 per 30 days) ; QL (360 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 29

41 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 30 hydrocodone-ibuprofen oral tablet ; QL (50 per 30 days) hydromorphone (pf) injection solution 10 mg/ml 1 $0 B/D PA; MO; QL (120 per 30 days) hydromorphone oral liquid ; QL (1500 per 30 days) hydromorphone oral tablet ; QL (180 per 30 days) ibuprofen-oxycodone oral tablet ; QL (28 per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG ; QL (60 per 30 days) levorphanol tartrate oral tablet ; QL (120 per 30 days) methadone injection solution 1 $0 B/D PA; QL (160 per 30 days) methadone intensol oral concentrate ; QL (120 per 30 days) methadone oral concentrate ; QL (120 per 30 days) methadone oral solution 10 mg/5 ml ; QL (600 per 30 days) methadone oral solution 5 mg/5 ml ; QL (1200 per 30 days) methadone oral tablet 10 mg ; QL (120 per 30 days) methadone oral tablet 5 mg ; QL (240 per 30 days) methadone oral tablet,soluble 1 $0 QL (30 per 30 days) methadose oral concentrate ; QL (120 per 30 days) methadose oral tablet,soluble ; QL (30 per 30 days) morphine (pf) injection solution 0.5 mg/ml 1 $0 B/D PA; QL (2400 per 30 days) morphine (pf) injection solution 1 mg/ml 1 $0 B/D PA; MO; QL (1200 per 30 days) morphine concentrate oral solution ; QL (300 per 30 days) morphine intravenous syringe 10 mg/ml 1 $0 B/D PA; QL (200 per 30 days) morphine intravenous syringe 8 mg/ml 1 $0 B/D PA; QL (250 per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg ; QL (50 per 30 days) ; QL (60 per 30 days)

42 morphine oral capsule,extend.release pellets ; QL (60 per 30 days) morphine oral solution ; QL (900 per 30 days) morphine oral tablet ; QL (180 per 30 days) morphine oral tablet extended release 100 mg ; QL (60 per 30 days) morphine oral tablet extended release 15 mg, 30 mg, 60 mg ; QL (90 per 30 days) morphine oral tablet extended release 200 mg ; QL (30 per 30 days) oxycodone oral capsule ; QL (360 per 30 days) oxycodone oral concentrate ; QL (180 per 30 days) oxycodone oral solution ; QL (1200 per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg ; QL (180 per 30 days) oxycodone oral tablet 30 mg ; QL (134 per 30 days) oxycodone oral tablet 5 mg ; QL (360 per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg ; QL (360 per 30 days) oxycodone-aspirin oral tablet ; QL (360 per 30 days) oxymorphone oral tablet 10 mg ; QL (200 per 30 days) oxymorphone oral tablet 5 mg ; QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg ; QL (90 per 30 days) ; QL (67 per 30 days) ; QL (50 per 30 days) reprexain oral tablet ; QL (50 per 30 days) zamicet oral solution 1 $0 QL (5550 per 30 days) 非麻醉性止痛劑 ACEPHEN RECTAL SUPPOSITORY 120 MG, 650 MG 4 $0 MO; * ACEPHEN RECTAL SUPPOSITORY 325 MG acetadryl oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 31

43 acetaminophen extra strength oral tablet acetaminophen oral drops,suspension acetaminophen oral liquid acetaminophen oral tablet 4 $0 MO; * acetaminophen pm extra str oral tablet acetaminophen pm oral tablet acetaminophen rectal suppository 120 mg, 650 mg added strength headache relief oral tablet ADDED STRENGTH PAIN RELIEVER ORAL TABLET adult low dose aspirin oral tablet,delayed release (dr/ec) 4 $0 MO; * aspir-81 oral tablet,delayed release (dr/ec) aspirin childrens oral tablet,chewable aspirin low dose oral tablet,delayed release (dr/ec) 4 $0 MO; * aspirin low-strength oral tablet,chewable aspirin oral tablet 325 mg 4 $0 MO; * aspirin oral tablet,chewable 4 $0 MO; * aspirin oral tablet,delayed release (dr/ec) 325 mg, 500 mg, 81 mg aspirin oral tablet,delayed release (dr/ec) 650 mg 4 $0 MO; * aspirin rectal suppository 4 $0 MO; * aspirin, buffered oral tablet aspir-trin oral tablet,delayed release (dr/ec) 4 $0 MO; * athenol oral tablet bayer advanced oral tablet bayer aspirin oral tablet 4 $0 MO; * 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 32

44 bufferin oral tablet 325 mg buprenorphine-naloxone sublingual tablet ; QL (90 per 30 days) butorphanol tartrate injection solution 1 mg/ml ; QL (720 per 30 days) butorphanol tartrate injection solution 2 mg/ml ; QL (360 per 30 days) butorphanol tartrate nasal spray,non-aerosol ; QL (40 per 30 days) celecoxib oral capsule child aspirin oral tablet,chewable child pain rel-fever reducer rectal suppository children's aspirin oral tablet,chewable 4 $0 MO; * children's fever reducing rectal suppository children's pain relief oral liquid children's silapap oral liquid diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical drops diclofenac-misoprostol oral tablet,ir & delay rel,biphasic diflunisal oral tablet diphenhydramine-acetaminophen oral tablet e.c. prin oral tablet,delayed release (dr/ec) ecotrin low strength oral tablet,delayed release (dr/ec) enteric coated aspirin oral tablet,delayed release (dr/ec) 4 $0 MO; * etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr ex-strength medi-tabs oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 33

45 ex-strength medi-tabs pm oral tablet fenoprofen oral tablet fever reducer rectal suppository feverall rectal suppository 120 mg, 325 mg, 650 mg flurbiprofen oral tablet headache formula added str oral tablet headache formula oral tablet headache pm oral tablet headache relief (asa-acet-caf) oral tablet ibu-drops oral drops,suspension ibuprofen ib oral tablet ibuprofen oral capsule ibuprofen oral drops,suspension ibuprofen oral suspension ibuprofen oral tablet 100 mg ibuprofen oral tablet 200 mg 4 $0 MO; * ibuprofen oral tablet 400 mg, 600 mg, 800 mg infants ibu-drops oral drops,suspension infant's ibuprofen oral drops,suspension INFANT'S MEDI-PROFEN ORAL DROPS,SUSPENSION infant's non-aspirin oral drops,suspension INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML infant's pain reliever oral drops,suspension infants profenib oral drops,suspension i-prin oral tablet ketoprofen oral capsule 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 34

46 ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg lite coat aspirin oral tablet lo-dose aspirin oral tablet,delayed release (dr/ec) MAPAP (ACETAMINOPHEN) ORAL CAPSULE 4 $0 MO; * masophen oral tablet meclofenamate oral capsule medi-profen oral tablet medi-tabs oral tablet medi-tabs pm oral tablet mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet migraine formula oral tablet migraine pain reliever oral tablet migraine relief oral tablet nabumetone oral tablet nalbuphine injection solution 10 mg/ml 1 $0 B/D PA; MO; QL (200 per 30 days) nalbuphine injection solution 20 mg/ml 1 $0 B/D PA; MO; QL (100 per 30 days) naloxone injection syringe 1 mg/ml naltrexone oral tablet NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg non-aspirin extra strength oral capsule non-aspirin extra strength oral liquid 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 35

47 non-aspirin extra strength oral tablet non-aspirin nightime oral tablet non-aspirin oral tablet non-aspirin pain relief oral tablet 500 mg non-aspirin pain relief pm oral tablet non-aspirin pm oral tablet NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR NUCYNTA ORAL TABLET oxaprozin oral tablet pain relief adult oral liquid pain relief extra strength oral tablet pain relief oral capsule pain relief oral liquid pain relief oral tablet 500 mg pain relief pm oral tablet pain relief pm rapid release oral tablet pain relief regular strength oral tablet pain reliever (acetam-aspirin) oral tablet pain reliever extra strength oral tablet pain reliever oral capsule pain reliever oral tablet pain reliever pm ex-strength oral tablet pain reliever pm oral tablet mg pain-off oral tablet pamprin max oral tablet percogesic extra strength oral tablet 4 $0 MO; * percogesic oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 36

48 pharbetol oral tablet piroxicam oral capsule provil oral tablet severe allergy oral tablet SUBOXONE SUBLINGUAL FILM 12-3 MG ; QL (60 per 30 days) SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG sulindac oral tablet super pain relief oral tablet tactinal extra strength oral tablet tactinal oral tablet tolmetin oral capsule tolmetin oral tablet ; QL (90 per 30 days) tramadol oral tablet ; QL (240 per 30 days) tramadol oral tablet extended release 24 hr 100 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg ; QL (30 per 30 days) ; QL (30 per 30 days) tramadol-acetaminophen oral tablet ; QL (240 per 30 days) TRI-BUFFERED ASPIRIN ORAL TABLET 4 $0 MO; * tylophen oral capsule VOLTAREN GEL TOPICAL GEL 1 % 2 $0 ST; MO wal-profen oral capsule wal-profen oral tablet 心理治療藥物 ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ; QL (90 per 30 days) 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 37

49 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 2 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 38 ABILIFY ORAL TABLET 10 MG ; QL (90 per 30 days) ABILIFY ORAL TABLET 15 MG, 20 MG ; QL (60 per 30 days) ABILIFY ORAL TABLET 2 MG ; QL (450 per 30 days) ABILIFY ORAL TABLET 30 MG ; QL (30 per 30 days) ABILIFY ORAL TABLET 5 MG ; QL (180 per 30 days) alprazolam oral tablet 1 $0 PA; MO alprazolam oral tablet extended release 24 hr 1 $0 PA; MO alprazolam oral tablet,disintegrating 1 $0 PA; MO amitriptyline oral tablet 1 $0 PA; MO amoxapine oral tablet amphetamine salt combo oral tablet aripiprazole oral tablet 10 mg ; QL (90 per 30 days) aripiprazole oral tablet 15 mg ; QL (60 per 30 days) aripiprazole oral tablet 2 mg ; QL (450 per 30 days) ARIPIPRAZOLE ORAL TABLET 20 MG ; QL (60 per 30 days) ARIPIPRAZOLE ORAL TABLET 30 MG ; QL (30 per 30 days) aripiprazole oral tablet 5 mg ; QL (180 per 30 days) BRINTELLIX ORAL TABLET BRISDELLE ORAL CAPSULE bupropion hcl oral tablet bupropion hcl oral tablet extended release bupropion hcl oral tablet extended release 24 hr buspirone oral tablet chlorpromazine injection solution chlorpromazine oral tablet citalopram oral solution

50 citalopram oral tablet clomipramine oral capsule 1 $0 PA; MO clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium oral tablet 1 $0 PA; MO clozapine oral tablet 100 mg, 25 mg, 50 mg clozapine oral tablet 200 mg 1 $0 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG 1 $0 2 $0 desipramine oral tablet dexmethylphenidate oral capsule,er biphasic dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr diazepam intensol oral concentrate 1 $0 PA; MO diazepam oral solution 5 mg/5 ml 1 $0 PA; MO diazepam oral tablet 1 $0 PA; MO doxepin oral capsule 1 $0 PA; MO doxepin oral concentrate 1 $0 PA; MO duloxetine oral capsule,delayed release(dr/ec) EMSAM TRANSDERMAL PATCH 24 HOUR ergoloid oral tablet 1 $0 PA; MO escitalopram oxalate oral solution escitalopram oxalate oral tablet eszopiclone oral tablet ; QL (30 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 39

51 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 40 FANAPT ORAL TABLET ; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE PACK ; QL (8 per 28 days) FAZACLO ORAL TABLET,DISINTEGRATING 150 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 2 $0 fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG ; QL (30 per 30 days) ; QL (30 per 30 days) fluphenazine decanoate injection solution 1 $0 B/D PA; MO fluphenazine hcl injection solution 1 $0 B/D PA; MO fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR GEODON INTRAMUSCULAR RECON SOLN 2 $0 B/D PA; MO guanfacine oral tablet extended release 24 hr guanidine oral tablet haloperidol decanoate intramuscular solution 1 $0 B/D PA; MO haloperidol lactate injection solution 1 $0 B/D PA; MO haloperidol lactate oral concentrate haloperidol oral tablet

52 HETLIOZ ORAL CAPSULE 2 $0 PA; MO; QL (30 per 30 days) imipramine hcl oral tablet 1 $0 PA; MO imipramine pamoate oral capsule 1 $0 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE IRENKA ORAL CAPSULE,DELAYED RELEASE(DR/EC) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR ; QL (30 per 30 days) ; QL (60 per 30 days) 2 $0 B/D PA; MO 2 $0 B/D PA; MO LATUDA ORAL TABLET lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution 8 meq/5 ml lorazepam intensol oral concentrate 1 $0 PA; MO lorazepam oral tablet 1 $0 PA; MO loxapine succinate oral capsule maprotiline oral tablet MARPLAN ORAL TABLET metadate er oral tablet extended release methamphetamine oral tablet methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 41

53 methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil oral tablet 1 $0 PA; MO nefazodone oral tablet nortriptyline oral capsule nortriptyline oral solution olanzapine intramuscular recon soln olanzapine oral tablet olanzapine oral tablet,disintegrating olanzapine-fluoxetine oral capsule ORAP ORAL TABLET oxazepam oral capsule 1 $0 PA; MO paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL ORAL SUSPENSION perphenazine oral tablet perphenazine-amitriptyline oral tablet 1 $0 PA; MO phenelzine oral tablet PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR protriptyline oral tablet quetiapine oral tablet RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 42

54 risperidone oral solution risperidone oral tablet risperidone oral tablet,disintegrating ROZEREM ORAL TABLET ; QL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR ; QL (60 per 30 days) sertraline oral concentrate sertraline oral tablet STRATTERA ORAL CAPSULE SURMONTIL ORAL CAPSULE 2 $0 PA; MO temazepam oral capsule 1 $0 PA; MO thioridazine oral tablet 1 $0 PA; MO thiothixene oral capsule tranylcypromine oral tablet trazodone oral tablet trifluoperazine oral tablet venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VERSACLOZ ORAL SUSPENSION 2 $0 VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) ; QL (30 per 30 days) XYREM ORAL SOLUTION ; LA ziprasidone hcl oral capsule 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 43

55 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 44 zolpidem oral tablet ; QL (30 per 30 days) zolpidem oral tablet,ext release multiphase ; QL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG 心血管 高血壓 / 血脂 抗心律失常藥物 2 $0 B/D PA amiodarone intravenous solution 1 $0 B/D PA; MO amiodarone intravenous syringe 1 $0 amiodarone oral tablet flecainide oral tablet mexiletine oral capsule MULTAQ ORAL TABLET pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml 1 $0 propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate injection solution quinidine gluconate oral tablet extended release quinidine sulfate oral tablet sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg 1 $0 sotalol af oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg TIKOSYN ORAL CAPSULE 抗高血壓藥物

56 acebutolol oral capsule afeditab cr oral tablet extended release amiloride oral tablet amiloride-hydrochlorothiazide oral tablet amlodipine oral tablet amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet amlodipine-valsartan-hcthiazid oral tablet atenolol oral tablet atenolol-chlorthalidone oral tablet AZOR ORAL TABLET benazepril oral tablet benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET BENICAR ORAL TABLET ; QL (30 per 30 days) betaxolol oral tablet bisoprolol fumarate oral tablet bisoprolol-hydrochlorothiazide oral tablet bumetanide injection solution bumetanide oral tablet BYSTOLIC ORAL TABLET candesartan oral tablet candesartan-hydrochlorothiazid oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet cartia xt oral capsule,extended release 24hr carvedilol oral tablet chlorothiazide oral tablet chlorothiazide sodium intravenous recon soln 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 45

57 chlorthalidone oral tablet 25 mg, 50 mg clonidine hcl oral tablet clonidine transdermal patch weekly COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 2 $0 ST; MO DEMSER ORAL CAPSULE 2 $0 PA; MO diltiazem hcl intravenous recon soln 1 $0 B/D PA diltiazem hcl intravenous solution 1 $0 B/D PA diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg 1 $0 dilt-xr oral capsule,ext release degradable doxazosin oral tablet enalapril maleate oral tablet enalapril-hydrochlorothiazide oral tablet EPANED ORAL RECON SOLN eplerenone oral tablet eprosartan oral tablet felodipine oral tablet extended release 24 hr fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet furosemide injection solution 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 46

58 furosemide injection syringe 1 $0 B/D PA; MO furosemide oral solution 10 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine injection solution 1 $0 B/D PA; MO hydralazine oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide oral tablet irbesartan oral tablet irbesartan-hydrochlorothiazide oral tablet isradipine oral capsule labetalol intravenous solution 1 $0 B/D PA; MO labetalol intravenous syringe 20 mg/4 ml (5 mg/ml) 1 $0 B/D PA labetalol oral tablet lisinopril oral tablet lisinopril-hydrochlorothiazide oral tablet losartan oral tablet losartan-hydrochlorothiazide oral tablet matzim la oral tablet extended release 24 hr methyclothiazide oral tablet methyldopa-hydrochlorothiazide oral tablet 1 $0 PA; MO metolazone oral tablet metoprolol succinate oral tablet extended release 24 hr metoprolol ta-hydrochlorothiaz oral tablet metoprolol tartrate intravenous solution 1 $0 B/D PA; MO metoprolol tartrate oral tablet minoxidil oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 47

59 moexipril oral tablet moexipril-hydrochlorothiazide oral tablet nadolol oral tablet nadolol-bendroflumethiazide oral tablet nicardipine intravenous solution nicardipine oral capsule nifedical xl oral tablet extended release 24hr nifedipine oral tablet extended release 24hr nimodipine oral capsule perindopril erbumine oral tablet pindolol oral tablet prazosin oral capsule propranolol intravenous solution 1 $0 B/D PA propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid oral tablet quinapril oral tablet quinapril-hydrochlorothiazide oral tablet ramipril oral capsule REMODULIN INJECTION SOLUTION 2 $0 B/D PA; MO reserpine oral tablet 1 $0 PA; MO spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet taztia xt oral capsule, extended release TEKAMLO ORAL TABLET TEKTURNA HCT ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 48

60 TEKTURNA ORAL TABLET telmisartan oral tablet telmisartan-hydrochlorothiazid oral tablet terazosin oral capsule timolol maleate oral tablet torsemide oral tablet trandolapril oral tablet trandolapril-verapamil oral tablet, ir & er, biphasic 24hr triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet valsartan oral tablet valsartan-hydrochlorothiazide oral tablet verapamil intravenous solution 1 $0 B/D PA; MO verapamil intravenous syringe 1 $0 B/D PA verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release 強心苷類 digitek oral tablet 1 $0 PA; MO digox oral tablet digoxin injection solution 1 $0 PA; MO digoxin oral solution 50 mcg/ml 1 $0 PA; MO digoxin oral tablet 1 $0 PA; MO LANOXIN ORAL TABLET 2 $0 PA; MO 凝血治療 AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR BRILINTA ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 49

61 cilostazol oral tablet clopidogrel oral tablet 300 mg ; QL (1 per 30 days) clopidogrel oral tablet 75 mg COUMADIN ORAL TABLET EFFIENT ORAL TABLET ELIQUIS ORAL TABLET enoxaparin subcutaneous solution ; QL (180 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml ; QL (60 per 30 days) ENOXAPARIN SUBCUTANEOUS SYRINGE 120 MG/0.8 ML ENOXAPARIN SUBCUTANEOUS SYRINGE 150 MG/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 enoxaparin subcutaneous syringe 80 mg/0.8 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 ; QL (48 per 30 days) ; QL (60 per 30 days) ; QL (18 per 30 days) ; QL (24 per 30 days) ; QL (36 per 30 days) ; QL (48 per 30 days) ; QL (24 per 30 days) ; QL (15 per 30 days) ; QL (12 per 30 days) ; QL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION ; QL (30 per 30 days) FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML ; QL (30 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 50

62 FRAGMIN SUBCUTANEOUS SYRINGE 12,500 ANTI-XA UNIT/0.5 ML FRAGMIN SUBCUTANEOUS SYRINGE 15,000 ANTI-XA UNIT/0.6 ML FRAGMIN SUBCUTANEOUS SYRINGE 18,000 ANTI-XA UNIT/0.72 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 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) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) in nacl (pf) intravenous parenteral solution 2,000 unit/1,000 ml ; QL (15 per 30 days) ; QL (18 per 30 days) ; QL (21.6 per 30 days) ; QL (6 per 30 days) ; QL (9 per 30 days) 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 2 $0 B/D PA heparin (porcine) injection solution 1 $0 B/D PA; MO heparin, porcine (pf) injection syringe 1 $0 B/D PA; MO jantoven oral tablet MEPHYTON ORAL TABLET 3 $0 MO; * pentoxifylline oral tablet extended release PRADAXA ORAL CAPSULE 2 $0 ST; MO PROMACTA ORAL TABLET 2 $0 PA; MO tranexamic acid intravenous solution 1 $0 B/D PA; MO VITAMIN K INJECTION SOLUTION 3 $0 MO; * VITAMIN K1 INJECTION SOLUTION 3 $0 MO; * warfarin oral tablet XARELTO ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 51

63 XARELTO ORAL TABLETS,DOSE PACK 降血脂 / 膽固醇藥物 amlodipine-atorvastatin oral tablet atorvastatin oral tablet cholestyramine light oral powder in packet colestipol oral granules colestipol oral tablet CRESTOR ORAL TABLET fenofibrate micronized oral capsule fenofibrate nanocrystallized oral tablet fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) fluvastatin oral capsule gemfibrozil oral tablet JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG 2 $0 PA; MO; LA 2 $0 PA; MO lovastatin oral tablet niacin oral tablet 4 $0 MO; * niacin oral tablet extended release 24 hr niacin oral tablet extended release 250 mg, 500 mg, 750 mg 4 $0 MO; * omega-3 acid ethyl esters oral capsule pravastatin oral tablet prevalite oral powder simvastatin oral tablet VYTORIN ORAL TABLET 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 52

64 VYTORIN ORAL TABLET VYTORIN ORAL TABLET VYTORIN ORAL TABLET WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL TABLET ZETIA ORAL TABLET 雜類心血管藥物 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR VECAMYL ORAL TABLET 2 $0 硝酸酯類 ISORDIL ORAL TABLET isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr nitro-bid transdermal ointment nitroglycerin intravenous solution 1 $0 B/D PA nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol NITROSTAT SUBLINGUAL TABLET 皮膚病 / 局部治療 治牛皮癬 / 抗皮脂溢藥物 acitretin oral capsule 10 mg ACITRETIN ORAL CAPSULE 17.5 MG, 25 MG calcipotriene topical cream calcipotriene topical ointment 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 53

65 calcipotriene topical solution calcitrene topical ointment calcitriol topical ointment COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 2 $0 ST; MO 2 $0 ST; MO selenium sulfide topical suspension 燒傷治療 silver sulfadiazine topical cream ssd topical cream 角質離解劑 SAL-PLANT TOPICAL GEL 4 $0 MO; * wart remover topical gel 雜類皮膚病藥物 ammonium lactate topical cream ammonium lactate topical lotion CARAC TOPICAL CREAM diaper rash relief topical ointment diclofenac sodium topical gel 1 $0 PA; MO ELIDEL TOPICAL CREAM 2 $0 ST; MO fluorouracil topical cream fluorouracil topical solution imiquimod topical cream in packet methoxsalen rapid oral capsule PANRETIN TOPICAL GEL podofilox topical solution 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 54 REGRANEX TOPICAL GEL ; QL (30 per 30 days)

66 tacrolimus topical ointment VALCHLOR TOPICAL GEL zinc oxide topical ointment zinc oxide topical ointment 20 % 4 $0 MO; * ZYCLARA TOPICAL CREAM IN METERED- DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN PACKET 痤瘡治療 adapalene topical cream 1 $0 PA; MO adapalene topical gel 1 $0 PA; MO amnesteem oral capsule benzoyl peroxide topical lotion 5 % 4 $0 MO; * claravis oral capsule clindamycin phosphate topical foam clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel 1-5 % ery pads topical swab erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin with ethanol topical swab erythromycin-benzoyl peroxide topical gel metronidazole topical cream metronidazole topical gel metronidazole topical lotion rosadan topical cream rosadan topical gel 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 55

67 TAZORAC TOPICAL CREAM TAZORAC TOPICAL GEL tretinoin microspheres topical gel with pump 1 $0 PA; MO tretinoin topical cream 1 $0 PA; MO tretinoin topical gel 1 $0 PA; MO 局部麻醉劑 lidocaine (pf) injection solution 10 mg/ml (1 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO lidocaine hcl laryngotracheal solution lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % 1 $0 lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl urethral gel 1 $0 lidocaine topical adhesive patch,medicated 1 $0 PA; MO lidocaine topical ointment lidocaine-prilocaine topical cream lta pre-attached laryngotracheal solution 1 $0 局部抗菌藥物 bacitracin topical ointment 4 $0 MO; * bacitracin zinc topical packet bacitraycin plus topical ointment 500 unit/gram gentamicin topical cream 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 56

68 gentamicin topical ointment mupirocin calcium topical cream mupirocin topical ointment sulfacetamide sodium (acne) topical suspension TRIPLE ANTIBIOTIC TOPICAL OINTMENT 4 $0 MO; * 局部抗真菌劑 antifungal (tolnaftate) topical cream ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER 4 $0 MO; * athlete's foot (terbinafine) topical cream athlete's foot (tolnaftate) topical cream athlete's foot af topical cream baza antifungal topical cream 4 $0 MO; * ciclodan topical cream ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension clotrimazole topical cream clotrimazole topical solution clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion econazole topical cream inzo antifungal topical cream jock itch (terbinafine) topical cream ketoconazole topical cream ketoconazole topical shampoo 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 57

69 micatin topical cream miconazole nitrate topical cream 4 $0 MO; * nuzole topical cream nyamyc topical powder nystatin topical cream nystatin topical ointment nystatin topical powder nystatin-triamcinolone topical cream nystatin-triamcinolone topical ointment nystop topical powder podactin topical powder secura antifungal topical cream 4 $0 MO; * tolnaftate topical cream tolnaftate topical powder 局部抗病毒藥物 ABREVA TOPICAL CREAM 4 $0 MO; * acyclovir topical ointment DENAVIR TOPICAL CREAM 局部外用皮質激素 ala-cort topical cream alclometasone topical cream alclometasone topical ointment amcinonide topical cream amcinonide topical lotion amcinonide topical ointment beta-hc topical lotion 4 $0 MO; * betamethasone dipropionate topical cream betamethasone dipropionate topical lotion 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 58

70 betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical foam betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol-emollient topical cream cormax topical solution dermarest eczema (hydrocort) topical lotion desonide topical cream desonide topical lotion desonide topical ointment desoximetasone topical cream desoximetasone topical gel desoximetasone topical ointment diflorasone topical cream diflorasone topical ointment fluocinolone topical cream fluocinolone topical oil fluocinolone topical ointment 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 59

71 fluocinolone topical solution fluocinonide topical cream 0.1 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e topical cream fluticasone topical cream fluticasone topical lotion fluticasone topical ointment halobetasol propionate topical cream halobetasol propionate topical ointment HYDRO SKIN TOPICAL LOTION 4 $0 MO; * hydrocortisone acetate topical cream hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient topical cream hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate topical cream hydrocortisone valerate topical ointment MEDI-CORTISONE TOPICAL CREAM mometasone topical cream mometasone topical ointment mometasone topical solution prednicarbate topical cream prednicarbate topical ointment triamcinolone acetonide topical aerosol 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 60

72 triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex topical ointment triderm topical cream 局部酶 SANTYL TOPICAL OINTMENT 局部滅疥癬藥物 / 滅虱藥物 lice killing (permethrin) topical liquid lice treatment (permethrin) topical liquid LICE TREATMENT TOPICAL LIQUID 1 % lindane topical lotion lindane topical shampoo malathion topical lotion permethrin topical cream permethrin topical liquid 4 $0 MO; * PYRETHRIN LICE TREATMENT M TOPICAL LIQUID 診斷 / 雜類藥劑 沖洗液 lactated ringers irrigation solution neomycin-polymyxin b gu irrigation solution 雜類藥劑 acamprosate oral tablet,delayed release (dr/ec) ADAGEN INTRAMUSCULAR SOLUTION 2 $0 B/D PA; MO alendronate oral tablet 40 mg ; QL (30 per 30 days) anagrelide oral capsule 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 61

73 ARALAST NP INTRAVENOUS RECON SOLN 500 MG 2 $0 B/D PA; MO CARBAGLU ORAL TABLET, DISPERSIBLE 2 $0 PA; MO; LA cevimeline oral capsule CHEMET ORAL CAPSULE CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION d10 % & 0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 10 % in water (d10w) intravenous parenteral solution dextrose 20 % in water (d20w) intravenous parenteral solution dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 40 % in water (d40w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 1 $0 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 62

74 dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA disulfiram oral tablet etidronate disodium oral tablet EXJADE ORAL TABLET, DISPERSIBLE FERRIPROX ORAL TABLET 2 $0 PA; MO FOSRENOL ORAL POWDER IN PACKET 2 $0 FOSRENOL ORAL TABLET,CHEWABLE INCRELEX SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO KIONEX ORAL POWDER levocarnitine (with sugar) oral solution 1 $0 B/D PA; MO levocarnitine intravenous solution 1 $0 B/D PA; MO levocarnitine oral tablet 1 $0 B/D PA; MO midodrine oral tablet NORTHERA ORAL CAPSULE 2 $0 PA; MO pilocarpine hcl oral tablet RAVICTI ORAL LIQUID 2 $0 PA; MO RENVELA ORAL POWDER IN PACKET riluzole oral tablet risedronate oral tablet 30 mg 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 63

75 sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation solution sodium polystyrene (sorb free) oral suspension 1 $0 SYPRINE ORAL CAPSULE VELPHORO ORAL TABLET,CHEWABLE zoledronic acid-mannitol-water intravenous solution 戒煙藥 1 $0 B/D PA; MO buproban oral tablet extended release CHANTIX CONTINUING MONTH BOX ORAL TABLET CHANTIX ORAL TABLET CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK nicotine (polacrilex) buccal gum 4 $0 MO; * nicotine (polacrilex) buccal lozenge 2 mg 4 $0 MO; * nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr 4 $0 MO; * NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON- AEROSOL nts step 1 transdermal patch 24 hour quit 2 buccal gum quit 4 buccal gum stop smoking aid buccal lozenge 耳 鼻 / 喉科用藥 雜類藥劑 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 64

76 12 HOUR NASAL SPRAY NASAL SPRAY,NON-AEROSOL afrin no drip(oxymetazolin) nasal mist altamist nasal aerosol,spray AYR SALINE NASAL DROPS 4 $0 MO; * azelastine nasal aerosol,spray ; QL (60 per 30 days) azelastine nasal spray,non-aerosol ; QL (60 per 30 days) chlorhexidine gluconate mucous membrane mouthwash denta 5000 plus dental cream dentagel dental gel DRISTAN LONG LASTING NASAL MIST ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % little remedies nasal aerosol,spray nasal moisturizing nasal aerosol,spray NASAL SPRAY (OXYMETAZOLINE) NASAL SPRAY,NON-AEROSOL nasal spray (sodium chloride) nasal aerosol,spray ; QL (60 per 30 days) ; QL (30 per 30 days) OCEAN NASAL NASAL AEROSOL,SPRAY 4 $0 MO; * olopatadine nasal spray,non-aerosol ; QL (30.5 per 30 days) oralone dental paste periogard mucous membrane mouthwash saline mist nasal aerosol,spray 4 $0 MO; * saline nasal mist nasal aerosol,spray saline nasal nasal aerosol,spray saline nose nasal aerosol,spray sf 5000 plus dental cream 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 65

77 sf dental gel sinex ultra fine mist 12-hour nasal mist sinus relief (oxymetazoline) nasal mist triamcinolone acetonide dental paste vicks qlearquil(oxymetazoline) nasal mist 雜類耳用製劑 acetasol hc otic drops acetic acid otic solution fluocinolone acetonide oil otic drops hydrocortisone-acetic acid otic drops ofloxacin otic drops 耳用類固醇 / 抗生素 CORTISPORIN-TC OTIC DROPS,SUSPENSION neomycin-polymyxin-hc otic drops,suspension neomycin-polymyxin-hc otic solution 內分泌 / 糖尿病 腎上腺激素 ACTHAR H.P. INJECTION GEL 2 $0 PA; MO A-HYDROCORT INJECTION RECON SOLN 2 $0 B/D PA; MO cortisone oral tablet dexamethasone intensol oral drops dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection solution 1 $0 B/D PA; MO fludrocortisone oral tablet hydrocortisone oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 66

78 KENALOG INJECTION SUSPENSION methylprednisolone acetate injection suspension 1 $0 B/D PA; MO methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 125 mg, 40 mg 1 $0 B/D PA; MO millipred oral tablet prednisolone sodium phosphate oral solution 15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating prednisone intensol oral concentrate prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack 10 mg RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML triamcinolone acetonide injection suspension 10 mg/ml triamcinolone acetonide injection suspension 40 mg/ml 2 $0 B/D PA; MO 1 $0 veripred 20 oral solution 1 $0 抗甲狀腺藥劑 methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 糖尿病治療 acarbose oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 67

79 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 MG ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 MG ALCOHOL PADS TOPICAL PADS, MEDICATED BYDUREON SUBCUTANEOUS PEN INJECTOR BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 $0 ST; MO; QL (60 per 30 days) 2 $0 ST; MO; QL (30 per 30 days) BYETTA SUBCUTANEOUS PEN INJECTOR CYCLOSET ORAL TABLET 2 $0 ST; MO FARXIGA ORAL TABLET GAUZE PADS 2X2 glimepiride oral tablet glipizide oral tablet glipizide oral tablet extended release 24hr glipizide-metformin oral tablet mg ; QL (240 per 30 days) glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT INJECTION RECON SOLN GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN HUMALOG MIX SUBCUTANEOUS SUSPENSION HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN ; QL (120 per 30 days)

80 HUMALOG MIX SUBCUTANEOUS SUSPENSION HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN 70/30 SUBCUTANEOUS SUSPENSION HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN HUMULIN N SUBCUTANEOUS SUSPENSION 2 $0 HUMULIN R INJECTION SOLUTION HUMULIN R U-500 "CONCENTRATED" SUBCUTANEOUS SOLUTION INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1/2 ML, 1 ML JANUMET ORAL TABLET ; QL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR ; QL (60 per 30 days) JANUVIA ORAL TABLET ; QL (30 per 30 days) JARDIANCE ORAL TABLET KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG, MG LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN ; QL (60 per 30 days) ; QL (30 per 30 days) LEVEMIR SUBCUTANEOUS SOLUTION 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 69

81 metformin oral tablet metformin oral tablet extended release 24 hr metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet NEEDLES, INSULIN DISP.,SAFETY NOVOFINE NEEDLE NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION NOVOLIN N SUBCUTANEOUS SUSPENSION NOVOLIN R INJECTION SOLUTION NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX FLEXPEN SUBCUTANEOUS INSULIN PEN NOVOLOG MIX SUBCUTANEOUS SOLUTION NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE NOVOLOG SUBCUTANEOUS SOLUTION NOVOTWIST NEEDLE 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 70 ONGLYZA ORAL TABLET ; QL (30 per 30 days) pioglitazone oral tablet pioglitazone-glimepiride oral tablet ; QL (30 per 30 days) pioglitazone-metformin oral tablet ; QL (90 per 30 days) PROGLYCEM ORAL SUSPENSION repaglinide oral tablet 0.5 mg ; QL (930 per 30 days) repaglinide oral tablet 1 mg ; QL (480 per 30 days) repaglinide oral tablet 2 mg ; QL (240 per 30 days)

82 SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR tolazamide oral tablet tolbutamide oral tablet VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 雜類激素 ALDURAZYME INTRAVENOUS SOLUTION 2 $0 B/D PA; MO ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP ANDROGEL TRANSDERMAL GEL IN PACKET ANDROID ORAL CAPSULE cabergoline oral tablet ; QL (20 per 30 days) calcitonin (salmon) nasal spray,non-aerosol calcitriol intravenous solution 1 mcg/ml 1 $0 B/D PA; MO calcitriol oral capsule 1 $0 B/D PA; MO calcitriol oral solution 1 $0 B/D PA; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chorionic gonadotropin, human intramuscular recon soln 2 $0 B/D PA; MO 1 $0 PA; MO danazol oral capsule desmopressin injection solution desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral tablet ELAPRASE INTRAVENOUS SOLUTION 2 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 71

83 ELELYSO INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO FABRAZYME INTRAVENOUS RECON SOLN 35 MG 2 $0 B/D PA; MO fortical nasal spray,non-aerosol KORLYM ORAL TABLET 2 $0 PA; MO KUVAN ORAL TABLET,SOLUBLE 2 $0 PA; MO MIACALCIN INJECTION SOLUTION 2 $0 B/D PA; MO MYOZYME INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO NAGLAZYME INTRAVENOUS SOLUTION 2 $0 B/D PA; MO NATPARA SUBCUTANEOUS CARTRIDGE 2 $0 PA; MO novarel intramuscular recon soln 1 $0 PA; MO OXANDROLONE ORAL TABLET 10 MG oxandrolone oral tablet 2.5 mg pamidronate intravenous solution 1 $0 B/D PA; MO paricalcitol oral capsule 1 $0 B/D PA; MO PREGNYL INTRAMUSCULAR RECON SOLN 2 $0 PA; MO SAMSCA ORAL TABLET 15 MG 2 $0 PA; MO; QL (30 per 30 days) SAMSCA ORAL TABLET 30 MG 2 $0 PA; MO; QL (60 per 30 days) SENSIPAR ORAL TABLET SOMAVERT SUBCUTANEOUS RECON SOLN 2 $0 B/D PA; MO SYNAREL NASAL SPRAY,NON-AEROSOL testosterone enanthate intramuscular oil 1 $0 B/D PA; MO VPRIV INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO ZAVESCA ORAL CAPSULE ZEMPLAR INTRAVENOUS SOLUTION 2 $0 B/D PA; MO zoledronic acid intravenous solution 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 72

84 ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML 甲狀腺激素 LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG 2 $0 B/D PA; MO levothyroxine oral tablet 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 liothyronine intravenous solution liothyronine oral tablet SYNTHROID ORAL TABLET 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 腸胃病 止瀉藥 / 解痙藥 anti-diarrhea oral tablet ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET 4 $0 MO; * anti-diarrheal oral suspension atropine injection syringe 0.05 mg/ml, 0.1 mg/ml BISMATROL ORAL SUSPENSION 262 MG/15 ML 1 $0 4 $0 MO; * BISMATROL ORAL TABLET,CHEWABLE bismuth maximum strength oral suspension bismuth oral suspension bismuth oral tablet,chewable diamode oral tablet diarrhea relief (bismuth subs) oral suspension dicyclomine oral capsule 1 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 73

85 dicyclomine oral solution 1 $0 PA; MO dicyclomine oral tablet 1 $0 PA; MO diotame oral tablet,chewable glycopyrrolate injection solution glycopyrrolate oral tablet kaopectate (bismuth subsalicy) oral suspension kaopectate ex str (bismuth ss) oral suspension 4 $0 MO; * k-pec antidiarrheal (bism sub) oral suspension loperamide oral capsule loperamide oral tablet medi-bismuth oral tablet,chewable methscopolamine oral tablet pepto-bismol oral tablet,chewable 4 $0 MO; * pink bismuth maximum strength oral suspension pink bismuth oral suspension pink bismuth oral tablet,chewable 4 $0 MO; * soothe regular strength oral suspension stomach relief max strength oral suspension stomach relief oral suspension stomach relief oral tablet,chewable stomach relief original oral suspension 雜類胃腸藥物 ACID GONE ANTACID ORAL SUSPENSION ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION ALMACONE ORAL SUSPENSION 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 74

86 ALMACONE-2 ORAL SUSPENSION alophen oral tablet,delayed release (dr/ec) aluminum hydroxide gel oral suspension 320 mg/5 ml aluminum hydroxide gel oral suspension 600 mg/5 ml 4 $0 MO; * AMITIZA ORAL CAPSULE ; QL (60 per 30 days) antacid anti-gas double str oral suspension antacid anti-gas oral suspension antacid extra-strength oral suspension antacid liquid oral suspension antacid maximum strength oral suspension antacid oral suspension antacid oral tablet,chewable mg antacid plus anti-gas oral suspension antacid regular strength oral suspension ANTACID TABLET ORAL TABLET,CHEWABLE antacid ultra strength oral tablet,chewable 1,177 mg antacid with simethicone oral suspension antacid-antigas oral suspension antacid-simethicone ds oral suspension APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR balsalazide oral capsule bisacodyl oral tablet,delayed release (dr/ec) 4 $0 MO; * bisa-lax oral tablet,delayed release (dr/ec) BUDESONIDE ORAL CAPSULE,DELAYED,EXTEND.RELEASE CANASA RECTAL SUPPOSITORY 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 75

87 child suppository rectal suppository children's pepto oral tablet,chewable CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 2 $0 B/D PA; ST; MO CIMZIA SUBCUTANEOUS SYRINGE KIT 2 $0 ST; MO citrate of magnesia oral solution CLEARLAX ORAL POWDER 4 $0 MO; * col-rite oral capsule comfort gel extra strength oral suspension comfort gel oral suspension compro rectal suppository constulose oral solution cromolyn oral concentrate CYSTADANE ORAL POWDER dimenhydrinate oral tablet 4 $0 MO; * DIOCTO ORAL LIQUID DIPENTUM ORAL CAPSULE DOC-Q-LACE ORAL CAPSULE 4 $0 MO; * docu oral liquid 4 $0 MO; * docu soft oral capsule docusate sodium oral capsule 4 $0 MO; * docusil oral capsule DRONABINOL ORAL CAPSULE 10 MG 2 $0 B/D PA; MO; QL (60 per 30 days) dronabinol oral capsule 2.5 mg, 5 mg 1 $0 B/D PA; MO; QL (60 per 30 days) dss oral capsule 250 mg ducodyl oral tablet,delayed release (dr/ec) dulcolax stool softener (dss) oral capsule 4 $0 MO; * EMEND ORAL CAPSULE 125 MG 2 $0 B/D PA; MO; QL (2 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 76

88 EMEND ORAL CAPSULE 40 MG 2 $0 B/D PA; MO; QL (1 per 1 day) EMEND ORAL CAPSULE 80 MG 2 $0 B/D PA; MO; QL (4 per 30 days) EMEND ORAL CAPSULE,DOSE PACK 2 $0 B/D PA; MO; QL (3 per 3 days) ENEMA RECTAL ENEMA 19-7 GRAM/118 ML enulose oral solution FIBER (CALCIUM POLYCARBOPHIL) ORAL TABLET 4 $0 MO; * fiber (psyllium husk/sugar) oral powder FIBER (WITH ASPARTAME) ORAL POWDER fiber laxative (husk/sugar) oral powder fiber laxative (methylcellulo) oral tablet fiber laxative (psyllium) s/f oral powder FIBER ORAL POWDER fiber smooth (sucrose) oral powder fiber smooth oral powder fiber therapy (ca polycarboph) oral tablet FIBER THERAPY (PSYLLIUM SEED) ORAL POWDER fiber therapy (psyllium) oral powder FIBER THERAPY ORAL POWDER FIBER THERAPY ORAL TABLET fiber-lax oral tablet 4 $0 MO; * fiber-tabs oral tablet flanax antacid oral suspension foaming antacid oral suspension foaming antacid oral tablet,chewable GATTEX ONE-VIAL SUBCUTANEOUS KIT 2 $0 PA; MO gavilax oral powder 4 $0 MO; * gavilyte-c oral recon soln 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 77

89 gavilyte-g oral recon soln gavilyte-n oral recon soln generlac oral solution gentlelax oral powder geri-kot oral tablet geri-lanta oral suspension geri-mox antacid-antigas oral suspension glycerin (adult) rectal suppository glycerin (child) rectal suppository glycolax oral powder granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml (1 ml) 1 $0 B/D PA; MO 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 78 granisetron hcl oral tablet 1 $0 B/D PA; MO; QL (2 per 1 day) hydrocortisone rectal enema KONSYL (SUGAR) ORAL POWDER 3.4 GRAM/11 GRAM KONSYL SUGAR-FREE ORAL POWDER IN PACKET 4 $0 MO; * lactulose oral solution 10 gram/15 ml laxa clear oral powder laxacin oral tablet laxative (glycerin-pediatric) rectal suppository laxative maximum strength oral tablet laxative oral tablet 15 mg, 17.2 mg, 25 mg laxative oral tablet,delayed release (dr/ec) laxative peg 3350 oral powder laxative pills oral tablet

90 laxative plus stool softener oral tablet laxative-senna oral tablet LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) LINZESS ORAL CAPSULE ; QL (30 per 30 days) liquid antacid oral suspension mg/5 ml LOTRONEX ORAL TABLET magnesium citrate oral solution 4 $0 MO; * masanti double strength oral suspension meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable 4 $0 MO; * medi-lax oral tablet medi-laxx oral tablet medi-natural oral tablet medi-natural senna-stool oral tablet mesalamine with cleansing wipe rectal enema kit metoclopramide hcl injection solution 1 $0 B/D PA; MO metoclopramide hcl injection syringe 1 $0 B/D PA metoclopramide hcl oral solution metoclopramide hcl oral tablet MI-ACID ORAL TABLET,CHEWABLE MILK OF MAGNESIA ORAL SUSPENSION 4 $0 MO; * mineral oil extra heavy oral oil MOTION SICKNESS ORAL TABLET motion sickness relief oral tablet MOVIPREP ORAL POWDER IN PACKET natural fiber laxative (sugar) oral powder, 3.4 gram/12 gram natural fiber laxative smooth oral powder 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 79

91 natural laxative oral tablet natural veg laxative(sennosid) oral tablet natural vegetable (psyllium) oral powder natural vegetable oral powder natural vegetable powder oral powder ondansetron hcl (pf) injection solution 1 $0 B/D PA; MO ondansetron hcl (pf) injection syringe 1 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 80 ondansetron hcl oral solution 1 $0 B/D PA; MO; QL (150 per 5 days) ondansetron hcl oral tablet 24 mg 1 $0 B/D PA; QL (1 per 1 day) ondansetron hcl oral tablet 4 mg, 8 mg 1 $0 B/D PA; MO; QL (12 per 5 days) ondansetron oral tablet,disintegrating 1 $0 B/D PA; MO; QL (12 per 5 days) p-col rite oral tablet peg 3350-electrolytes oral recon soln gram peg 3350-electrolytes oral recon soln gram 1 $0 peg-3350 with flavor packs oral recon soln 1 $0 peg-electrolyte soln oral recon soln 1 $0 peri-colace oral tablet 4 $0 MO; * polyethylene glycol 3350 oral powder powderlax oral powder prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet prochlorperazine rectal suppository procto-pak rectal cream proctosol hc rectal cream proctozone-hc rectal cream purelax oral powder

92 REGULOID ORAL POWDER 4 $0 MO; * RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE INTRAVENOUS RECON SOLN 2 $0 PA; MO ri-gel ii oral suspension ri-gel oral suspension riginic oral suspension ri-mox oral suspension ri-mox plus oral suspension SANCUSO TRANSDERMAL PATCH WEEKLY SANI-SUPP (ADULT) RECTAL SUPPOSITORY 2 $0 B/D PA; MO; QL (2 per 15 days) 4 $0 MO; * SENEXON-S ORAL TABLET 4 $0 MO; * senna lax oral tablet 4 $0 MO; * senna laxative oral tablet SENNA ORAL TABLET senna plus oral tablet 4 $0 MO; * senna-extra oral tablet senna-s oral tablet 4 $0 MO; * senno oral tablet sennosides-docusate sodium oral tablet sen-o-tab oral tablet silace oral liquid 4 $0 MO; * sodium bicarbonate oral tablet 650 mg 4 $0 MO; * soluble fiber oral tablet stimulant laxative plus oral tablet stool softener oral capsule 100 mg, 50 mg stool softener oral capsule 250 mg 4 $0 MO; * stool softener oral liquid 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 81

93 stool softener-laxative oral tablet stool softener-stimulant laxat oral tablet sulfasalazine oral tablet sulfazine ec oral tablet,delayed release (dr/ec) sulfazine oral tablet suppository adult rectal suppository TRANSDERM-SCOP TRANSDERMAL PATCH 72 HOUR travel sickness oral tablet trilyte with flavor packets oral recon soln ursodiol oral capsule ursodiol oral tablet vegetable laxative oral tablet wal-mucil fiber (aspartame) oral powder wal-mucil natural fiber lax oral powder woman's laxative oral tablet,delayed release (dr/ec) women's gentle laxative(bisac) oral tablet,delayed release (dr/ec) women's laxative (bisacodyl) oral tablet,delayed release (dr/ec) ; QL (10 per 30 days) women's stool softener oral capsule ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 潰瘍治療 acid control (ranitidine) oral tablet 150 mg acid controller oral tablet acid reducer (famotidine) oral tablet acid reducer (ranitidine) oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 82

94 amoxicil-clarithromy-lansopraz oral combo pack CARAFATE ORAL SUSPENSION cimetidine hcl oral solution cimetidine oral tablet DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS esomeprazole sodium intravenous recon soln 1 $0 B/D PA famotidine (pf) intravenous solution 1 $0 B/D PA; MO famotidine (pf)-nacl (iso-os) intravenous piggyback 1 $0 B/D PA famotidine oral suspension famotidine oral tablet 10 mg 4 $0 MO; * famotidine oral tablet 20 mg, 40 mg heartburn prevention oral tablet heartburn relief (ranitidine) oral tablet lansoprazole oral capsule,delayed release(dr/ec) misoprostol oral tablet nizatidine oral capsule nizatidine oral solution omeprazole oral capsule,delayed release(dr/ec) omeprazole oral tablet,delayed release (dr/ec) 4 $0 MO; * pantoprazole oral tablet,delayed release (dr/ec) pepcid ac oral tablet 20 mg 4 $0 MO; * ranitidine hcl injection solution 25 mg/ml 1 $0 B/D PA; MO ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 83

95 ranitidine hcl oral tablet 75 mg 4 $0 MO; * sucralfate oral tablet wal-zan 150 oral tablet zantac maximum strength oral tablet 4 $0 MO; * 免疫學 疫苗 / 生物技術 生物技術藥物 ACTIMMUNE SUBCUTANEOUS SOLUTION 2 $0 PA; MO ARCALYST SUBCUTANEOUS RECON SOLN AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT AVONEX INTRAMUSCULAR PEN INJECTOR KIT 2 $0 PA; MO 2 $0 PA; MO; QL (4 per 28 days) 2 $0 PA; MO; QL (2 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 2 $0 PA; MO; QL (2 per 28 days) EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG 2 $0 PA EXTAVIA SUBCUTANEOUS KIT 2 $0 PA; MO; QL (15 per 30 days) ILARIS (PF) SUBCUTANEOUS RECON SOLN 2 $0 PA; MO; LA INTRON A INJECTION RECON SOLN 2 $0 B/D PA; MO INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML 2 $0 B/D PA; MO LEUKINE INJECTION RECON SOLN 2 $0 PA; MO MOZOBIL SUBCUTANEOUS SOLUTION 2 $0 B/D PA; MO NEUMEGA SUBCUTANEOUS RECON SOLN NEUPOGEN INJECTION SOLUTION 2 $0 PA; MO NEUPOGEN INJECTION SYRINGE 2 $0 PA; MO 2 $0 B/D PA; MO; QL (21 per 21 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 84

96 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) NORDITROPIN NORDIFLEX SUBCUTANEOUS PEN INJECTOR PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 2 $0 PA; MO 2 $0 PA; MO 2 $0 PA; MO; QL (5 per 30 days) PEGINTRON SUBCUTANEOUS KIT 2 $0 PA; MO; QL (5 per 30 days) PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 2 $0 PA; MO; QL (24 per 30 days) 2 $0 PA; MO; QL (6 per 30 days) PROLEUKIN INTRAVENOUS RECON SOLN 2 $0 B/D PA; MO REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 2 $0 PA; MO; QL (6 per 28 days) 2 $0 PA; MO; QL (6 per 28 days) 2 $0 PA; MO; QL (4.2 per 180 days) 2 $0 PA; MO; QL (6 per 28 days) SYLATRON SUBCUTANEOUS KIT 2 $0 PA; MO 疫苗 / 雜類免疫藥物 ACTHIB (PF) INTRAMUSCULAR RECON SOLN ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 85

97 BEXSERO (PF) INTRAMUSCULAR SYRINGE BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION BOOSTRIX TDAP INTRAMUSCULAR SYRINGE CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE COMVAX (PF) INTRAMUSCULAR SUSPENSION DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 2 $0 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA fomepizole intravenous solution 1 $0 B/D PA; MO GAMMAGARD LIQUID INJECTION SOLUTION GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) GARDASIL (PF) INTRAMUSCULAR SUSPENSION GARDASIL (PF) INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML 2 $0 PA; MO 2 $0 PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 86

98 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO 2 $0 2 $0 IPOL INJECTION SUSPENSION IPOL INJECTION SYRINGE IXIARO (PF) INTRAMUSCULAR SYRINGE KINRIX (PF) INTRAMUSCULAR SUSPENSION 2 $0 KINRIX (PF) INTRAMUSCULAR SYRINGE 2 $0 MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT M-M-R II (PF) SUBCUTANEOUS RECON SOLN PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR SUSPENSION RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 87

99 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA 2 $0 ROTATEQ VACCINE ORAL SUSPENSION TENIVAC (PF) INTRAMUSCULAR SYRINGE tetanus toxoid,adsorbed (pf) intramuscular suspension TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 1 $0 B/D PA; MO TRUMENBA INTRAMUSCULAR SYRINGE 2 $0 TWINRIX (PF) INTRAMUSCULAR SUSPENSION 2 $0 B/D PA; MO 2 $0 B/D PA; MO TWINRIX (PF) INTRAMUSCULAR SYRINGE 2 $0 B/D PA; MO TYPHIM VI INTRAMUSCULAR SOLUTION 2 $0 TYPHIM VI INTRAMUSCULAR SYRINGE VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 50 UNIT/ML 2 $0 B/D PA; MO VAQTA (PF) INTRAMUSCULAR SYRINGE 2 $0 VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION VARIZIG INTRAMUSCULAR SOLUTION 2 $0 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 88

100 ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 肌骨骼 / 風濕病學 痛風治療 allopurinol oral tablet colchicine-probenecid oral tablet COLCRYS ORAL TABLET probenecid oral tablet ULORIC ORAL TABLET 骨質疏鬆治療 ; QL (1 per 365 days) alendronate oral solution ; QL (375 per 30 days) alendronate oral tablet 10 mg, 5 mg ; QL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg ; QL (5 per 30 days) FORTEO SUBCUTANEOUS PEN INJECTOR ; QL (2.4 per 28 days) ibandronate oral tablet ; QL (1 per 30 days) PROLIA SUBCUTANEOUS SYRINGE 2 $0 B/D PA; MO raloxifene oral tablet risedronate oral tablet 150 mg, 35 mg, 5 mg risedronate oral tablet 35 mg (12 pack) 1 $0 risedronate oral tablet,delayed release (dr/ec) 其他風濕藥物 ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) BENLYSTA INTRAVENOUS RECON SOLN 120 MG 2 $0 B/D PA; ST; MO 2 $0 B/D PA; MO CUPRIMINE ORAL CAPSULE DEPEN TITRATABS ORAL TABLET 2 $0 PA; MO ENBREL SUBCUTANEOUS RECON SOLN ; QL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ; QL (4 per 28 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 89

101 ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR HUMIRA CROHN'S DIS START PCK SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PED CROHN'S STARTER PK SUBCUTANEOUS SYRINGE KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 90 ; QL (8 per 28 days) ; QL (8 per 28 days) ; QL (4.8 per 180 days) ; QL (6 per 28 days) ; QL (1.2 per 28 days) ; QL (1.6 per 28 days) ; QL (4.8 per 28 days) leflunomide oral tablet ; QL (30 per 30 days) ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 2 $0 B/D PA; ST; MO SAVELLA ORAL TABLET ; QL (60 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 per 30 days) 產科 / 婦科 雌激素 / 孕激素 camila oral tablet COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML DEPO-PROVERA INTRAMUSCULAR SOLUTION DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 2 $0 B/D PA; MO 2 $0 B/D PA; MO errin oral tablet

102 ESTRACE VAGINAL CREAM estradiol oral tablet 1 $0 PA; MO estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml 1 $0 B/D PA; MO heather oral tablet jencycla oral tablet JINTELI ORAL TABLET jolivette oral tablet lyza oral tablet medroxyprogesterone intramuscular suspension ; QL (1 per 90 days) medroxyprogesterone intramuscular syringe ; QL (1 per 90 days) medroxyprogesterone oral tablet norethindrone (contraceptive) oral tablet norethindrone acetate oral tablet PREMARIN INJECTION RECON SOLN 2 $0 B/D PA; MO PREMARIN VAGINAL CREAM progesterone micronized oral capsule VAGIFEM VAGINAL TABLET VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY 雜類產科 / 婦科 3-day vaginal vaginal cream CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal cream clotrimazole 3 day vaginal cream 4 $0 MO; * clotrimazole vaginal cream 4 $0 MO; * clotrimazole-3 vaginal cream 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 91

103 clotrimazole-7 vaginal cream metronidazole vaginal gel 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 92 miconazole 7 vaginal suppository 4 $0 MO; *; QL (7 per 30 days) miconazole nitrate vaginal suppository ; QL (7 per 30 days) miconazole-3 vaginal suppository ; QL (3 per 3 days) NUVARING VAGINAL RING terconazole vaginal cream terconazole vaginal suppository ; QL (3 per 3 days) tranexamic acid oral tablet vandazole vaginal gel 口服避孕藥 / 相關藥劑 altavera (28) oral tablet alyacen 1/35 (28) oral tablet alyacen 7/7/7 (28) oral tablet amethia lo oral tablets,dose pack,3 month amethia oral tablets,dose pack,3 month amethyst oral tablet apri oral tablet aranelle (28) oral tablet ashlyna oral tablets,dose pack,3 month aubra oral tablet aviane oral tablet azurette (28) oral tablet balziva (28) oral tablet briellyn oral tablet camrese lo oral tablets,dose pack,3 month camrese oral tablets,dose pack,3 month caziant (28) oral tablet

104 chateal oral tablet cryselle (28) oral tablet cyclafem 1/35 (28) oral tablet cyclafem 7/7/7 (28) oral tablet dasetta 1/35 (28) oral tablet dasetta 7/7/7 (28) oral tablet daysee oral tablets,dose pack,3 month elinest oral tablet ELLA ORAL TABLET emoquette oral tablet enpresse oral tablet enskyce oral tablet estarylla oral tablet falmina (28) oral tablet gildess fe oral tablet gildess oral tablet introvale oral tablets,dose pack,3 month jolessa oral tablets,dose pack,3 month junel 1.5/30 (21) oral tablet junel 1/20 (21) oral tablet junel fe 1.5/30 (28) oral tablet junel fe 1/20 (28) oral tablet junel fe 24 oral tablet kariva (28) oral tablet kelnor 1/35 (28) oral tablet kurvelo oral tablet l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 93

105 l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) 1 $0 lessina oral tablet levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg levonorgestrel-ethinyl estrad oral tablet mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1 $0 levora-28 oral tablet low-ogestrel (28) oral tablet lutera (28) oral tablet marlissa oral tablet microgestin 1.5/30 (21) oral tablet microgestin 1/20 (21) oral tablet microgestin fe 1.5/30 (28) oral tablet microgestin fe 1/20 (28) oral tablet mono-linyah oral tablet mononessa (28) oral tablet myzilra oral tablet necon 0.5/35 (28) oral tablet necon 1/35 (28) oral tablet necon 10/11 (28) oral tablet necon 7/7/7 (28) oral tablet NEXT CHOICE ONE DOSE ORAL TABLET norgestimate-ethinyl estradiol oral tablet nortrel 0.5/35 (28) oral tablet nortrel 1/35 (21) oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 94

106 nortrel 1/35 (28) oral tablet nortrel 7/7/7 (28) oral tablet ogestrel (28) oral tablet orsythia oral tablet philith oral tablet pirmella oral tablet portia oral tablet previfem oral tablet quasense oral tablets,dose pack,3 month reclipsen (28) oral tablet sprintec (28) oral tablet sronyx oral tablet syeda oral tablet tilia fe oral tablet tri-estarylla oral tablet tri-legest fe oral tablet tri-linyah oral tablet trinessa (28) oral tablet tri-previfem (28) oral tablet tri-sprintec (28) oral tablet trivora (28) oral tablet velivet triphasic regimen (28) oral tablet vestura (28) oral tablet viorele (28) oral tablet wera (28) oral tablet wymzya fe oral tablet,chewable zarah oral tablet zenchent (28) oral tablet zenchent fe oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 95

107 zeosa oral tablet,chewable zovia 1/35e (28) oral tablet zovia 1/50e (28) oral tablet 催產藥 METHYLERGONOVINE INJECTION SOLUTION 1 $0 B/D PA; MO methylergonovine oral tablet 眼科 抗生素 AZASITE OPHTHALMIC DROPS bacitracin ophthalmic ointment bacitracin-polymyxin b ophthalmic ointment CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic drops erythromycin ophthalmic ointment garamycin ophthalmic drops 1 $0 gatifloxacin ophthalmic drops gentak ophthalmic ointment gentamicin ophthalmic drops gentamicin ophthalmic ointment levofloxacin ophthalmic drops NATACYN OPHTHALMIC DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic drops neo-polycin ophthalmic ointment 1 $0 ofloxacin ophthalmic drops 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 96

108 polycin ophthalmic ointment 1 $0 polymyxin b sulf-trimethoprim ophthalmic drops tobramycin ophthalmic drops TOBREX OPHTHALMIC OINTMENT VIGAMOX OPHTHALMIC DROPS 抗病毒藥 trifluridine ophthalmic drops ZIRGAN OPHTHALMIC GEL β 受體阻斷劑 betaxolol ophthalmic drops BETIMOL OPHTHALMIC DROPS 0.25 % BETOPTIC S OPHTHALMIC DROPS,SUSPENSION carteolol ophthalmic drops levobunolol ophthalmic drops 0.5 % metipranolol ophthalmic drops timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution 膽鹼酯酶抑制縮瞳劑 PHOSPHOLINE IODIDE OPHTHALMIC DROPS 睫狀肌麻痹擴瞳劑 cyclopentolate ophthalmic drops 1 % cyclopentolate ophthalmic drops 2 % 1 $0 tropicamide ophthalmic drops 直接作用縮瞳劑 pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 97

109 雜類眼科藥 AKWA TEARS (POLYVINYL ALCOHOL) OPHTHALMIC DROPS 4 $0 MO; * AKWA TEARS OPHTHALMIC OINTMENT 4 $0 MO; * altachlore ophthalmic drops altachlore ophthalmic ointment ARTIFICIAL TEARS (PETRO/MIN) OPHTHALMIC OINTMENT ARTIFICIAL TEARS OPHTHALMIC DROPS % 4 $0 MO; * artificial tears(hypromellose) ophthalmic drops azelastine ophthalmic drops cromolyn ophthalmic drops epinastine ophthalmic drops for sty relief ophthalmic ointment gonak ophthalmic drops goniosoft ophthalmic drops goniotaire ophthalmic drops goniovisc ophthalmic drops 4 $0 MO; * LASTACAFT OPHTHALMIC DROPS LUBRICANT EYE (PG-PEG 400) OPHTHALMIC DROPS lubricant eye (polyv alcohol) ophthalmic drops lubricant eye ophthalmic ointment %, % LUBRICATING PLUS OPHTHALMIC DROPPERETTE NATURAL BALANCE OPHTHALMIC DROPS 4 $0 MO; * PATADAY OPHTHALMIC DROPS 2 $0 ST; MO polyvinyl alcohol ophthalmic drops 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 98

110 pure & gentle eye ophthalmic drops RESTASIS OPHTHALMIC DROPPERETTE ; QL (60 per 30 days) sochlor ophthalmic drops sochlor ophthalmic ointment sodium chloride ophthalmic drops 4 $0 MO; * sodium chloride ophthalmic ointment 4 $0 MO; * tears again ophthalmic drops 4 $0 MO; * tears again ophthalmic ointment 4 $0 MO; * 非甾體類抗炎劑 bromfenac ophthalmic drops diclofenac sodium ophthalmic drops flurbiprofen sodium ophthalmic drops ILEVRO OPHTHALMIC DROPS,SUSPENSION ketorolac ophthalmic drops 青光眼口服藥 acetazolamide oral capsule, extended release acetazolamide oral tablet acetazolamide sodium injection recon soln methazolamide oral tablet 其他青光眼藥物 AZOPT OPHTHALMIC DROPS,SUSPENSION COMBIGAN OPHTHALMIC DROPS dorzolamide ophthalmic drops dorzolamide-timolol ophthalmic drops latanoprost ophthalmic drops LUMIGAN OPHTHALMIC DROPS 0.01 % ; QL (2.5 per 30 days) travoprost (benzalkonium) ophthalmic drops 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 99

111 類固醇 - 抗生素複方藥 neomycin-bacitracin-poly-hc ophthalmic ointment neomycin-polymyxin b-dexameth ophthalmic drops,suspension neomycin-polymyxin b-dexameth ophthalmic ointment neomycin-polymyxin-hc ophthalmic drops,suspension neo-polycin hc ophthalmic ointment 1 $0 TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION tobramycin-dexamethasone ophthalmic drops,suspension 類固醇 ALREX OPHTHALMIC DROPS,SUSPENSION dexamethasone sodium phosphate ophthalmic drops DUREZOL OPHTHALMIC DROPS fluorometholone ophthalmic drops,suspension FML S.O.P. OPHTHALMIC OINTMENT prednisolone acetate ophthalmic drops,suspension prednisolone sodium phosphate ophthalmic drops 類固醇 - 磺胺複方藥 BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT sulfacetamide-prednisolone ophthalmic drops 磺胺藥物 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 100

112 sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment 擬交感神經藥物 ALPHAGAN P OPHTHALMIC DROPS 0.1 % apraclonidine ophthalmic drops brimonidine ophthalmic drops 血管收縮劑 naphazoline ophthalmic drops 呼吸和過敏 抗組胺劑 / 抗過敏藥物 12 hour decongestant oral tablet extended release adult cough formula dm max oral liquid adult tussin chest congestion oral liquid adult tussin cough congest dm oral liquid adult tussin dm oral syrup adult tussin multi-symp cold oral liquid ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR aler-cap oral capsule ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION 4 $0 MO; *; QL (68 per 30 days) all day allergy (cetirizine) oral tablet 4 $0 MO; *; QL (34 per 30 days) all day allergy-d oral tablet extended release 12 hr allerclear d-12hr oral tablet extended release 12 hr 4 $0 MO; *; QL (68 per 30 days) ; QL (68 per 30 days) allerclear oral tablet ; QL (34 per 30 days) aller-ease oral tablet 180 mg ; QL (34 per 30 days) aller-ease oral tablet 60 mg ; QL (68 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 101

113 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 aller-fex oral tablet ; QL (34 per 30 days) allergy & congestion relief oral tablet extended release 12 hr ; QL (68 per 30 days) allergy (chlorpheniramine) oral tablet 4 $0 MO; * allergy 4-hour oral tablet allergy complete-d oral tablet extended release 12 hr ; QL (68 per 30 days) allergy d-12 oral tablet extended release 12 hr ; QL (68 per 30 days) allergy medication oral capsule allergy medicine oral capsule allergy relief (cetirizine) oral tablet ; QL (34 per 30 days) allergy relief (fexofenadine) oral tablet 180 mg ; QL (34 per 30 days) allergy relief (fexofenadine) oral tablet 60 mg ; QL (68 per 30 days) ALLERGY RELIEF (LORATADINE) ORAL SOLUTION allergy relief (loratadine) oral tablet 4 $0 MO; *; QL (34 per 30 days) allergy relief (loratadine) oral tablet,disintegrating allergy relief d12 oral tablet extended release 12 hr allergy relief(chlorpheniramn) oral tablet allergy relief(diphenhydramin) oral capsule allergy relief-d (cetirizine) oral tablet extended release 12 hr allergy relief-d (loratadine) oral tablet extended release 12 hr allergy-time oral tablet ; QL (34 per 30 days) ; QL (68 per 30 days) ; QL (68 per 30 days) ; QL (68 per 30 days) aller-tec d oral tablet extended release 12 hr ; QL (68 per 30 days) aller-tec oral tablet ; QL (34 per 30 days) allfen oral tablet

114 ambi 60pse-400gfn oral tablet 4 $0 MO; * ambi 60pse-4cpm oral tablet antitussive dm oral syrup APRODINE ORAL TABLET 4 $0 MO; * benzonatate oral capsule 100 mg, 200 mg 3 $0 MO; * biobron sf oral liquid biocotron oral liquid biogil oral liquid broncotron ped oral liquid BROTAPP DM ORAL ELIXIR BROTAPP ORAL LIQUID 4 $0 MO; * cetiri-d oral tablet extended release 12 hr ; QL (68 per 30 days) cetirizine oral solution 1 mg/ml cetirizine oral tablet 4 $0 MO; *; QL (34 per 30 days) cetirizine oral tablet,chewable 4 $0 MO; *; QL (34 per 30 days) cetirizine-pseudoephedrine oral tablet extended release 12 hr chest congestion relief d oral tablet CHEST CONGESTION RELIEF ORAL TABLET CHEST CONGESTION RELIEF PE ORAL TABLET 4 $0 MO; *; QL (68 per 30 days) chest-sinus congestion relief oral tablet child allergy relf(cetirizine) oral solution child chest congestion + cough oral liquid child delsym cough+chest dm oral liquid child mucinex chest congestion oral liquid CHILD MUCUS RELIEF COUGH ORAL LIQUID CHILD MUCUS RELIEF EXPECTORANT ORAL LIQUID 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 103

115 children's allergy complete oral solution children's allergy relief(lor) oral solution children's allergy(cetirizine) oral solution children's aller-tec oral solution children's cetirizine oral solution 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 children's cetirizine oral tablet,chewable 4 $0 MO; *; QL (34 per 30 days) children's chest congestion oral liquid CHILDREN'S COLD & COUGH DM ORAL SOLUTION children's cold & cough oral solution children's cough oral liquid children's dibromm dm cold & c oral solution children's mucinex cough oral liquid CHILDREN'S SILFEDRINE ORAL LIQUID children's wal-zyr oral solution children's wal-zyr oral tablet,chewable ; QL (34 per 30 days) child's all day allergy(cetir) oral solution chlorhist oral tablet chlorpheniramine maleate oral tablet chlortabs oral tablet CLARINEX ORAL SYRUP clemastine oral syrup 1 $0 PA; MO clemastine oral tablet 2.68 mg 1 $0 PA; MO CODITUSS DM ORAL LIQUID 4 $0 MO; * cold & cough dm oral solution cold & cough elixir oral solution COLD HEAD CONGESTION NIGHTTIME ORAL TABLET cold multi-symptom (chlorphen) oral tablet

116 complete allergy medicine oral capsule complete allergy oral capsule CONGESTAC ORAL TABLET cough & cold mucus relief cf oral liquid cough & cold oral liquid cough control (dextromethorph) oral capsule cough control (guaifenesin) oral liquid cough control cf (pe) oral liquid cough control dm max oral liquid cough control dm oral liquid cough control dm oral syrup cough formula dm oral syrup cough relief oral capsule COUGH SUPPRESSANT-EXPECTORANT ORAL SYRUP cough syrup dm oral syrup COUGHTAB ORAL TABLET cyproheptadine oral syrup 1 $0 PA; MO cyproheptadine oral tablet 1 $0 PA; MO delsym cough+chest congest dm oral liquid desgen dm oral liquid mg/5 ml desloratadine oral tablet desloratadine oral tablet,disintegrating despec-dm (phenyleph-dm-guaif) oral liquid mg/5 ml diabetic siltussin das-na oral liquid diabetic siltussin-dm max str oral liquid diabetic siltussin-dm oral liquid diabetic tussin dm oral liquid mg/5 ml 4 $0 MO; * diabetic tussin dm oral liquid mg/5 ml 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 105

117 diabetic tussin ex oral liquid 4 $0 MO; * diabetic tussin max st oral liquid 4 $0 MO; * diabetic tussin mucus relief oral liquid diphedryl oral capsule diphenhydramine hcl injection solution 50 mg/ml 1 $0 B/D PA; MO diphenhydramine hcl oral capsule 4 $0 MO; * dm max oral liquid double-tussin dm oral liquid ENDACOF - DM ORAL SOLUTION endacon oral liquid epinephrine injection auto-injector 0.3 mg/0.3 ml (1:1,000) epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN 2-PAK INJECTION AUTO- INJECTOR EPIPEN JR 2-PAK INJECTION AUTO- INJECTOR 1 $0 B/D PA; MO expectorant oral liquid fenesin ir oral tablet fenesin pe ir oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 ; QL (4 per 2 days) ; QL (4 per 2 days) fexofenadine oral tablet 180 mg 4 $0 MO; *; QL (34 per 30 days) fexofenadine oral tablet 60 mg 4 $0 MO; *; QL (68 per 30 days) geri-tussin oral liquid g-tron oral liquid guaiasorb dm oral liquid guaifenesin oral liquid guaifenesin oral tablet 200 mg 4 $0 MO; * guaifenesin oral tablet extended release 12hr 4 $0 MO; *

118 guaifenesin-dm oral liquid hydroxyzine hcl intramuscular solution 1 $0 B/D PA; MO intense cough reliever oral liquid mg/5 ml KIDKARE COUGH/COLD ORAL LIQUID levocetirizine oral solution levocetirizine oral tablet ; QL (30 per 30 days) liquibid d-r oral tablet loradamed oral tablet 4 $0 MO; *; QL (34 per 30 days) loratadine oral solution 4 $0 MO; * loratadine oral tablet 4 $0 MO; *; QL (34 per 30 days) loratadine oral tablet,disintegrating 4 $0 MO; *; QL (34 per 30 days) loratadine-d oral tablet extended release 12 hr 4 $0 MO; *; QL (68 per 30 days) maxiphen oral tablet 4 $0 MO; * medifin expectorant mucus rlf oral liquid medi-phedrine oral tablet medi-phedrine oral tablet extended release medi-phedryl oral capsule medi-tussin dm diabetic oral liquid medi-tussin dm oral syrup medi-tussin oral liquid mucinex allergy oral tablet ; QL (34 per 30 days) MUCINEX DM ORAL TABLET EXTENDED RELEASE 12 HR 4 $0 MO; * mucinex fast-max dm max oral liquid mucinex oral tablet extended release 12hr 600 mg 4 $0 MO; * mucosa oral tablet mucus dm max oral tablet extended release 12 hr mucus dm oral tablet extended release 12 hr 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 107

119 mucus relief chest oral tablet mucus relief cough oral liquid mucus relief d (phenylephrine) oral tablet mucus relief d (pseudoephed) oral tablet mucus relief er oral tablet extended release 12hr mucus relief oral tablet 200 mg mucus relief oral tablet 400 mg 4 $0 MO; * multi-symptom cold night time oral tablet NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID NASAL DECONGESTANT (PSEUDOEPH) ORAL TABLET nasal decongestant (pseudoeph) oral tablet extended release neo-tuss oral liquid night time cold oral tablet organ-i nr oral tablet 4 $0 MO; * pediatric cough & cold oral liquid mg/5 ml pharbechlor oral tablet pharbedryl oral capsule pres gen oral liquid promethazine oral tablet 1 $0 PA; MO pseudoephedrine hcl oral liquid 4 $0 MO; * pseudoephedrine hcl oral tablet 30 mg 4 $0 MO; * pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release 4 $0 MO; * refenesen oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 108

120 refenesen pe oral tablet ri-tussin dm oral syrup ri-tussin oral liquid SCOT-TUSSIN DM ORAL LIQUID siltussin dm das oral liquid SILTUSSIN SA ORAL LIQUID 4 $0 MO; * siltussin-dm oral syrup sinus & allergy non-drowsy oral tablet extended release sinus 12 hour oral tablet extended release sorbugen nr oral liquid SUDOGEST SINUS & ALLERGY ORAL TABLET suphedrin 12 hour oral tablet extended release suphedrin oral liquid suphedrin oral tablet suphedrine 12 hour oral tablet extended release suphedrine oral tablet tusnel diabetic oral liquid tussin cf cough-cold oral liquid TUSSIN CF ORAL LIQUID 4 $0 MO; * tussin chest congestion oral liquid tussin cough &chest congestion oral liquid tussin cough (dm only) oral capsule tussin cough dm oral liquid tussin dm clear oral syrup tussin dm cough & chest oral liquid tussin dm cough & chest oral syrup tussin dm cough oral syrup 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 109

121 tussin dm max oral liquid tussin dm oral liquid TUSSIN DM ORAL SYRUP MG/5 ML tussin expectorant oral liquid tussin honey oral liquid tussin oral liquid tussin oral tablet tussi-pres oral liquid valu-dryl allergy oral capsule valu-tapp oral liquid vicks qlearquil allergy oral tablet ; QL (34 per 30 days) wal-dryl allergy oral capsule wal-fex allergy oral tablet 180 mg ; QL (34 per 30 days) wal-itin oral tablet ; QL (34 per 30 days) wal-zyr (cetirizine) oral tablet ; QL (34 per 30 days) 肺製劑 acetylcysteine solution 1 $0 B/D PA; MO ADCIRCA ORAL TABLET 2 $0 PA; MO; QL (60 per 30 days) ADEMPAS ORAL TABLET 2 $0 PA; MO; LA ADVAIR DISKUS INHALATION BLISTER WITH DEVICE ADVAIR HFA INHALATION HFA AEROSOL INHALER 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 5 mg/ml albuterol sulfate oral syrup ; QL (120 per 30 days) ; QL (24 per 30 days) 1 $0 B/D PA; MO; QL (360 per 30 days) 1 $0 B/D PA; MO; QL (60 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 110

122 albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr ANORO ELLIPTA INHALATION BLISTER WITH DEVICE ASMANEX HFA INHALATION HFA AEROSOL INHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml ; QL (26 per 30 days) ; QL (2 per 30 days) 2 $0 QL (2 per 30 days) budesonide nasal spray,non-aerosol ; QL (26 per 30 days) CINRYZE INTRAVENOUS RECON SOLN 2 $0 PA; MO 1 $0 B/D PA; MO; QL (120 per 30 days) COMBIVENT RESPIMAT INHALATION MIST ; QL (8 per 30 days) cromolyn inhalation solution for nebulization 1 $0 B/D PA; MO; QL (240 per 30 days) DALIRESP ORAL TABLET ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML ESBRIET ORAL CAPSULE 2 $0 PA; MO FIRAZYR SUBCUTANEOUS SYRINGE 2 $0 PA; MO 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 ; QL (120 per 30 days) ; QL (300 per 30 days) ; QL (12 per 30 days) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 111

123 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 %) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 ; QL (36 per 30 days) ; QL (21 per 30 days) ; QL (50 per 30 days) fluticasone nasal spray,suspension ; QL (16 per 30 days) FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (60 per 30 days) ipratropium bromide inhalation solution 1 $0 B/D PA; MO; QL (315 per 30 days) ipratropium-albuterol inhalation solution for nebulization 1 $0 B/D PA; MO; QL (540 per 30 days) KALYDECO ORAL GRANULES IN PACKET 2 $0 PA; MO; QL (60 per 30 days) KALYDECO ORAL TABLET 2 $0 PA; MO; QL (60 per 30 days) LETAIRIS ORAL TABLET 2 $0 PA; MO; QL (30 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml 1 $0 B/D PA; MO metaproterenol oral syrup metaproterenol oral tablet montelukast oral granules in packet montelukast oral tablet montelukast oral tablet,chewable 1 $0 B/D PA; MO; QL (90 per 30 days) NASONEX NASAL SPRAY,NON-AEROSOL ; QL (51 per 30 days) OFEV ORAL CAPSULE 2 $0 PA; MO; QL (60 per 30 days) OPSUMIT ORAL TABLET 2 $0 PA; MO; LA PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION PROAIR HFA INHALATION HFA AEROSOL INHALER 2 $0 B/D PA; MO; QL (120 per 30 days) ; QL (18 per 30 days)

124 PROVENTIL HFA INHALATION HFA AEROSOL INHALER ; QL (20 per 30 days) PULMOZYME INHALATION SOLUTION 2 $0 B/D PA; MO SEREVENT DISKUS INHALATION BLISTER WITH DEVICE ; QL (120 per 30 days) sildenafil oral tablet 1 $0 PA; MO; QL (90 per 30 days) SYMBICORT INHALATION HFA AEROSOL INHALER terbutaline oral tablet ; QL (20 per 30 days) terbutaline subcutaneous solution 1 $0 B/D PA; MO theochron oral tablet extended release 12 hr 1 $0 theophylline oral solution 1 $0 theophylline oral tablet extended release theophylline oral tablet extended release 12 hr triamcinolone acetonide nasal aerosol,spray ; QL (17 per 30 days) TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) VENTOLIN HFA INHALATION HFA AEROSOL INHALER 2 $0 ; QL (54 per 30 days) VERAMYST NASAL SPRAY,SUSPENSION ; QL (20 per 30 days) XOLAIR SUBCUTANEOUS RECON SOLN 2 $0 PA; MO; QL (8.4 per 28 days) zafirlukast oral tablet 泌尿科 抗膽鹼能藥 / 解痙藥 flavoxate oral tablet GELNIQUE TRANSDERMAL GEL IN PACKET 2 $0 ST; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 113

125 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR oxybutynin chloride oral syrup oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr tolterodine oral capsule,extended release 24hr tolterodine oral tablet trospium oral capsule,extended release 24hr trospium oral tablet VESICARE ORAL TABLET 良性前列腺增生 (BPH) 治療 alfuzosin oral tablet extended release 24 hr finasteride oral tablet 5 mg tamsulosin oral capsule,extended release 24hr 膽鹼興奮劑 bethanechol chloride oral tablet 雜類泌尿科 CIALIS ORAL TABLET 2.5 MG, 5 MG 2 $0 PA; MO; QL (30 per 30 days) CYSTAGON ORAL CAPSULE ELMIRON ORAL CAPSULE potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) 維生素 補血藥 / 電解質 電解質 alcalak oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 114

126 antacid ext str (calcium carb) oral tablet,chewable ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE antacid oral tablet,chewable 200 mg calcium (500 mg) antacid ultra strength oral tablet,chewable 400 mg (1,000 mg) CALCITRATE ORAL TABLET 4 $0 MO; * calcium d (d3) oral tablet calcium d oral tablet 500 mg(1,250mg) unit calcium d oral tablet 500 mg(1,250mg) unit 4 $0 MO; * calcium d oral tablet,chewable 4 $0 MO; * calcium 500 oral tablet calcium 500 with d oral tablet 4 $0 MO; * CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) -400 UNIT 4 $0 MO; * calcium 600 oral tablet calcium 600 with vitamin d3 oral tablet calcium 600 with vitamin d3 oral tablet,chewable 4 $0 MO; * 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) calcium antacid oral tablet,chewable 320 mg (750 mg), 400 mg (1,000 mg) 4 $0 MO; * calcium antacid tropical oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 115

127 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) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) unit, 500mg (1,250mg) -600 unit calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) unit calcium carbonate-vitamin d3 oral tablet,chewable mg-unit 4 $0 MO; * 4 $0 MO; * 4 $0 MO; * calcium citrate + d oral tablet calcium citrate + oral tablet calcium citrate oral tablet 200 mg (950 mg) calcium citrate oral tablet 250 mg calcium 4 $0 MO; * calcium citrate-vitamin d3 oral tablet mg-unit calcium citrate-vitamin d3 oral tablet mg-unit 4 $0 MO; * calcium gluconate oral tablet 45 mg (500 mg) 4 $0 MO; * calcium gluconate oral tablet 60 mg (650 mg) calcium with vitamin d oral tablet calcium+d oral tablet 500 mg(1,250mg) -200 unit CITRUS CALCIUM ORAL TABLET 200 MG CALCIUM -250 UNIT CITRUS CALCIUM ORAL TABLET MG-UNIT 4 $0 MO; * dextrose-kcl-nacl intravenous solution 1 $0 B/D PA eliphos oral tablet flavor chews antacid oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 116

128 hi-cal plus vit d oral tablet high potency calcium oral tablet klor-con 10 oral tablet extended release klor-con 8 oral tablet extended release klor-con m15 oral tablet,er particles/crystals klor-con m20 oral tablet,er particles/crystals klor-con oral packet k-tab oral tablet extended release 8 meq 1 $0 lactated ringers intravenous parenteral solution laxative dietary supplement oral tablet MAG 64 ORAL TABLET EXTENDED RELEASE 4 $0 MO; * magnesium oxide oral tablet 4 $0 MO; * magnesium sulfate injection solution 1 $0 B/D PA; MO magnesium sulfate injection syringe 1 $0 B/D PA NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA oral electrolytes oral solution ORALYTE ORAL SOLUTION oyster shell + d3 oral tablet oyster shell calcium 500 oral tablet 4 $0 MO; * oyster shell calcium-vit d3 oral tablet mg-unit 4 $0 MO; * oystercal-d oral tablet PEDIALYTE ORAL SOLUTION 4 $0 MO; * pedialyte singles oral solution pediatric electrolyte oral solution pediatric freezer pops oral solution potassium bicarb and chloride oral tablet, effervescent 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 117

129 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 30 meq/100 ml, 40 meq/100 ml 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 1 $0 potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride-0.45 % nacl intravenous parenteral solution potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l 1 $0 1 $0 B/D PA; MO 1 $0 B/D PA 1 $0 B/D PA 1 $0 B/D PA; MO 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 118

130 potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l 1 $0 B/D PA ringers intravenous parenteral solution 1 $0 B/D PA smooth antacid oral tablet,chewable sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % intravenous parenteral solution sodium chloride 5 % intravenous parenteral solution sodium chloride intravenous parenteral solution 1 $0 sodium lactate intravenous solution 1 $0 super calcium oral tablet TUMS ULTRA ORAL TABLET,CHEWABLE 400 MG (1,000 MG) 4 $0 MO; * ultra strength antacid oral tablet,chewable ultra strength calcium antacid oral tablet,chewable 雜類營養產品 amino acids 15 % intravenous parenteral solution AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 1 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 119

131 AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 120

132 CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION electrolyte-48 in d5w intravenous parenteral solution HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION INTRALIPID INTRAVENOUS EMULSION 20 % INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 1 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA; MO 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 2 $0 liposyn iii intravenous emulsion 10 % 1 $0 B/D PA liposyn iii intravenous emulsion 20 % 1 $0 B/D PA; MO NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 121

133 PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 維生素 / 補血藥 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA; MO 2 $0 B/D PA 2 $0 B/D PA 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA; MO 2 $0 B/D PA a thru z advanced formula oral tablet a thru z select 50+ formula oral tablet a thru z select oral tablet mcg abc plus oral tablet 4 $0 MO; * animal chews oral tablet,chewable animal shapes complete oral tablet,chewable AQUASOL E ORAL DROPS 4 $0 MO; * ascorbic acid oral tablet 250 mg, 500 mg ascorbic acid oral tablet,chewable ascorbic acid with rose hips oral tablet b complex-vitamin c-folic acid oral tablet 4 $0 MO; * BALANCED B-100 ORAL TABLET 100 MG 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 122

134 b-complex with vitamin c oral tablet 4 $0 MO; * beta carotene oral capsule 4 $0 MO; * biotin oral capsule 2,500 mcg, 5 mg 4 $0 MO; * biotin oral tablet 1 mg, 300 mcg 4 $0 MO; * biotin oral tablet 800 mcg c-1000 oral tablet c-1000 with rose hips oral tablet c-250 oral tablet c-500 oral tablet c-500 oral tablet,chewable CALCIDOL ORAL DROPS centamin oral liquid central vite with lutein oral tablet central-vite oral tablet mg-mcg central-vite senior oral tablet central-vite with lycopene oral tablet central-vite women's under 50 oral tablet century adults 50+ oral tablet century mature oral tablet mgmcg-mcg, mcg century oral tablet mg-mcg century ultimate women's oral tablet mg-mcg CEROVITE ADVANCED FORMULA ORAL TABLET 4 $0 MO; * CEROVITE ORAL LIQUID 4 $0 MO; * CERTAVITE SENIOR-ANTIOXIDANT ORAL TABLET 4 $0 MO; * chewable multi vitamin oral tablet,chewable child vitamin with minerals oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 123

135 children's chewable complete oral tablet,chewable children's chewable oral tablet,chewable children's chewable vitamin oral tablet,chewable children's chewable w/minerals oral tablet,chewable children's iron oral drops children's multivit w/extra c oral tablet,chewable children's vitamin with iron oral tablet,chewable CHILD'S CHEWABLE VITAMINS/IRON ORAL TABLET,CHEWABLE child's vitamin with iron oral tablet,chewable child's vitamin with vitamin c oral tablet,chewable cholecalciferol (vitamin d3) oral capsule 1,000 unit, 5,000 unit, 50,000 unit cholecalciferol (vitamin d3) oral capsule 10,000 unit, 2,000 unit, 400 unit 4 $0 MO; * complete 50+ oral tablet complete multi 50+ oral tablet complete multivitamin oral tablet complete multivitamin-mineral oral tablet complete senior oral tablet mgmcg-mcg cyanocobalamin (vitamin b-12) injection solution 4 $0 MO; * 3 $0 MO; * D-2000 ORAL CAPSULE 4 $0 MO; * daily multiple oral tablet mg-mcg 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 124

136 daily multivitamin with iron oral tablet daily vitamin formula + iron oral tablet dialyvite 800 oral tablet 4 $0 MO; * dialyvite vitamin d oral capsule 4 $0 MO; * dino-life oral tablet,chewable dino-life with extra c oral tablet,chewable dino-life with iron-zinc oral tablet,chewable ELDERTONIC ORAL ELIXIR 4 $0 MO; * ergocalciferol (vitamin d2) oral capsule 3 $0 MO; * ergocalciferol (vitamin d2) oral drops 4 $0 MO; * essentia oral tablet ezfe 200 oral capsule 4 $0 MO; * FERATE ORAL TABLET 240 MG (27 MG IRON) 4 $0 MO; * FER-IRON ORAL DROPS FERREX 150 ORAL CAPSULE 4 $0 MO; * ferrous gluconate oral tablet 236 mg (27 mg iron), 256 mg (28 mg iron) ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (36 mg iron), 324 mg (38 mg iron), 325 mg (36 mg iron) 4 $0 MO; * ferrous sulfate oral drops 4 $0 MO; * ferrous sulfate oral liquid 4 $0 MO; * ferrous sulfate oral solution 4 $0 MO; * ferrous sulfate oral tablet,delayed release (dr/ec) fluoritab oral tablet,chewable 0.5 mg fluoride (1.1 mg) 4 $0 MO; * folic acid oral tablet 1 mg 3 $0 MO; * folic acid oral tablet 400 mcg, 800 mcg 4 $0 MO; * fruit c oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 125

137 fruit c-500 oral tablet,chewable full spectrum b-vitamin c oral tablet GERIATON ORAL LIQUID gummi bear multivitamin oral tablet,chewable gummy swirls oral tablet,chewable honey bears oral tablet,chewable honey bears with iron-zinc oral tablet,chewable hydroxocobalamin intramuscular solution 3 $0 MO; * iferex 150 oral capsule 4 $0 MO; * iron high potency oral tablet kid's vitamins + extra c oral tablet,chewable kid's vitamins + iron oral tablet,chewable kid's vitamins oral tablet,chewable little animals oral tablet,chewable little animals-iron oral tablet,chewable lumitene oral capsule lysiplex plus oral liquid 4 $0 MO; * multi complete with iron oral tablet multi-day with iron oral tablet MULTI-DELYN ORAL LIQUID 4 $0 MO; * MULTI-DELYN WITH IRON ORAL LIQUID multivital platinum oral tablet mcg multivitamin with minerals oral liquid multi-vite oral tablet myferon 150 oral capsule 4 $0 MO; * NEPHRONEX ORAL LIQUID one daily multivitamin-iron oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 126

138 one daily plus iron oral tablet mg-mcg one daily women's health oral tablet one daily women's oral tablet 18 mg iron-400 mcg-450 mg ca one-a-day teen advantage oral tablet pantothenic acid oral tablet 4 $0 MO; * POLY-IRON ORAL CAPSULE 4 $0 MO; * POLY-VITAMIN ORAL DROPS POLY-VITAMIN WITH IRON ORAL DROPS 1,500 UNIT-400 UNIT-10 MG/ML POLYVITAMIN/IRON ORAL TABLET,CHEWABLE POLY-VITAMINS ORAL TABLET,CHEWABLE prenatal vitamin oral tablet 1 $0 PROSIGHT ORAL TABLET pyridoxine injection solution 3 $0 MO; * pyridoxine oral tablet 100 mg, 25 mg, 50 mg pyridoxine oral tablet 250 mg 4 $0 MO; * RENA-VITE ORAL TABLET 4 $0 MO; * sentry oral tablet mg-mcg sentry senior oral tablet sodium fluoride oral tablet 1 $0 soothing pureway-c oral tablet spectravite adult 50+ oral tablet spectravite advanced formula oral tablet spectravite senior oral tablet mcg spectravite ultra women oral tablet stress 500 oral tablet stress formula 600 c oral tablet 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 127

139 STRESS FORMULA ORAL TABLET STRESS FORMULA WITH IRON ORAL TABLET 4 $0 MO; * super b complex-vitamin c oral tablet super b-50 complex oral capsule THERA VITAMIN ORAL TABLET 4 $0 MO; * THERA-M ORAL TABLET THERA-M ORAL TABLET 9 MG IRON-400 MCG 4 $0 MO; * therapeutic-m oral tablet 9 mg iron-400 mcg thera-tabs m oral tablet thiamine hcl injection solution 3 $0 MO; * thiamine hcl oral tablet 100 mg, 50 mg thiamine hcl oral tablet 250 mg 4 $0 MO; * TRI-VITA ORAL DROPS TRI-VITAMIN ORAL DROPS 4 $0 MO; * vitacel (with lutein) oral tablet 4 $0 MO; * vitalets oral tablet,chewable vitamin a oral capsule 10,000 unit 4 $0 MO; * vitamin a oral capsule 25,000 unit, 8,000 unit vitamin b complex oral capsule VITAMIN B-1 ORAL TABLET 4 $0 MO; * VITAMIN B-12 ORAL TABLET 1,000 MCG, 500 MCG VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 50 MG 4 $0 MO; * 4 $0 MO; * vitamin b-6 oral tablet 200 mg, 250 mg vitamin c oral tablet 1,000 mg, 250 mg 4 $0 MO; * vitamin c oral tablet 100 mg 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 128

140 VITAMIN C ORAL TABLET,CHEWABLE 500 MG 4 $0 MO; * vitamin c with rose hips oral tablet 4 $0 MO; * VITAMIN D2 ORAL CAPSULE 3 $0 MO; * vitamin d3 oral capsule 1,000 unit, 2,000 unit, 400 unit 4 $0 MO; * vitamin e (dl, acetate) oral capsule 400 unit 4 $0 MO; * vitamin e oral capsule 100 unit, 200 unit, 400 unit 4 $0 MO; * VITAMINS B COMPLEX ORAL CAPSULE 4 $0 MO; * yelets oral tablet zoo chews oral tablet,chewable 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 129

141 索引 1 acid reducer (ranitidine) hour decongestant acitretin HOUR NASAL SPRAY 65 ACITRETIN ACTEMRA day vaginal ACTHAR H.P A ACTHIB (PF) a thru z advanced formula ACTIMMUNE ACTOPLUS MET XR a thru z select acyclovir... 3, 58 a thru z select 50+ formula acyclovir sodium ADACEL(TDAP abacavir... 3 ADOLESN/ADULT)(PF) 85 abacavir-lamivudinezidovudine ADAGEN adapalene abc plus ADCIRCA ABELCET... 2 added strength headache ABILIFY relief ABILIFY DISCMELT ADDED STRENGTH PAIN ABILIFY MAINTENA... 37, 38 RELIEVER ABRAXANE ADEFOVIR... 3 ABREVA ADEMPAS acamprosate adrucil acarbose adult cough formula dm max acebutolol ACEPHEN adult low dose aspirin acetadryl adult tussin chest acetaminophen congestion acetaminophen extra adult tussin cough congest strength dm acetaminophen pm adult tussin dm acetaminophen pm extra str adult tussin multi-symp cold acetaminophen-codeine ADVAIR DISKUS acetasol hc ADVAIR HFA acetazolamide ADVANCED ANTACIDacetazolamide sodium ANTIGAS acetic acid afeditab cr acetylcysteine AFINITOR acid control (ranitidine) AFINITOR DISPERZ acid controller afrin no drip(oxymetazolin) ACID GONE ANTACID acid reducer (famotidine).. 82 AGGRENOX A-HYDROCORT AKWA TEARS AKWA TEARS (POLYVINYL ALCOHOL) ala-cort ALAVERT D-12 ALLERGY- SINUS ALBENZA... 9 albuterol sulfate , 111 alcalak alclometasone ALCOHOL PADS ALDURAZYME alendronate... 61, 89 aler-cap alfuzosin ALIMTA ALINIA... 9 all day allergy (cetirizine) 101 ALL DAY ALLERGY (CETIRIZINE) all day allergy-d allerclear allerclear d-12hr aller-ease aller-fex allergy & congestion relief allergy (chlorpheniramine) allergy 4-hour allergy complete-d allergy d allergy medication allergy medicine allergy relief (cetirizine) allergy relief (fexofenadine) allergy relief (loratadine). 102 ALLERGY RELIEF (LORATADINE) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 130

142 allergy relief d allergy relief(chlorpheniramn). 102 allergy relief(diphenhydramin) 102 allergy relief-d (cetirizine)102 allergy relief-d (loratadine) allergy-time aller-tec aller-tec d allfen allopurinol ALMACONE ALMACONE alophen ALPHAGAN P alprazolam ALREX altachlore altamist altavera (28) aluminum hydroxide gel alyacen 1/35 (28) alyacen 7/7/7 (28) amantadine hcl... 3 ambi 60pse-400gfn ambi 60pse-4cpm AMBISOME... 2 amcinonide amethia amethia lo amethyst AMIFOSTINE CRYSTALLINE amikacin... 9 amiloride amiloridehydrochlorothiazide amino acids 15 % AMINOSYN 10 % AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartanhcthiazid ammonium lactate amnesteem amoxapine amoxicil-clarithromylansopraz amoxicillin amoxicillin-pot clavulanate12 amphetamine salt combo. 38 amphotericin b... 2 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA anagrelide anastrozole ANDROGEL ANDROID animal chews animal shapes complete. 122 ANORO ELLIPTA antacid... 75, 115 antacid anti-gas antacid anti-gas double str antacid ext str (calcium carb) antacid extra-strength ANTACID EXTRA- STRENGTH antacid liquid antacid maximum strength antacid plus anti-gas antacid regular strength ANTACID TABLET antacid ultra strength. 75, 115 antacid with simethicone antacid-antigas antacid-simethicone ds anti-diarrhea anti-diarrheal ANTI-DIARRHEAL (LOPERAMIDE) antifungal (tolnaftate) ANTIFUNGAL (TOLNAFTATE) antitussive dm APOKYN apraclonidine apri APRISO APRODINE APTIOM APTIVUS... 3 AQUASOL E ARALAST NP aranelle (28) ARCALYST aripiprazole ARIPIPRAZOLE ARTIFICIAL TEARS ARTIFICIAL TEARS (PETRO/MIN) artificial tears(hypromellose) ascorbic acid ascorbic acid with rose hips ashlyna ASMANEX HFA ASMANEX TWISTHALER aspir 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 131

143 aspirin aspirin childrens aspirin low dose aspirin low-strength aspirin, buffered aspir-trin ASTAGRAF XL atenolol atenolol-chlorthalidone athenol athlete's foot (terbinafine). 57 athlete's foot (tolnaftate) athlete's foot af atorvastatin ATOVAQUONE... 9 atovaquone-proguanil... 9 ATRIPLA... 3 atropine ATROVENT HFA aubra AVASTIN AVELOX IN NACL (ISO- OSMOTIC) aviane AVONEX AVONEX (WITH ALBUMIN) AYR SALINE AZACITIDINE AZASAN AZASITE azathioprine azelastine... 65, 98 AZILECT azithromycin... 8 AZOPT AZOR aztreonam... 9 azurette (28) B b complex-vitamin c-folic acid baciim... 9 bacitracin... 9, 56, 96 bacitracin zinc bacitracin-polymyxin b bacitraycin plus baclofen BALANCED B balsalazide balziva (28) BANZEL BARACLUDE... 3 bayer advanced bayer aspirin baza antifungal BCG VACCINE, LIVE (PF) b-complex with vitamin c 123 BELEODAQ benazepril benazeprilhydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzonatate benzoyl peroxide benztropine beta carotene beta-hc betamethasone dipropionate... 58, 59 betamethasone valerate betamethasone, augmented betaxolol... 45, 97 bethanechol chloride BETIMOL BETOPTIC S BEXSERO (PF) bicalutamide BICILLIN C-R BICILLIN L-A BICNU biobron sf biocotron biogil biotin bisacodyl bisa-lax BISMATROL bismuth bismuth maximum strength bisoprolol fumarate bisoprololhydrochlorothiazide bleomycin BLEPHAMIDE S.O.P BOOSTRIX TDAP BOSULIF briellyn BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac bromocriptine broncotron ped BROTAPP BROTAPP DM budesonide BUDESONIDE bufferin bumetanide buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl buspirone BUSULFEX butalbital-acetaminop-cafcod butorphanol tartrate BYDUREON BYETTA BYSTOLIC C c c-1000 with rose hips c 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 132

144 c cabergoline CALCIDOL calcipotriene... 53, 54 calcitonin (salmon) CALCITRATE calcitrene calcitriol... 54, 71 calcium calcium d calcium d (d3) calcium 500 with d calcium CALCIUM D(3) calcium 600 with vitamin d calcium acetate calcium antacid CALCIUM ANTACID calcium antacid tropical calcium carbonate calcium carbonate-vitamin d calcium citrate calcium citrate calcium citrate + d calcium citrate-vitamin d calcium gluconate calcium with vitamin d calcium+d camila camrese camrese lo CANASA CANCIDAS... 2 candesartan candesartanhydrochlorothiazid CAPASTAT... 9 CAPRELSA captopril captoprilhydrochlorothiazide CARAC CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carboplatin carteolol cartia xt carvedilol CAYSTON... 9 caziant (28) cefaclor... 6 cefadroxil... 6 cefazolin... 6 cefazolin in dextrose (isoos)... 6 cefdinir... 7 cefditoren pivoxil... 7 cefepime... 7 cefixime... 7 cefotaxime... 7 cefotetan... 7 cefoxitin... 7 cefoxitin in dextrose, isoosm... 7 cefpodoxime... 7 cefprozil... 7 ceftazidime... 7 ceftriaxone... 7 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib CELLCEPT CELLCEPT INTRAVENOUS CELONTIN centamin central vite with lutein central-vite central-vite senior central-vite with lycopene central-vite women's under century century adults century mature century ultimate women's cephalexin... 7, 8 CEREZYME CEROVITE CEROVITE ADVANCED FORMULA CERTAVITE SENIOR- ANTIOXIDANT CERVARIX VACCINE (PF) cetiri-d cetirizine cetirizine-pseudoephedrine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chateal CHEMET CHEST CONGESTION RELIEF chest congestion relief d. 103 CHEST CONGESTION RELIEF PE chest-sinus congestion relief chewable multi vitamin child allergy relf(cetirizine) child aspirin child chest congestion + cough child delsym cough+chest dm child mucinex chest congestion CHILD MUCUS RELIEF COUGH CHILD MUCUS RELIEF EXPECTORANT 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 133

145 child pain rel-fever reducer child suppository child vitamin with minerals children's allergy complete children's allergy relief(lor) children's allergy(cetirizine) children's aller-tec children's aspirin children's cetirizine children's chest congestion children's chewable children's chewable complete children's chewable vitamin children's chewable w/minerals children's cold & cough CHILDREN'S COLD & COUGH DM children's cough children's dibromm dm cold & c children's fever reducing children's iron children's mucinex cough104 children's multivit w/extra c children's pain relief children's pepto children's silapap CHILDREN'S SILFEDRINE children's vitamin with iron children's wal-zyr child's all day allergy(cetir) CHILD'S CHEWABLE VITAMINS/IRON child's vitamin with iron child's vitamin with vitamin c chloramphenicol sod succinate... 9 chlorhexidine gluconate chlorhist chloroquine phosphate... 9 chlorothiazide chlorothiazide sodium chlorpheniramine maleate chlorpromazine chlortabs chlorthalidone cholecalciferol (vitamin d3) cholestyramine light chorionic gonadotropin, human CIALIS ciclodan ciclopirox CIDOFOVIR... 3 cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 13, 96 ciprofloxacin lactate cisplatin citalopram... 38, 39 citrate of magnesia CITRUS CALCIUM cladribine claravis CLARINEX clarithromycin... 8 CLEARLAX clemastine CLEOCIN clindamycin hcl... 9 clindamycin pediatric... 9 clindamycin phosphate 9, 55, 91 clindamycin-benzoyl peroxide CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 134

146 clobetasol clobetasol-emollient clomipramine clonazepam clonidine clonidine hcl... 39, 46 clopidogrel clorazepate dipotassium clotrimazole... 2, 57, 91 clotrimazole 3 day clotrimazole clotrimazole clotrimazole-betamethasone clozapine CLOZAPINE COARTEM... 9 codeine sulfate CODITUSS DM colchicine-probenecid COLCRYS cold & cough dm cold & cough elixir COLD HEAD CONGESTION NIGHTTIME cold multi-symptom (chlorphen) colestipol COLISTIN (COLISTIMETHATE NA) 9 col-rite COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ comfort gel comfort gel extra strength 76 COMPLERA... 3 complete complete allergy complete allergy medicine complete multi complete multivitamin complete multivitaminmineral complete senior compro COMVAX (PF) CONGESTAC constulose COPAXONE COREG CR cormax cortisone CORTISPORIN-TC COSENTYX PEN COSENTYX PEN (2 PENS) cough & cold cough & cold mucus relief cf cough control (dextromethorph) cough control (guaifenesin) cough control cf (pe) cough control dm cough control dm max cough formula dm cough relief COUGH SUPPRESSANT- EXPECTORANT cough syrup dm COUGHTAB COUMADIN CRESTOR CRIXIVAN... 3 cromolyn... 76, 98, 111 cryselle (28) CUBICIN... 9 CUPRIMINE cyanocobalamin (vitamin b- 12) cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate CYCLOPHOSPHAMIDE CYCLOSERINE... 9 CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYSTADANE CYSTAGON cytarabine D d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride D d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine daily multiple daily multivitamin with iron daily vitamin formula + iron DALIRESP danazol dantrolene DAPSONE... 9 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 9 dasetta 1/35 (28) dasetta 7/7/7 (28) daunorubicin DAUNOXOME daysee DECITABINE DELESTROGEN delsym cough+chest congest dm demeclocycline DEMSER DENAVIR denta 5000 plus dentagel DEPEN TITRATABS DEPO-PROVERA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 135

147 DEPO-SUBQ PROVERA dermarest eczema (hydrocort) desgen dm desipramine desloratadine desmopressin desonide desoximetasone despec-dm (phenyleph-dmguaif) dexamethasone dexamethasone intensol.. 66 dexamethasone sodium phosphate... 66, 100 DEXILANT dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) 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. 105 diabetic siltussin-dm diabetic siltussin-dm max str diabetic tussin dm diabetic tussin ex diabetic tussin max st diabetic tussin mucus relief dialyvite dialyvite vitamin d diamode diaper rash relief diarrhea relief (bismuth subs) DIASTAT diazepam... 23, 39 diazepam intensol diclofenac potassium diclofenac sodium.. 33, 54, 99 diclofenac-misoprostol dicloxacillin dicyclomine... 73, 74 didanosine... 3 diflorasone diflunisal digitek digox digoxin dihydroergotamine DILANTIN 30 MG diltiazem hcl dilt-xr dimenhydrinate dino-life dino-life with extra c dino-life with iron-zinc DIOCTO diotame DIPENTUM diphedryl diphenhydramine hcl diphenhydramineacetaminophen diskets disulfiram divalproex dm max DOC-Q-LACE docu docu soft docusate sodium docusil donepezil dorzolamide dorzolamide-timolol double-tussin dm doxazosin doxepin doxorubicin doxy doxycycline hyclate doxycycline monohydrate. 14 DRISTAN LONG LASTING dronabinol DRONABINOL DROXIA dss ducodyl dulcolax stool softener (dss) duloxetine DURAMORPH (PF) DUREZOL E e.c. prin e.e.s econazole ecotrin low strength EDURANT... 3 EFFIENT EGRIFTA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 136

148 ELAPRASE ELDERTONIC electrolyte-48 in d5w ELELYSO ELIDEL ELIGARD elinest eliphos ELIQUIS ELITEK ELIXOPHYLLIN ELLA ELMIRON EMCYT EMEND... 76, 77 emoquette EMSAM EMTRIVA... 3 enalapril maleate enalaprilhydrochlorothiazide ENBREL... 89, 90 ENBREL SURECLICK ENDACOF - DM endacon endocet ENEMA ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin ENOXAPARIN enpresse enskyce entacapone ENTECAVIR... 3 enteric coated aspirin enulose EPANED epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK EPIRUBICIN epitol EPIVIR... 3 EPIVIR HBV... 3 eplerenone eprosartan EPZICOM... 3 ergocalciferol (vitamin d2) ergoloid ERIVEDGE errin ERWINAZE ery pads ERYPED ERYTHROCIN... 8 ERYTHROCIN (AS STEARATE)... 8 erythromycin... 9, 96 erythromycin ethylsuccinate... 8 erythromycin with ethanol. 55 erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole sodium essentia estarylla ESTRACE estradiol estradiol valerate eszopiclone ethambutol ethosuximide etidronate disodium etodolac etoposide EVOTAZ... 3 EXELON exemestane EXJADE expectorant ex-strength medi-tabs ex-strength medi-tabs pm. 34 EXTAVIA ezfe F FABRAZYME falmina (28) famciclovir... 3, 4 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) FANAPT FARESTON FARXIGA FARYDAK FASLODEX FAZACLO felbamate felodipine fenesin ir fenesin pe ir fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid (choline) fenoprofen fentanyl FENTANYL CITRATE FERATE FER-IRON FERREX FERRIPROX ferrous gluconate ferrous sulfate FETZIMA fever reducer feverall fexofenadine FIBER FIBER (CALCIUM POLYCARBOPHIL) fiber (psyllium husk/sugar) 77 FIBER (WITH ASPARTAME) fiber laxative (husk/sugar) 77 fiber laxative (methylcellulo) fiber laxative (psyllium) s/f 77 fiber smooth fiber smooth (sucrose) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 137

149 FIBER THERAPY fiber therapy (ca polycarboph) FIBER THERAPY (PSYLLIUM SEED) fiber therapy (psyllium) fiber-lax fiber-tabs finasteride FIRAZYR flanax antacid flavor chews antacid flavoxate flecainide FLOVENT DISKUS FLOVENT HFA , 112 fluconazole... 2 fluconazole in dextrose(isoo)... 2 flucytosine... 2 FLUDARABINE fludrocortisone flunisolide fluocinolone... 59, 60 fluocinolone acetonide oil. 66 fluocinonide fluocinonide-e fluoritab fluorometholone fluorouracil... 17, 54 fluoxetine FLUOXETINE fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 60, 112 fluvastatin fluvoxamine FML S.O.P foaming antacid folic acid fomepizole fondaparinux FONDAPARINUX for sty relief FORADIL AEROLIZER FORFIVO XL FORTEO fortical foscarnet... 4 fosinopril fosinoprilhydrochlorothiazide fosphenytoin FOSRENOL FRAGMIN... 50, 51 fruit c fruit c full spectrum b-vitamin c. 126 furosemide... 46, 47 FUZEON... 4 FYCOMPA G gabapentin GABITRIL galantamine GAMMAGARD LIQUID GAMUNEX-C ganciclovir sodium... 4 garamycin GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX ONE-VIAL GAUZE PAD gavilax gavilyte-c gavilyte-g gavilyte-n GAZYVA GELNIQUE GEMCITABINE gemfibrozil generlac gengraf gentak gentamicin... 10, 56, 57, 96 gentamicin in nacl (iso-osm) GENTAMICIN IN NACL (ISO-OSM) gentlelax GEODON GERIATON geri-kot geri-lanta geri-mox antacid-antigas.. 78 geri-tussin gildess gildess fe GILENYA GILOTRIF GLATOPA GLEEVEC GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycerin (adult) glycerin (child) glycolax glycopyrrolate gonak goniosoft goniotaire goniovisc granisetron (pf) granisetron hcl griseofulvin microsize... 2 griseofulvin ultramicrosize.. 2 g-tron guaiasorb dm guaifenesin guaifenesin-dm guanfacine guanidine gummi bear multivitamin. 126 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 138

150 gummy swirls H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI... 4 HAVRIX (PF)... 86, 87 headache formula headache formula added str headache pm headache relief (asa-acetcaf) heartburn prevention heartburn relief (ranitidine) heather heparin (porcine) heparin (porcine) in 5 % dex heparin (porcine) in nacl (pf) heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN hi-cal plus vit d high potency calcium honey bears honey bears with iron-zinc HORIZANT HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PED CROHN'S STARTER PK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U hydralazine HYDRO SKIN hydrochlorothiazide hydrocodoneacetaminophen hydrocodone-ibuprofen hydrocortisone... 60, 66, 78 hydrocortisone acetate hydrocortisone butyrate hydrocortisone butyremollient hydrocortisone valerate hydrocortisone-acetic acid 66 hydromorphone hydromorphone (pf) hydroxocobalamin hydroxychloroquine hydroxyurea hydroxyzine hcl HYPERRAB S/D (PF) I ibandronate IBRANCE ibu-drops ibuprofen ibuprofen ib ibuprofen-oxycodone ICLUSIG idarubicin iferex IFOSFAMIDE ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) infants ibu-drops infant's ibuprofen INFANT'S MEDI-PROFEN infant's non-aspirin INFANT'S PAIN RELIEF infant's pain reliever infants profenib INLYTA INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1/2 ML, 1 ML INTELENCE... 4 intense cough reliever INTRALIPID INTRON A introvale INVANZ INVEGA INVEGA SUSTENNA INVEGA TRINZA INVIRASE... 4 inzo antifungal IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 65, 112 ipratropium-albuterol i-prin irbesartan irbesartanhydrochlorothiazide IRENKA IRINOTECAN iron high potency ISENTRESS... 4 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 139

151 isoniazid ISORDIL isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX itraconazole... 2 ivermectin IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JINTELI jock itch (terbinafine) jolessa jolivette junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe JUXTAPID K KADCYLA KADIAN KALETRA... 4 KALYDECO kaopectate (bismuth subsalicy) kaopectate ex str (bismuth ss) kariva (28) kelnor 1/35 (28) KENALOG ketoconazole... 2, 57 ketoprofen... 34, 35 ketorolac KEYTRUDA KHEDEZLA KIDKARE COUGH/COLD kid's vitamins kid's vitamins + extra c kid's vitamins + iron KINRIX (PF) KIONEX klor-con klor-con klor-con klor-con m klor-con m KOMBIGLYZE XR KONSYL (SUGAR) KONSYL SUGAR-FREE.. 78 KORLYM k-pec antidiarrheal (bism sub) k-tab kurvelo KUVAN L l norgest/e.estradiol-e.estrad... 93, 94 labetalol lactated ringers... 61, 117 lactulose lamivudine... 4 LAMIVUDINE-ZIDOVUDINE... 4 lamotrigine LANOXIN lansoprazole LASTACAFT latanoprost LATUDA laxa clear laxacin laxative laxative (glycerin-pediatric) laxative dietary supplement laxative maximum strength laxative peg laxative pills laxative plus stool softener laxative-senna leflunomide LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in nacl (isoos) levobunolol levocarnitine levocarnitine (with sugar).. 63 levocetirizine levofloxacin... 14, 96 levofloxacin in d5w LEVOLEUCOVORIN CALCIUM levonorgestrel levonorgestrel-ethinyl estrad levora levorphanol tartrate levothyroxine LEVOTHYROXINE levoxyl LEXIVA... 4 LIALDA lice killing (permethrin) LICE TREATMENT lice treatment (permethrin) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 140

152 lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine lindane LINEZOLID LINZESS liothyronine liposyn iii liquibid d-r liquid antacid lisinopril lisinopril-hydrochlorothiazide lite coat aspirin lithium carbonate lithium citrate little animals little animals-iron little remedies lo-dose aspirin LOMUSTINE loperamide loradamed loratadine loratadine-d lorazepam lorazepam intensol losartan losartan-hydrochlorothiazide LOTRONEX lovastatin low-ogestrel (28) loxapine succinate lta pre-attached lubricant eye LUBRICANT EYE (PG-PEG 400) lubricant eye (polyv alcohol) LUBRICATING PLUS LUMIGAN lumitene LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED lutera (28) LYNPARZA LYRICA lysiplex plus LYSODREN lyza M MAG magnesium citrate magnesium oxide magnesium sulfate malathion MAPAP (ACETAMINOPHEN) maprotiline marlissa MARPLAN masanti double strength masophen MATULANE matzim la maxiphen meclizine meclofenamate medi-bismuth MEDI-CORTISONE medifin expectorant mucus rlf medi-lax medi-laxx medi-natural medi-natural senna-stool.. 79 medi-phedrine medi-phedryl medi-profen medi-tabs medi-tabs pm medi-tussin medi-tussin dm medi-tussin dm diabetic medroxyprogesterone mefenamic acid mefloquine megestrol MEKINIST meloxicam melphalan hcl MENACTRA (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MEPHYTON meprobamate mercaptopurine meropenem mesalamine with cleansing wipe mesna MESNEX MESTINON MESTINON TIMESPAN metadate er metaproterenol metaxalone metformin methadone methadone intensol methadose methamphetamine methazolamide methenamine hippurate methimazole methotrexate sodium methotrexate sodium (pf).. 19 methoxsalen rapid methscopolamine methyclothiazide methyldopahydrochlorothiazide methylergonovine METHYLERGONOVINE methylphenidate... 41, 42 methylprednisolone 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 141

153 methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol tahydrochlorothiaz metoprolol tartrate metronidazole... 10, 55, 92 metronidazole in nacl (isoos) mexiletine MIACALCIN MI-ACID micatin miconazole miconazole nitrate... 58, 92 miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) 94 microgestin fe 1/20 (28) midodrine migergot migraine formula migraine pain reliever migraine relief MILK OF MAGNESIA millipred mineral oil extra heavy minocycline minoxidil mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) modafinil moexipril moexiprilhydrochlorothiazide mometasone mono-linyah mononessa (28) montelukast morgidox morphine... 30, 31 morphine (pf) morphine concentrate MOTION SICKNESS motion sickness relief MOVIPREP moxifloxacin MOZOBIL mucinex mucinex allergy MUCINEX DM mucinex fast-max dm max mucosa mucus dm mucus dm max mucus relief mucus relief chest mucus relief cough mucus relief d (phenylephrine) mucus relief d (pseudoephed) mucus relief er MULTAQ multi complete with iron multi-day with iron MULTI-DELYN MULTI-DELYN WITH IRON multi-symptom cold night time multivital platinum multivitamin with minerals multi-vite mupirocin mupirocin calcium MUSTARGEN mycophenolate mofetil mycophenolate sodium myferon MYOZYME MYRBETRIQ myzilra N nabumetone nadolol nadolol-bendroflumethiazide nafcillin... 12, 13 NAFCILLIN NAFCILLIN IN DEXTROSE ISO-OSM NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK naphazoline NAPRELAN CR naproxen naproxen sodium naratriptan nasal decongestant (pseudoeph) NASAL DECONGESTANT (PSEUDOEPH) nasal moisturizing NASAL SPRAY (OXYMETAZOLINE) nasal spray (sodium chloride) NASONEX NATACYN nateglinide NATPARA NATURAL BALANCE natural fiber laxative (sugar) 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 142

154 natural fiber laxative smooth natural laxative natural veg laxative(sennosid) natural vegetable natural vegetable (psyllium) natural vegetable powder. 80 NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 10/11 (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin neomycin-bacitracin-poly-hc neomycin-bacitracinpolymyxin neomycin-polymyxin b gu. 61 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc... 66, 100 neo-polycin neo-polycin hc NEORAL neo-tuss NEPHRAMINE 5.4 % NEPHRONEX NEUMEGA NEUPOGEN NEUPRO nevirapine... 4 NEXAVAR NEXT CHOICE ONE DOSE niacin nicardipine nicotine nicotine (polacrilex) NICOTROL NICOTROL NS nifedical xl nifedipine night time cold NILANDRON nimodipine nitro-bid nitrofurantoin macrocrystal nitrofurantoin monohyd/mcryst nitroglycerin NITROSTAT nizatidine non-aspirin non-aspirin extra strength 35, 36 non-aspirin nightime non-aspirin pain relief non-aspirin pain relief pm. 36 non-aspirin pm NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR... 4 novarel NOVOFINE NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOVOTWIST NOXAFIL... 2 nts step NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX NUVARING nuzole nyamyc nystatin... 2, 58 nystatin-triamcinolone nystop O OCEAN NASAL octreotide acetate OCTREOTIDE ACETATE 20 OFEV ofloxacin... 14, 66, 96 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine omega-3 acid ethyl esters 52 omeprazole ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) one daily multivitamin-iron one daily plus iron one daily women's one daily women's health127 one-a-day teen advantage ONFI ONGLYZA 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 143

155 OPDIVO OPSUMIT ORACEA oral electrolytes oralone ORALYTE ORAP ORENCIA (WITH MALTOSE) organ-i nr orsythia oxacillin OXACILLIN oxacillin in dextrose(isoosm) OXACILLIN IN DEXTROSE(ISO-OSM) 13 OXALIPLATIN oxandrolone OXANDROLONE oxaprozin oxazepam oxcarbazepine oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oxymorphone oyster shell + d oyster shell calcium oyster shell calcium-vit d oystercal-d P pacerone PACLITAXEL pain relief pain relief adult pain relief extra strength pain relief pm pain relief pm rapid release pain relief regular strength 36 pain reliever pain reliever (acetamaspirin) pain reliever extra strength pain reliever pm pain reliever pm ex-strength pain-off pamidronate pamprin max PANRETIN pantoprazole pantothenic acid paricalcitol paromomycin paroxetine hcl PASER PATADAY PAXIL p-col rite PEDIALYTE pedialyte singles pediatric cough & cold pediatric electrolyte pediatric freezer pops PEDVAX HIB (PF) peg 3350-electrolytes peg-3350 with flavor packs PEGANONE peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM pentoxifylline pepcid ac pepto-bismol percogesic percogesic extra strength. 36 PERFOROMIST peri-colace perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline pharbechlor pharbedryl pharbetol phenelzine phenobarbital... 24, 25 PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended philith PHOSPHOLINE IODIDE.. 97 pilocarpine hcl... 63, 97 pindolol pink bismuth pink bismuth maximum strength pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE podactin podofilox polycin polyethylene glycol POLY-IRON polymyxin b sulfate polymyxin b sulftrimethoprim 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 144

156 polyvinyl alcohol POLY-VITAMIN POLY-VITAMIN WITH IRON POLYVITAMIN/IRON POLY-VITAMINS POMALYST portia potassium bicarb and chloride potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl , 119 potassium citrate POTIGA powderlax PRADAXA pramipexole pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 67, 100 prednisone prednisone intensol PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % prenatal vitamin oral tablet pres gen prevalite previfem PREZCOBIX... 4 PREZISTA... 4, 5 PRIFTIN PRIMAQUINE primidone PRISTIQ PROAIR HFA probenecid procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate 80 prochlorperazine maleate. 80 PROCRIT procto-pak proctosol hc proctozone-hc progesterone micronized.. 91 PROGLYCEM PROLEUKIN PROLIA PROMACTA promethazine propafenone propranolol propranololhydrochlorothiazid propylthiouracil PROQUAD (PF) PROSIGHT PROSOL 20 % protriptyline PROVENTIL HFA provil pseudoephedrine hcl PULMOZYME pure & gentle eye purelax PURIXAN pyrazinamide PYRETHRIN LICE TREATMENT M pyridostigmine bromide pyridoxine Q QUADRACEL (PF) quasense quetiapine quinapril quinaprilhydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate quit quit R RABAVERT (PF) raloxifene ramipril RANEXA ranitidine hcl... 83, 84 RAPAMUNE RAVICTI RAYOS REBIF (WITH ALBUMIN). 85 REBIF REBIDOSE REBIF TITRATION PACK 85 reclipsen (28) RECOMBIVAX HB (PF) refenesen refenesen pe regonol REGRANEX REGULOID RELENZA DISKHALER... 5 RELISTOR REMICADE REMODULIN RENA-VITE RENVELA repaglinide reprexain RESCRIPTOR... 5 reserpine RESTASIS RETROVIR... 5 REVLIMID REYATAZ... 5 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 145

157 RHEUMATREX ribavirin... 5 rifabutin rifampin ri-gel ri-gel ii riginic riluzole rimantadine... 5 ri-mox ri-mox plus ringers risedronate... 63, 89 RISPERDAL CONSTA risperidone ri-tussin ri-tussin dm RITUXAN rivastigmine tartrate... 27, 28 rizatriptan ropinirole rosadan ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL saline mist saline nasal saline nasal mist saline nose SAL-PLANT SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANI-SUPP (ADULT) SANTYL SAPHRIS (BLACK CHERRY) SAVELLA SCOT-TUSSIN DM secura antifungal selegiline hcl selenium sulfide SELZENTRY... 5 SENEXON-S SENNA senna lax senna laxative senna plus senna-extra senna-s senno sennosides-docusate sodium sen-o-tab SENSIPAR sentry sentry senior SEREVENT DISKUS SEROQUEL XR sertraline severe allergy sf 66 sf 5000 plus SIGNIFOR silace sildenafil siltussin dm das SILTUSSIN SA siltussin-dm silver sulfadiazine SIMULECT simvastatin sinex ultra fine mist 12-hour sinus & allergy non-drowsy sinus 12 hour sinus relief (oxymetazoline) sirolimus SIRTURO smooth antacid sochlor sodium bicarbonate sodium chloride... 64, 99, 119 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium polystyrene (sorb free) SOLTAMOX soluble fiber SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT soothe regular strength soothing pureway-c sorbugen nr sorine sotalol sotalol af SOVALDI... 5 spectravite adult spectravite advanced formula spectravite senior spectravite ultra women spironolactone spironolactonhydrochlorothiaz sprintec (28) SPRYCEL sronyx ssd stavudine... 5 stimulant laxative plus STIVARGA stomach relief stomach relief max strength stomach relief original stool softener stool softener-laxative stool softener-stimulant laxat 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 146

158 stop smoking aid STRATTERA STREPTOMYCIN stress STRESS FORMULA stress formula 600 c STRESS FORMULA WITH IRON STRIBILD... 5 SUBOXONE sucralfate SUDOGEST SINUS & ALLERGY sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine sulfamethoxazoletrimethoprim sulfasalazine sulfazine sulfazine ec sulindac sumatriptan sumatriptan succinate super b complex-vitamin c super b-50 complex super calcium super pain relief suphedrin suphedrin 12 hour suphedrine suphedrine 12 hour suppository adult SUPRAX... 8 SURMONTIL SUSTIVA... 5 SUTENT syeda SYLATRON SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS... 5 SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T TABLOID tacrolimus... 21, 55 TACROLIMUS tactinal tactinal extra strength TAFINLAR TAMIFLU... 5 tamoxifen tamsulosin TARCEVA TARGRETIN TASIGNA TAZORAC taztia xt tears again TECFIDERA TEFLARO... 8 TEGRETOL XR TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartanhydrochlorothiazid temazepam TENIVAC (PF) terazosin terbinafine hcl... 2 terbutaline terconazole testosterone enanthate tetanus toxoid,adsorbed (pf) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracycline THALOMID theochron theophylline THERA VITAMIN THERA-M therapeutic-m thera-tabs m thiamine hcl thioridazine thiothixene tiagabine TIKOSYN tilia fe timolol maleate... 49, 97 tinidazole TIVICAY... 5 tizanidine TOBRADEX ST tobramycin TOBRAMYCIN IN % NACL tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone TOBREX tolazamide tolbutamide tolcapone tolmetin tolnaftate tolterodine topiramate TOPIRAMATE toposar TOPOTECAN torsemide tramadol tramadol-acetaminophen.. 37 trandolapril trandolapril-verapamil tranexamic acid... 51, 92 TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % travel sickness travoprost (benzalkonium) 99 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 147

159 trazodone TREANDA TRECATOR TRELSTAR tretinoin TRETINOIN (CHEMOTHERAPY) tretinoin microspheres triamcinolone acetonide... 60, 61, 66, 67, 113 triamterenehydrochlorothiazid trianex TRI-BUFFERED ASPIRIN 37 triderm tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah trilyte with flavor packets.. 82 trimethoprim trinessa (28) TRIPLE ANTIBIOTIC tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ... 5 TRI-VITA TRI-VITAMIN trivora (28) TROPHAMINE 10 % TROPHAMINE 6% tropicamide trospium TRUMENBA TRUVADA... 5 TUDORZA PRESSAIR TUMS ULTRA tusnel diabetic tussin TUSSIN CF tussin cf cough-cold tussin chest congestion tussin cough &chest congestion tussin cough (dm only) tussin cough dm tussin dm TUSSIN DM tussin dm clear tussin dm cough tussin dm cough & chest 109 tussin dm max tussin expectorant tussin honey tussi-pres TWINRIX (PF) TYBOST... 5 TYGACIL TYKERB tylophen TYPHIM VI TYSABRI TYZEKA... 6 U ULORIC ultra strength antacid ultra strength calcium antacid unithroid ursodiol V VAGIFEM valacyclovir... 6 VALCHLOR VALCYTE... 6 VALGANCICLOVIR... 6 valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartanhydrochlorothiazide valu-dryl allergy valu-tapp vancomycin VANCOMYCIN vandazole VAQTA (PF) VARIVAX (PF) VARIZIG VECAMYL vegetable laxative VELCADE velivet triphasic regimen (28) VELPHORO venlafaxine VENTOLIN HFA VERAMYST verapamil veripred VERSACLOZ VESICARE vestura (28) vicks qlearquil allergy vicks qlearquil(oxymetazoline) VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC... 6 VIEKIRA PAK... 6 VIGAMOX VIIBRYD VIMPAT VINBLASTINE vincasar pfs vincristine vinorelbine viorele (28) VIRACEPT... 6 VIRAMUNE XR... 6 VIRAZOLE... 6 VIREAD... 6 vitacel (with lutein) vitalets vitamin a vitamin b complex 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 148

160 VITAMIN B VITAMIN B vitamin b VITAMIN B vitamin c VITAMIN C vitamin c with rose hips VITAMIN D vitamin d vitamin e vitamin e (dl, acetate) VITAMIN K VITAMIN K VITAMINS B COMPLEX 129 VITEKTA... 6 VIVELLE-DOT VOLTAREN GEL voriconazole... 2 VORICONAZOLE... 2 VOTRIENT VPRIV VYTORIN VYTORIN VYTORIN VYTORIN W wal-dryl allergy wal-fex allergy wal-itin wal-mucil fiber (aspartame) wal-mucil natural fiber lax. 82 wal-profen wal-zan wal-zyr (cetirizine) warfarin wart remover WELCHOL wera (28) woman's laxative women's gentle laxative(bisac) women's laxative (bisacodyl) women's stool softener wymzya fe X XALKORI XARELTO... 51, 52 XENAZINE XGEVA XIFAXAN XIGDUO XR XOLAIR XTANDI XYREM Y yelets YERVOY YF-VAX (PF) Z zafirlukast ZALTRAP zamicet zantac maximum strength 84 zarah ZAVESCA ZELBORAF ZEMPLAR zenchent (28) zenchent fe ZENPEP zeosa ZETIA ZIAGEN... 6 zidovudine... 6 zinc oxide ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid-mannitolwater ZOLINZA zolmitriptan zolpidem ZOMETA zonisamide zoo chews ZORTRESS ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZYCLARA ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA ZYVOX 若您有任何疑問, 請致電 GuildNet Gold Plus FIDA, 電話為 , 週一至週日早 8 點至晚 8 點 TTY/TDD, 請致電 該電話免費 更多詳細資訊, 請瀏覽網站 149

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